Every finding on record at Deanwood Rehabilitation and Wellness Center

Based on observation, record review, resident and staff interview, for one (1) of eight (8) sampled residents, facility staff failed to ensure that Resident #4 was provided with adequate supervision and assistance to prevent accidents. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervisions/Devices on January 30, 2026 at 6:14 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on January 30, 2026 at 8:21 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 2, 2026 at 4:30 PM. After removal of the immediacy, the deficient practice was lowered to a scope and severity level of D.The findings included:Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia and Hypertension.A care plan focus area, revised on 10/29/25: [Resident #4] to use the stairs when going down and when coming back in, with an escort.A physician's order dated 12/11/25 directed, Oxygen supplementation, administer oxygen 2-3L (liters)/minute via Nasal Cannula, every shift for COPD.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive response; no functional impairment in range of motion; did not use any devices for mobility; independent with transfers and walking 150 feet; and that he used oxygen therapy.During an observation on the 2-north stairwell on 01/30/26 at 3:47 PM, the resident was observed alone, going down the stairwell, noticeably short of breath. The resident had oxygen on via nasal cannula at 3 liters and was carrying a portable oxygen cylinder E-tank [3 feet tall, aluminum tank that weighs approximately 8 pounds] in a wheeled caddy. When asked, the resident stated, I don't like taking the elevators, so I take the stairs. When asked how he got to the stairwell, the resident stated that a staff member let him down. It should be noted that all the stairwells in the facility require manual entry of a 4-digit code when entering from the units.During a face-to-face interview on 01/30/26 at 3:55 PM, the findings were brought to the attention of Employee #1 (Administrator). Employee #1 stated that Resident #4 uses the stairwell because he is claustrophobic and that, He should have someone with him when he's using the stairs.The evidence showed that serious harm was likely to occur as Resident #4 was noted to be short of breath, alone in the stairwell, carrying an oxygen tank. Facility staff failed to provide adequate supervision of Resident #4. Based on these findings, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervisions/Devices on January 30, 2026 at 6:14 PM.The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on January 30, 2026 at 8:21 PM that documented, Following the time that the surveyors notified the facility, Resident #4 was immediately assessed by a licensed nurse on 1/30/26, including a head-to-toe assessment and fall risk assessment. The resident sustained no injuries, had no change in condition, no evidence of shortness of breath, and vital signs were within normal limits. The resident refused skin assessment, and all documentation was entered in the electronic health record on l /30/26 at 16:56. The resident was determined to be at a low fall risk by using the Fall Risk Assessment with a score of 2.On 1/30/26, at 16:59 Resident #4 received education by a licensed nurse regarding safety on the stairs, safety with oxygen tank/portable 02 use, oxygen tubings, fall precautions, safety precautions, LOA leave-of-absence (LOA) precautions.The Nurse Educator/designee initiated staff education for all staff beginning 1/30/26 on stair safety, resident supervision, including documentation of escort refusal. Staff that have not yet completed education will receive education when they come on their shift.The resident's care plan was updated on 1/30/26 by licensed nurse to reflect non-compliance with staff escort while using the stairwell.The code for the stairwell was changed on 1/30/26 and education was provided to all staff.Date of Compliance: 2/2/26.Verification for the removal of the immediacy was performed by the Survey Team onsite on February 2, 2026 at 4:30 PM. Cross Reference 22B DCMR Sec. 3211.1(d)

Based on observations, record review and staff interviews, facility staff failed to implement infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections as evidenced by: failure to perform hand hygiene and don required personal protective equipment (PPE) prior to entering Resident #8's room who was on contact precautions; one (1) of five (5) hand sanitizer stations on unit 2 south were not operable; and failure to have an operable hand soap dispenser and hand soap in one staff restroom.The findings included:Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included: End Stage Renal Disease and Diastolic Congestive Heart Failure. Review of the resident's medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 11, indicating moderate cognitive impairment.01/27/26 at 2:00 PM Situation Background Assessment Request (SBAR) Communication Tool:Situation - bacteria conjunctiva of the left eye.Nurse Practitioner (NP) notified in person at 2:05 PM.Resident was noted with left eye redness when she came back from dialysis. NP was informed in person and she ordered Moxifloxacin ophthalmic solution 0.5% instill 1 drop in left eye three times a day for Bacterial Conjunctivitis for 7 Days. Resident denied pain.A physician's order dated 01/27/26 directed, Place patient on contact isolation for 10 days, every shift for Conjunctivitis.During an observation on unit 3 north on 01/28/26 at 1:22 PM, a pink sign was posted on Resident #8's door that documented, Isolation Droplet/Contact Precautions. Staff and providers must clean hands when entering and exiting, gown, N95 respirator, eye protection, gloves. Keep door closed. Use dedicated or disposable equipment. Clean and disinfect shared equipment. A blue PPE holder was noted with gloves and gowns. During a face-to-face interview on 01/28/26 at 1:23 PM, in front of Resident #8's room, Employee #10 (3 north Unit Manager) was asked why the resident was on droplet and contact precautions. Employee #10 stated, [Resident #10] has conjunctivitis, I'm not sure why it says 'droplet/contact precautions. It should be just contact precautions. As this interview was happening, a staff member was observed entering Resident #8's room. The staff member failed to perform hand hygiene or don any PPE before entering the room. During an observation on 01/28/26 at 1:27 PM, Employee #11 (Certified Nurse Aide/CNA) was asked why she failed to perform hand hygiene and don PPE before entering Resident #8's room, who was on contact precautions. Employee #8 stated, I was just going in there to replace her water.2. During a dining observation on unit 2 south on 01/29/26, at 12:30 PM, in the hallway closest to the nurse's station, two (2) facility staff were observed distributing and delivering resident meal trays without performing hand hygiene. Upon assessment, it was noted that the alcohol-based hand rub station outside of room [ROOM NUMBER] was not functioning (the handle to push that allows the alcohol-based hand sanitizer to be dispensed was broken). During a face-to-face interview on 01/29/26 at 12:35 PM, the findings were brought to the attention of Employee #8 (2 south Unit Manager). The employee acknowledged the findings and stated that he would provide education and let maintenance know that the hand sanitizing station needs to be replaced. 3. During an observation on 02/02/26 at 10:46 AM of the 2 south staff restroom, the hand soap dispenser was observed to be broken and nonfunctional. A bottle of Sterex Medical Hospital bath and shampoo was placed at the sink for staff to use to wash their hands. During a face-to-face interview on 02/02/26 at 10:51 AM, the observation was brought to the attention of Employee #11 (Infection Preventionist). Employee #11 stated, The 'Sterex bath and shampoo' is used to bathe residents and is not acceptable for staff to use for hand hygiene purposes. I am not sure how long the soap dispenser has been broken or how long staff have been using the shampoo to wash their hands. I will get maintenance to come and fix the soap dispenser now.The evidence that facility staff failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections.These findings were brought to the attention of Employee #2 (Director of Nursing/DON) on 02/02/26 at approximately 4:45 PM. Employee #2 acknowledged the findings and stated that education will be provided. Cross Reference 22B DCMR Sec. 3217.6

Based on record reviews, resident and staff interviews, for three (3) of eight (8) sampled residents, facility staff inaccurately documented that Residents' #5 and #6 received showers when they did not; and facility staff failed to accurately complete Resident #4's Safe Smoker Assessment.The findings included:Review of the facility's Clinical Documentation/Record policy dated January 2026 documented in part:Documentation entries into organization documents or the health record (including but not limited to provider orders) must be accurate, valid, complete, and authenticated, that is, the information is truthful.Review of the 2 south shower, bath and skin sweep sheets document provided to the surveyor on 01/29/26 showed that on Mondays and Thursdays, day shift, the residents in room [ROOM NUMBER] (private) and 229D were scheduled to get a shower.Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Cirrhosis of the Liver, Muscle Weakness, Sickle- Cell Disease and Heart Failure.Review of the resident's medical record revealed the following:A census tracking sheet that showed Resident #5 resided in room [ROOM NUMBER] (private room) since 01/11/26.A physician's order dated 11/27/25 that directed, Shower twice a week and per patient request in the morning every Monday, Thursday.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 11, indicating moderate cognitive impairment; rejection of care behaviors not exhibited; and independent with showers and bathing.Review of Resident #5's Treatment Administration Record (TAR) for January 2026 showed that facility staff documented a checkmark and their initials to indicate that a shower was completed for the resident on 01/29/26, day shift. Review of the Certified Nurse Aide (CNA) documentation for January 2026 showed that facility staff documented their initials on 01/29/26 to indicate that Shower preferred day of Monday and Thursday in morning with skin check. Document refusals was completed.During a face-to-face interview on 01/29/26 at 3:03 PM, Resident #5 stated, I didn't take a shower today, I didn't want one and I told them that.Resident #6 was admitted to the facility on [DATE], to room [ROOM NUMBER]D with multiple diagnoses that included: Hemiplegia and Hemiparesis, Chronic Obstructive Pulmonary Disease and Muscle Disease. Review of the resident's medical record revealed the following: A physician's order dated 12/18/25 that directed, Shower twice a week and per patient request, every day shift every Monday, Thursday.An admission MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 08, indicating moderate cognitive impairment; rejection of care behaviors not exhibited; and required substantial/maximal assistance to shower/bathe.Review of the Resident #6's TAR for January 2026 showed that facility staff documented a checkmark and their initials to indicate that a shower was completed for the resident on 01/29/26, day shift. Review of the CNA documentation for January 2026 showed that facility staff documented their initials to indicate that Shower preferred day of Monday and Thursday in morning with skin check. Document refusals was completed.During a face-to-face interview on 01/29/26 at 3:05 PM, Resident #6 stated, I didn't take a shower today. I wouldn't take a shower here! I don't shower after the people at this place.A face-to-face interview was conducted on 01/29/26 at 3:07 PM, with Employee #9, (Registered Nurse/RN), who was assigned to Residents' #5 and #6. When asked if the residents received showers today, the employee stated, No. The CNA told me that the residents were washed up in the bed. The surveyor then asked Employee #9 why she documented that showers were administered when they were not. The employee stated, I should've documented that they refused their showers and got a bed bath instead. The evidence showed that both Resident #5 and 6's assigned CNA and nurse documented that they had received a shower on 01/29/26, day shift, when they did not.During a face-to-face interview on 01/29/26 at 3:10 PM, the findings were brought to the attention of Employee #7 (2 south Unit Manager). The employee acknowledged the findings and stated that education will be provided. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia and Hypertension. Review of the resident's medical record revealed the following: A care plan focus area revised on 10/29/25, [Resident #4] is on oxygen therapy r/t (related to) COPD had interventions that included, [Resident #4] has O2 (oxygen) via nasal prongs @ (2-3)L/M (liters per minute) continuously.A physician's order dated 12/11/25 directed, Oxygen Supplementation. Administer Oxygen 2-3L/min via Nasal Cannula, every shift for COPD.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for [NAME] Status (BIMS) summary score of 15, indicating intact cognitive response; no functional impairment in range of motion; and used oxygen therapy while a resident. 01/09/26 Quarterly Safe Smoker Assessment:Resident's preferred method of tobacco - cigarettes.Does the resident have an order for continuous or PRN (as needed oxygen) - no.Recommended personal protective equipment for safe smoking based on the therapy assessment - supervision.The IDT determined that the resident is deemed safe smoker.During a face-to-face interview on 02/02/26 at 1:45 PM, Resident #4 stated that he does not smoke cigarettes and has not smoked cigarettes in almost ten (10) years. The evidence showed that facility staff inaccurately documented that Resident #4 did not have an order for continuous or PRN oxygen on the Safe Smoker Assessment. During a face-to-face interview on 02/02/26 at 1:51 PM, Employee #7 (2 south Unit Manager) stated, The process for completing the smoking assessment is to talk to the resident, do an assessment and review the medical record for any orders for oxygen use. The employee reviewed Resident #4's Safe Smoker Assessment, physician's orders, and stated, That was an oversight.

Based on observation, record reviews and staff interviews, for two (2) of eight (8) sampled residents, facility staff failed to ensure that resident's Minimum Data Set (MDS) assessment were accurately coded for rejection of care behaviors and one wandering behaviors. Residents' #6 and #1.The findings included: Resident #6 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Vascular Accident (CVA), Hemiplegia and Hemiparesis, Chronic Obstructive Pulmonary Disease and Muscle Disease. Review of the resident's medical record revealed the following: 12/24/25 at 11:44 AM Nurses Note: Resident alert, oriented and verbally responsive. resident refused lab, MD (medical doctor) and RP (representative) notified. Lab rescheduled. A care plan focus area revised on 12/24/25: [Resident #6] is noncompliant with treatment/care, had interventions that included, if resists care, leave and return later and provide education to patient/family. An admission MDS assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary of 08, indicating moderate cognitive impairment and that rejection of care behaviors were not exhibited. The evidence showed that facility staff failed to code Resident #6's admission MDS for rejection of behavior. During a face-to-face interview on 02/02/26, at 1:27 PM the findings were brought to the attention of Employee #3 (MDS Coordinator) who stated, Coding is based on the IDT (interdisciplinary) meetings and looking at all documentation during the lookback period of seven (7) days. Rejection of care should have been coded. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Anemia, Chronic Kidney Disease, Stage 3, Alzheimer's Disease, and Benign Prostatic Hyperplasia (BPH). Review of the resident's medical record revealed the following: 01/14/26 at 5:00 PM Situation Background Assessment Request (SBAR) Communication Tool:Situation: Altered Mental Status, lethargy.At around 4:15 PM, resident was observed seizing on the chair for a minute, had a pulse but not responding. 911 was called, arrived at the unit at 4:32 PM, took resident via stretcher at 4:48 PM to [hospital name]. A Complaint, #2722122, filed with the State Agency on 01/20/26 documented in part:On 01/14/26, between 4:00 PM and 4:15 PM, [Resident #1] was found nonresponsive by a nurse who just came on duty. The ambulance paramedic arrived and took over. [Resident #1] was transported to [hospital name]. This nursing home has mistreated him and neglected to care for him. 01/20/26 at 8:56 PM admission Note: Resident is admitted from [hospital name].Upon assessment, resident is alert and verbally responsive, oriented to person. A Significant Change MDS assessment dated [DATE] showed that facility staff coded: in section B (cognitive status), a BIMS summary score of 03, indicating severely impaired cognitive status; in section E (behaviors), wandering behaviors occurred four (4) to (6) days and wandering placed resident at significant risk of getting to a potentially dangerous place (stairs, outside of the facility). During an initial observation on 01/28/26 at approximately 2:00 PM, [Resident #1] was observed sitting in the 5 south day room, in a Geri chair. The resident was alert to self only. The resident had a staff member sitting next to him. When asked, the staff member stated that the resident is not ambulatory and that someone sits next to him to make sure he doesn't try to get up and fall.During a face-to-face interview on 01/28/26 at 2:06 PM, Employee #4 (5 south Unit Manager) stated, [Resident #1] has not exhibited any wandering behaviors for a while now, at least a couple of months. Review of the resident's progress notes and Treatment Administration Record (TAR) for January 2026 showed no documented evidence that he had any wandering behaviors.During a face-to-face interview on 02/04/26 at 10:43 AM, Employee #5 (MDS Coordinator) reviewed the Resident #1's January 2026 progress notes and TAR and stated, Section E is filled out by the Social Worker. I am not sure why he coded wandering behaviors.During a face-to-face interview on 02/04/26 at 10:47 AM, Employee #6 (Social Worker), who completed section E of the MDS assessment, reviewed Resident #1's January 2026 progress notes and TAR. When asked why he coded the resident for having wandering behaviors that occurred 4 to 6 days in the last 7 day look back period, the employee stated, He's (Resident #1) had a history of wandering behaviors in the past but that doesn't seem to be the case now. This was a mistake. I will make a modification now.The evidence showed that facility staff inaccurately coded Resident #1's admission MDS assessment for having wandering behaviors.Cross Reference 22B DCMR Sec. 3231.12

Based on observation, record review and staff interview, for one (1) of eight (8) sampled residents, facility staff failed to implement Resident #4's care plan intervention of having an escort when using the stairwell. The findings included:Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia and Hypertension. Review of the resident's medical record revealed the following: A care plan focus area revised on 10/29/25: [Resident #4] to use the stairs when going down and when coming back in, with an escort. A physician's order dated 12/11/25 directed, Oxygen Supplementation. Administer Oxygen 2-3L/min via Nasal Cannula, every shift for COPD.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive response; shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat; and used oxygen therapy.During an observation on the 2-north stairwell on 01/30/26 at 3:47 PM, the resident was observed alone, going down the stairwell, noticeably short of breath. The resident had oxygen on via nasal cannula at 3 liters and was carrying a portable oxygen cylinder E-tank [3 feet tall, aluminum tank that weighs approximately 8 pounds] in a wheeled caddy. When asked, the resident stated, I don't like taking the elevators, so I take the stairs. When asked how he got to the stairwell, the resident stated that a staff member let him down. It should be noted that all the stairwells in the facility require manual entry of a 4-digit code when entering from the units.During a face-to-face interview on 01/30/26 at 3:55 PM, the findings were brought to the attention of Employee #1 (Administrator). Employee #1 stated that Resident #4 uses the stairwell because he is claustrophobic and that, He should have someone with him when he's using the stairs.The evidence showed that facility staff failed to implement Resident #4's care plan intervention of having an escort when using the stairwell.Cross Reference 22B DCMR Sec. 3210.4

Based on observation, record review, resident and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to ensure that a resident who needed continuous oxygen was provided with such care. Resident #4.The findings included: Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia and Hypertension. Review of the resident's medical record revealed the following: A care plan focus area last revised on 10/29/25, [Resident #4] is on oxygen therapy r/t (related to) COPD, had interventions that included: for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus and oxygen settings: [Resident #4] has O2 (oxygen) via nasal prongs @ (2-3 )L/M (liters per minute) continuously. A physician's order dated 12/11/25 directed, Oxygen Supplementation. Administer Oxygen 2-3 L/min via Nasal Cannula, every shift for COPD.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive response; shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat; and used oxygen therapy while a resident.During an observation on the 2-north stairwell on 01/30/26 at 3:47 PM, the resident was observed alone, going down the stairwell, noticeably short of breath. The resident had oxygen on via nasal cannula at 3 liters and was carrying a portable oxygen cylinder E-tank [3 feet tall, aluminum tank that weighs approximately 8 pounds] in a wheeled caddy. Upon inspection, the oxygen tank's indicator was in the red area that marked 0 refill, indicating that the tank was empty. During a face-to-face interview on 01/30/26 at 3:51 PM, Employee #7 (2 south Unit Manager), acknowledged that Resident #4's oxygen was empty when he was observed short of breath and alone in the stairwell. The employee stated, The assigned nurse is supposed to check and make sure that resident's oxygen tanks are not empty when they are leaving the unit.The evidence showed that facility staff failed to ensure that Resident #4, who required continuous oxygen, was provided with continuous oxygen.

Based on observations and staff interview, for one (1) out of three (3) dining observations, facility staff failed to distribute and serve food in accordance with professional standards for food service safety.The findings included: Code of Federal Regulations (CFR) S483.60(i) Food Safety Requirements documents in part:Hand Washing, Gloves, and Antimicrobial Gel - Employees should never use bare hand contact with any foods, ready to eat or otherwise. Since the skin carries microorganisms, it is critical that staff involved in food preparation, distribution and serving consistently utilize good hygienic practices and techniques. Staff should have access to proper hand-washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods.Staff must decontaminate hands by proper hand washing (preferred) or use of hand sanitizers (when hand washing sinks are not available) when outside the kitchen in the following situations: Prior to starting meal delivery. Prior to entering or exiting resident rooms/common areas. During a dining observation on unit 2 south on 01/29/26, at 12:30 PM, in the hallway closest to the nurse's station, two (2) facility staff were observed distributing and delivering resident meal trays without performing hand hygiene. Upon assessment, it was noted that the alcohol-based hand rub station outside of room [ROOM NUMBER] was not functioning (the handle to push that allows the alcohol-based hand sanitizer to be dispensed was broken). During a face-to-face interview on 01/29/26 at 12:35 PM, the findings were brought to the attention of Employee #8 (2 south Unit Manager). The employee acknowledged the findings and stated that he would provide education and let maintenance know that the hand sanitizing station needs to be replaced. Cross Reference 22B DCMR Sec. 3219.1

Based on record reviews and staff interview, facility staff failed to meet the State requirement of providing a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day on 01/30/26, when an Immediate Jeopardy was identified. The census on that day was 273.The findings included: Review of the facility's staffing revealed that they failed to meet the requirement of providing a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day on 01/30/26. The total direct nursing hours per resident on 01/30/26 was 3.9, the same day an Immediate Jeopardy was identified. During a face-to-face interview on 02/04/26 at 2:53 PM, the findings were brought to the attention of Employee #8 (Staffing Coordinator). The employee acknowledged the findings and stated, I hear that '4.1' number a lot and we are working hard on meeting that requirement.Cross Reference 22B DCMR Sec. 3211.5

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by dust buildup in 25 of 25 residents' rooms, soiled window tracks and frames in one (1) of eight (8) dayrooms, dirty floors in 13 of 53 residents' rooms, sticky floors in nine (9) of 53 residents' rooms, a foul smell on one (1) of eight (8) resident care unit, dirty toilets in two (2) of 53 residents' rooms, dirty trash cans in three (3) of 53 residents' rooms, stained privacy curtains in three (3) of 53 residents' rooms, and dusty window blinds in five (5) of 53 residents' rooms.The findings include:During an environmental walkthrough of the facility on September 17, 2025, between10:30 AM, and 2:00 PM, the following issues were identified: 1. Dust buildup was observed under the handwashing sinks, under the beds, in wall corners, around the nightstands and dressers, and chairs in 25 of 25 resident's rooms on the fourth and fifth floor. 2. Window tracks and frames from three (3) of three (3) glass windows in the dayroom on 5 south were soiled with traces of cobweb/spider web. 3. Floors were dirty throughout in residents' rooms 512, 522, 529, 531, 532, 415, 421, 422, 423, 425, 428, 433, and #220, 13 of 53 residents' rooms surveyed. 4. Floors were sticky in the dayroom on unit 5 South, and in residents' rooms #520,401, 402, 407, 211, 215, 219, 225, and #227, nine (9) of 53 residents' rooms surveyed. 5. A strong urine odor was evident in the 3 North resident care units, and in resident room [ROOM NUMBER]. 6. The toilets in resident room [ROOM NUMBER], and resident room [ROOM NUMBER] were soiled with dark stains throughout, two (2) of 53 residents' rooms. 7. Trash cans in residents' room [ROOM NUMBER] and 322, were soiled at the bottom, and the trash can in room [ROOM NUMBER] had a broken step pedal, three (3) of 53 residents' rooms. 8. Privacy curtains in three (3) of 53 residents' rooms were stained (335, 324, and #303). 9. Window blinds in five (5) of 53 residents' rooms #529, 520, 512, 401, and #227, were dusty.These observations were acknowledged by Employee #1 during a face-to-face interview on September 17, 2025, at approximately 4:00 PM.

Based on observations and interview, facility staff failed to maintain an efficient pest control system as evidenced by flies that were seen in three (3) of 13 resident's rooms on the third floor.The findings include:1. Numerous flies were observed in resident room [ROOM NUMBER] on unit 3 North. Further investigation revealed a trash can that was soiled at the bottom with a dark substance that seemed to attract the flies. The trash can was placed in a large trash bag, disposed of, and replaced. 2. Flies were evident in resident room [ROOM NUMBER]. Further investigation revealed a dark, lumpy substance that was on the floor, under a portable toilet that was around the foot of the bed on the B side of the double occupancy room. The substance was eventually identified as human waste by staff and the room was immediately cleaned and the floor disinfected. 3. Two (2) flies were observed on the privacy curtain in room [ROOM NUMBER], side A of the double occupancy room, and two (2) other flies were seen on a pillow, on the bed located on the B side of the room.Facility leadership was immediately made aware of these findings and proceeded to implement measures to address these issues.Employee #1 acknowledged the findings during a face-to-face interview on September 17, 2025, at approximately 1:00 PM.

Based on observation, record review and staff interview, for one (1) of six sampled residents, facility staff inaccurately documented that they administered Trazadone (antidepressant medication) 50 MG (milligrams), one tablet to Resident #1.The findings included: A facility policy titled Administering Medications dated 01/2025 documented:- Medications are administered in accordance with prescriber's orders.- The individual administering the medication checks the label to verify the right medication, right dose, right time and right method (route).Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy.Review of the resident's medical record showed the following: An admission Minimum Date Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 02 indicating severely impaired cognitive function; total mood severity score of 10, indicating moderate depression; and received antidepressant medications.A physician's order dated 08/14/25 directed, Trazodone HCl oral tablet 50 MG, give 1 tablet by mouth at bedtime for Depression.Review of the Resident #1's Medication Administration Record (MAR) for August 2025 showed that facility staff documented a check mark and their initials to indicate that the resident received Trazodone HCl oral tablet 50 MG, 1 tablet by mouth at bedtime for Depression on 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25.During an observation of the 2 south medication cart 2 on 08/19/25 at 10:25 AM, it showed a blister packet with Resident #1's name labeled, Trazadone 50 MG tab[let]. Give 0.5 tablet by mouth at bedtime for Depression. The tablets were noted to be white and were in half tablet form (25 MG). The evidence showed that Resident #1 only had Trazadone 25 MG (50 MG half tablets) available for administration however, facility staff documented that they administered Trazodone 50 MG, 1 tablet by mouth at bedtime on 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25.During a face-to-face interview on 08/19/25 at approximately 3:00 PM Employee #2 (Assistant Director of Nursing/ADON), acknowledged the findings and was asked how they were ensuring that Resident #1 was receiving Trazadone 50 MG, 1 tablet when the resident only had available 25 MG tablets. Employee #2 stated, A prudent nurse would know to give two of the half tablets to equal the 50 MG, but I don't have a way of knowing if that is what was being done.Cross reference 22B DCMR Sec. 3231.10

Based on observation, record review and staff interview, for one (1) of six (6) sampled residents, facility staff failed to ensure that Resident #1 had the correct Trazadone (antidepressant medication) dose available for administration and failed to ensure that the resident received the correct dose of 50 MG (milligrams) for five (5) days.The findings included:A facility policy titled Administering Medications dated 01/2025 documented:- Medications are administered in accordance with prescriber's orders.- The individual administering the medication checks the label to verify the right medication, right dose, right time and right method (route).Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy.Review of the resident's medical record showed the following: A physician's order dated 08/04/25 that directed, Trazodone HCl (Hydrochloride) oral tablet 50 MG (milligrams), give 1 tablet by mouth at bedtime for Depression. It should be noted that this order was discontinued on 08/08/25.A care plan focus area: [Resident #1] uses antidepressant medication, initiated on 08/06/25 had interventions that included: Administer antidepressant medications as ordered by physician. A physician's order dated 08/08/25 directed, Trazodone HCl oral tablet 50 MG, give 0.5 tablet by mouth at bedtime for Depression. An admission Minimum Date Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 02 indicating severely impaired cognitive function; total mood severity score of 10, indicating moderate depression; and received antidepressant medications.08/12/25 at 6:10 PM Nurses Note: - At 5:30 PM, observed 911 on the floor heading towards the resident's room. - Per 911 crew, they were called by family who stated that the resident has been sleeping and will not wake up. - Observed the resident in room sleeping and lethargic but responded when called. - Resident left facility with 911 crew at 6:20 PM, accompanied by family.08/13/25 at 6:50 PM Nurses Note: - Resident returned to the facility from hospital in a stretcher at approximately 6:45 PM.08/14/25 at 7:00 PM Physician's Progress Note: - Patient seen earlier. She had gone to the emergency room (ER) for altered mental status and evaluated with no new findings.A physician's order dated 08/14/25 directed, Trazodone HCl oral tablet 50 MG, give 1 tablet by mouth at bedtime for Depression.During an initial observation of the 2 south medication cart 2 on 08/19/25 at 10:25 AM, it showed a blister packet with Resident #1's name labeled, Trazadone 50 MG tab[let]. Give 0.5 tablet by mouth at bedtime for Depression. The tablets were noted to be white and were in half tablet form (25 MG). Review of the Resident #1's Medication Administration Record (MAR) for August 2025 showed that facility staff documented a check mark and their initials to indicate that the resident received Trazodone HCl oral tablet 50 MG, 1 tablet by mouth at bedtime for Depression on 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25.During a face-to-face interview on 08/19/25 at approximately 3:00 PM Employee #2 (Assistant Director of Nursing/ADON), was asked how they were ensuring that Resident #1 was receiving Trazadone 50 MG, 1 tablet when the resident only had available 25 MG tablets. Employee #2 stated, A prudent nurse would know to give two of the half tablets to equal the 50 MG, but I don't have a way of knowing if that is what was being done.The evidence showed that facility staff failed to ensure that Resident #1 had the correct dose of Trazadone 50 MG available for administration and failed to ensure that the resident had received the correct dose 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25 (five days).It should be noted that Resident #1 did not suffer any negative outcomes from this deficient practice.Cross reference 22B DCMR Sec. 3211.1(a)

Based on observations, record reviews and staff interviews, for one (1) of six (6) sampled residents, facility nursing staff failed to ensure that one resident received care and services according to accepted standards of clinical nursing practice as evidenced by no documented evidence that the physician was notified prior to a licensed registered nurse altering a resident's medication order label. Resident #1.The findings included:According to the National Institute of Health (NIH)- The standard of practice for registered nurses (RNs) is that they do not have the authority to prescribe medication independently.- Advanced Practice Registered Nurses (APRNs), specifically nurse practitioners (NPs), do, with their authority determined by state Nurse Practice Acts. https://www.ncbi.nlm.nih.gov/books/NBK574557/A facility policy titled Administering Medications dated 01/2025 documented:- Medications are administered in accordance with prescriber's orders.- If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the resident's attending physician to discuss the concerns.A facility policy titled Physician Medication Orders dated 01/2025 documented:- Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.- All drug orders shall be entered into the electronic medical record, dated and signed by the person lawfully authorized to give such an order. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy.Review of the resident's medical record showed the following: A physician's order dated 08/08/25 directed, Trazodone HCl (Hydrochloride) oral tablet 50 MG (milligrams), give 0.5 tablet by mouth at bedtime for Depression. This order was discontinued on 08/14/25.An admission Minimum Date Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 02 indicating severely impaired cognitive function; total mood severity score of 10, indicating moderate depression; and received antidepressant medications.A physician's order dated 08/14/25 directed, Trazodone HCl oral tablet 50 MG, give 1 tablet by mouth at bedtime for Depression.During an initial observation of the 2 south medication cart 2 on 08/19/25 at 10:25 AM, it showed a blister packet with Resident #1's name labeled, Trazadone 50 MG tab[let]. Give 0.5 tablet by mouth at bedtime for Depression. The tablets were noted to be white and were in half tablet form (25 MG). It should be noted that the surveyor took a photo of the blister packet at the time of the observation. During a second observation of the 2 south medication cart 2 on 08/19/25 at 2:42 PM it showed that the same blister packet with Resident #1's name labeled, Trazadone 50 mg tab[let] had been altered by a facility staff. Facility staff crossed out 0.5 and wrote in 2 so that the label now documented, Give 2 tablet by mouth at bedtime for Depression 8/14/25. During a face-to-face interview at the time of the observation, Employee #4 (2 south Unit Manager) was asked who was responsible for altering the label and physician's order on the blister packet, the employee stated, I don't know.Review of Resident #1's progress notes from 08/14/25 to the time of the second observation on 08/19/25 at 2:42 PM showed no documented evidence that any facility staff had made the physician aware that Resident #1 had only Trazadone 25 MG tablets available for administration. During a face-to-face interview on 08/19/25 at approximately 3:00 PM, the findings were brought to the attention of Employee #2 (Assistant Director of Nursing/ADON). The employee acknowledged that the pharmacy label for Resident #1's Trazadone blister packet had been altered and stated, An audit was done by the PRN (as needed) nurse after you looked at the medication cart and he found that the order did not match what was in the cart. When asked who gave the PRN nurse the order medication order on the blister packet label, Employee #2 stated, Trazadone is not a narcotic, so the nurses are allowed to use their own judgement and make adjustments in order for the resident to receive the correct dose. When asked if that is within the scope and practice of a licensed registered nurse to make medication prescription order adjustments, Employee #2 stated, That's what a prudent nurse would do.The evidence showed that a licensed nurse, who did not have prescribing authority, made medication prescription order changes to Resident #1's Trazadone medication order label with no evidence that the resident's physician was made aware. Cross reference 22B DCMR Sec. 3227.11

Based on observations, and resident and staff interview, the facility failed to maintain the required comfortable air temperature range of 71°F to 81°F for one for one (1) of 10 sampled residents. (Resident #2) The findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Hemiplegia, Cervical Disk Disorder and Morbid Obesity. A quarterly Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 10 indicating that the resident's cognitive status was moderately impaired. During an observation on 1/23/2025 at 10:45am, the resident was observed lying in bed alert, oriented to name, place and time. At the time of observation, the resident was lying in bed with a heavy blanket covering her, stating that her room has been cold for the past week. The resident further stated that her room gets colder at night. The resident added that she informed the nursing staff her room was cold, but she couldn't recall the nurse's name. At the time of observation, the resident's room air temperature was measured to be at 66 °F. During a second observation on 1/23/2025 at 2:45pm, the resident room air temperature was measured to be at 68 °F at the time of observation. The resident was observed still lying in bed in her room with a heavy blanket covering her, saying that that her room was still cold. During a face-to-face interview on 1/23/2025 at 2:45pm, Employee #3 (Maintenance Director) and Employee #1 (Adminstrator) stated that they were unaware of Resident #2's room temperature not meeting the required temperature range of 71 to 81°F. Additionally, they stated that residents' room temperatures are monitored daily, but they do not keep a record of it. They further stated that there is an electronic system called Reqqer to log maintenance job requests and record tasks that are completed, but the system is hardly used. Employee #3 added that most of the maintenance jobs are completed as they are reported in person to the maintenance team. During an observation on 1/24/2025 at approximately 9:50am, room air temperatures were measured in 24 rooms located in different spaces across the 2nd, 3rd, 4th and 5th floors. Resident #2's room temperature was also measured at this time and was 73 °F. At the time of the observation, Resident #2 was observed in her room lying in bed with a heavy blanket covering her, again stating that her room was cold, and colder at night.

Based on observation and staff and resident interviews, the facility staff failed to provide respect to a resident when the resident spoke about a concern with her television for one (1) of 10 sampled residents (Resident # 2). The findings included: Resident #2 was admitted on [DATE] with multiple diagnoses including Hemiplegia, Cervical Disk Disorder and Morbid Obesity. A quarterly Minimum Date Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 10 indicating that the resident's cognitive status was moderately impaired. During an observation with Employee #2 (DON) and Employee #4 (Assigned RN) on 01/24/25 at approximately 10 AM, Resident #2 was noted in her room lying in bed, well groomed, alert, oriented to person, place, time, and situation. At the time of the observation, the resident stated that she prefers to stay in bed and watch tv, but her tv had not worked for approximately a week. As the resident was speaking, Employee #4 interrupted and stated, That's not true. Her tv was working the other day. During a face-to-face interview on 01/24/25 at approximately 12 PM, Resident #2 stated that she felt disrespected when Employee #4 interrupted her during our earlier conversation. The resident said that the employee tried to make it seem that she didn't know what was going on with her tv. During a face-to-face interview on 01/24/25 at approximately 1PM, Employee #4 stated that she was not trying to be disrespectful with the resident. She interrupted because the resident has periods of confusion, and she wanted to inform the resident that she observed her tv working earlier in the week. During a face-to-face interview on 01/24/25 at approximately 2 PM, Employee #1 (Administrator) stated that the facility was in the process of changing to a new cable provider, and there may have been some interruptions with service. The Administrator also said that residents and families were informed about the possible disruption in cable service prior to the change. Additionally, the Administrator stated that she would have maintenance to check Resident #2's tv.

Based on record review and interview, the facility failed to implement their Advanced Directive (5 Wishes) policy for one (1) of three (3) sample residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia and acute respiratory failure. A physician order dated [DATE] instructed, No, CPR (Cardiopulmonary Resuscitation) palliative and supportive care. A review a policy tilted, End of Life Planning Policy-Five Wishes dated 01/2023 documented in part, The policy applies to all residents upon admission and throughout their stay, with assessments and updates conducted by the social worker and the Interdisciplinary Team The social worker will complete the Advanced Life Care Planning Assessment with 48 to 72 hours of admission .The Interdisciplinary Care Planning Team will review M.O.S.T [and] Advanced Directives [5 wishes] with the resident during quarterly care planning session to determine if the resident wishes to make changes in such directives . A review of a document titled, Advanced Life Care Planning Five Elements/Wishes form documented in part, Form completed by: Employee # 4 [Social Service Assistant] .The kind of treatment I want .DNR (Do Not Resuscitate). Additionally, the form lacked documented evidence that it was completed by a social worker. A care plan dated [DATE] documented in part, Problem- Advanced Life Care Planning: I have made the following decisions regarding end-of-life care: Do Not Resuscitate. Interventions .DNR (Do Not Resuscitate) . During a face-to-face interview on [DATE] at 11:41 AM, Employee #3 (Lead Social Worker) stated that the social service assistant will complete the 5-wishes form, and the social worker will review and sign it. He could not explain why the social worker did not sign the form.

Based on record review and interview, the facility failed to have documented evidence that the resident or the resident representative was provided with a written copy of the base line care plan. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including pneumonia and acute respiratory failure. A review of the resident's Base Line Care Plan dated 10/14/23 documented in part, Initial Baseline Care Plan meeting held today for [Resident #1] 10/14/2023 in the resident's room with all the team members present. Resident responsible party] joined via telephone conference. The care plan lacked documented evidence, a written copy was provided to the resident or resident's party responsible. A review of the progress notes dated from 10/14/23 to 10/31/23 lacked documented evidence that a written copy of the Base Line Care Plan was provided to the resident or the resident's representative. An admission Minimum Date Set assessment dated [DATE] revealed resident had a brief Interview for Mental Status summary score of 7 indicating the resident cognitive status was severely impaired. Past Non-compliance Information: During a face-to-face interview on 11/12/24 at approximately 1 PM, Employee #2 (DON) the DON stated that the facility identified early last year that the Base Line Care Plan process needed to be update to ensure that the residents and residents' representatives were provided a copy. As a result, the Base Line Care Plan was modified to include a section for staff to document the date and who was provided with a copy. - On January 7, 2024, the facility identified a gap in verifying that residents or their representatives had received the Baseline Care Plan. The following corrective actions were taken: - On January 10, 2024, the QA Regional Consultant provided education to the social workers, unit managers, DON, ADON, and Administrator. This training aimed to ensure accurate completion of the Baseline Care Plan assessment and confirm that the document is sent to the resident and/or their representative. - The QAPI team was informed by the Regional QA Consultant on January 25, 2024, about upcoming updates to the Baseline Care Plan assessment to ensure that the document is provided to residents and/or their representatives as per policy. - Based on the recommendation of the QAPI team the existing Baseline Care Plan was retired and the new template for the Baseline Care Plan was created on February 13, 2024 to ensure compliance per policy. - On February 13, 2024, the Baseline Care Plan was implemented to specify the format in which the Baseline Care Plan was prepare. The previously mentioned interventions were implemented before the State Agency's on-site visit of 11/08/24.

Based on observations, record reviews, resident and staff interviews, for three (3) of 94 sampled residents, facility staff failed to provide adequate supervision for residents as evidenced by: 1. Resident #120, who uses a wheelchair for locomotion and requires medications to treat multiple diagnoses, eloped from the facility on 04/29/24; 2. Resident #64 having an unwitnessed fall from her wheelchair; and 3. Resident #79 having multiple falls with injury. The facility's census on 04/29/24 was 265. Due to this failure, an Immediate Jeopardy was identified on May 2, 2024, at 11:30 AM related to the elopement of Resident #120. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on May 3, 2024, at 12:18 AM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on May 8, 2024, at 4:36 PM. After removal of the immediacy, the deficient practice remained at actual harm and the scope and severity of a G. The findings included: 1. Facility staff failed to provide adequate supervision of the main entrance lobby and parking lot areas as evidenced by Resident #120, who uses a wheelchair for locomotion and requires medications to treat multiple diagnoses, eloped from the facility on 04/29/24. Per the facility's plan of correction from their last Recertification Survey, with a compliance date of 08/24/22, the facility stipulated that: Supervisory lobby employee will ensure that residents sitting outside are supervised. Findings will be reported to the front desk who will call the unit for the nurse to come and address the issue immediately. Review of the facility's policy titled Routine Resident Checks/Supervision/Rounding with a revision date of 01/2024 documented the following: For alert, oriented residents that do not have any recent change in condition and prefer to leave the unit for fresh air or to move around the facility or to smoke (but are not at risk for elopement) may be rounded on once every 4 hours. Documentation for this rounding is not required unless an abnormality is found, or the resident cannot be located. Review of the facility's policy titled Elopement/Missing Resident Policy with a revision date of 01/2024 documented the following: If a resident is missing. Initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an unauthorized leave or pass or discharged against medical advice. b. If the resident was not authorized, call a code for the missing resident. [CODE PINK] Resident #120 was admitted to the facility on [DATE] with diagnoses that included, Type 2 Diabetes Mellitus, Hypertension, Atrial Fibrillation, Seizure Disorder, Schizoaffective Disorder, and Gait Abnormality. Review of the resident's medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded the resident as having a BIMS (Brief Interview for Mental Status) summary score of, 09, indicating the resident had moderately impaired cognition and used a wheelchair for locomotion. The MDS assessment showed no documented behaviors for elopement or wandering. Per the care plan for Resident #120, initiated on 07/26/23 and last updated on 03/05/24 showed focus statement [resident name] has Seizure Disorder. 9/11/23 resident found on the floor unresponsive. 3/4/24 Resident had a seizure activity that lasted for 3 minutes. Review of Resident #120's Wandering/Elopement Assessment prior to the resident's elopement showed he was not an elopement risk on the following dates: 07/24/23, 09/18/23, 10/25/23, 12/12/23 and 03/11/24. Observation of the facility at the start of the survey on April 18, 2024, revealed pedestrian and car gates located at the main entrance to the facility that were always safeguarded by a security guard. Per World Weather, the weather forecast listed the following for [NAME], DC: on 04/29/24: Day- 86 degrees Night - 68 degrees on 04/30/24: Day- 84 degrees Night - 70 degrees https://worldweather. info/forecast/usa/washington_4/29-april/ and; Review of Resident #120's April 2024 Medication Administration Record documented that the resident was to receive the following medications on 04/29/24 at 9:00 PM: Melatonin 3 mg (milligrams) tablet by mouth (for sleep), Atorvastatin 20 mg tablet by mouth (for cholesterol), Trazadone HCL 50 mg tablet by mouth (Schizoaffective Disorder), Propranolol HCL 40 mg tablet by mouth (for tremors), and Depakote 500 mg delayed release tablet by mouth (for mood stabilization). During a face-to-face interview on 04/30/2024 at 5:30 PM with Employee #4, the assigned Certified Nurse Assistant (CNA) stated that when he came to work at 3:00 PM (on 04/29/24) he saw Resident #120 at 3:30 PM. The next time I saw the resident was after 4:00 PM, talking with the charge nurse, asking to go out for a fresh air break. He went downstairs. The CNA stated that he went to Resident #120's room at 9:00 PM to check if he needed any help. He was not back, and his dinner was not eaten. I was worried that he did not eat his food. This was after 9:00 PM. I went downstairs to the front of the building and could not find the resident. I talked with security (evening shift front desk security guard) about the resident, and they said they did not see him. The resident usually goes out and comes back with no issues. I then reached out to the charge nurse and let him know that I could not find the resident. During a face-to-face interview on 04/30/24, at 5:59 PM with Employee #5, Licensed Nurse who was assigned to care for Resident #120 on 04/29/2024 the evening shift (3PM -11 PM), stated that he saw the resident at the start of his shift around 3:15 PM and then again at 4:55 PM to administer the resident's 5:00 PM medications. At that time, Resident #120 stated to the nurse that he was going to go outside to get some fresh air. The assigned nurse further stated that he did not look for the resident until approximately 9:00 PM in preparation to administer his 9:00 PM medications. It was at this time that the assigned nurse realized that the resident's whereabouts were not known. During a telephone interview conducted on 05/01/24 at approximately 10:00 AM, Employee #6, the Night Shift (10:00 PM-6:00 AM) Gate Security Officer, stated that he leaves the car, and the pedestrian gates open from 11:00 PM to about 11:30 PM for the change of shift, but he did not see any resident leave through either of the gates on 04/29/24. During a telephone interview conducted on 05/01/24 at approximately 10:15 AM, with Employee #7, the Security Supervisor, stated that, The front gate was 'acting up,' [malfunctioning] on 04/29/24. He further stated that he believes the resident left the facility after 10:00 PM. During a telephone interview conducted on 05/01/24 at 10:40 AM with Employee #8, the Night Shift Desk Security Officer (located inside the building) stated that she worked on 04/29/24 on the shift that starts at 10:00 PM and ends at 6:00 AM, and she did not see (Resident #120) during her shift. She further stated that a CNA called and stated that the resident was missing. At 12:22 AM [on 04/30/2024] the Security Officer called a Code Pink/ (Missing Resident). During a telephone interview conducted on 05/01/24 at 11:00 AM, Employee #9, the Evening Shift Security Guard, stated he worked from 2:00 PM to 10:00 PM on 04/29/24, and he saw Resident #120 sitting in front of the building at the end of his shift at approximately 10:00 PM and he greeted the resident as he left the facility. It should be noted that Resident #120's assigned nurse and CNA both stated that it was at approximately 9:00 PM when they both noted that the resident was not on the unit or in the front of the building. A review of the facility's investigation documents showed the following on 04/30/24: 12:15 AM- Administrator and the Director of Nursing were alerted. 12:17 AM - A Code Pink (Missing Resident) was called. It should be noted that this Code Pink was called 3 hours after nursing staff first realized that the resident was missing at approximately 9:00 PM on 04/29/24. 12:25 AM - Metropolitan Police Department was called. The facility submitted an incident report to the State Agency on 04/30/24 at 3:21 AM which documented, [Resident #120] BIMS 09 was admitted to [Facility name] since 7/24/2023. Resident was last seen talking to other residents in the courtyard around approximately 8pm. During routine checks, the resident was not in his room, search was expanded to other areas of the facility, as resident is often socializing with multiple residents. Code Pink initiated. Resident not found in the facility; police called, search and investigation is ongoing. Guardian notified. During a face-to-face interview conducted on 04/30/24 at 1:21 PM Employee #1, (Administrator) stated that the facility's staff drove to 14th and U Street, NW and they were able to locate the resident sitting in his wheelchair on the sidewalk. The resident initially refused to get in the car with staff, the police were called and helped to put the resident in the staff member's car. The resident and staff returned to the facility. The resident was then assessed by the nurse and the physician and guardian were notified at 1:15 PM on 04/30/24. During a face-to-face interview with Employee #2, the Director of Nursing on 05/01/24 at 11:20 AM, she stated that the expectation is for licensed staff to physically see their assigned patients every 2-4 hours. It should be noted that approximately 14 hours, after Resident #120 was missing from the facility he was found on 04/30/24 at 11:00 AM in the community at 14th and U Streets, NW which is approximately a 20-30-minute drive from the facility. A review of a Physician's Progress Note dated 04/30/24 at 4:04 PM documented: The patient seen awake in bed with smell of alcohol in room, he reports feeling well and have (had) been drinking. No visit injury. Vital signs obtained by nursing. An Immediate Jeopardy was identified on May 2, 2024, at 11:30 AM, related to the elopement of Resident #120. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on May 3, 2024, at 12:18 AM and included the following: -Regarding the concern, resident #120 was found by facility staff at 14th and U street NW at 11:11am on 4/30/24 and returned to the facility on 4/30/24 at around 1pm EST. A head-to-toe assessment was done for the resident by the licensed nurse on 4/30/24 with no new issues noted. -Resident #120's elopement risk assessment was updated by the licensed nurse on 4/30/24 to ensure the resident received proper interventions and prevent future incidences. Resident #120's picture was added in the elopement binder in all locations (front desk, all nursing units and security booth) to ensure that staff are aware of his elopement risk and ensure its safety. The resident was given a Wanderguard and placed on 1:1 for the period of 72 hours to identify any new exit seeking behaviors. -Resident #'s care plan was modified for elopement on 4/30/24 to ensure there are interventions for elopement in place and ensure resident's safety to prevent further elopement incidences. The two Security guards that worked on 4/29/24 for the shift of 2pm to 10pm and the shift of 10pm to 6am at the gate were suspended pending investigation, effective 4/30/24. The identified security guard that left the gate open was terminated effective 5/2/24. The gates inspection and maintenance were completed on 4/30/24 by [Name of Company]. The maintenance Department will complete weekly gates inspection. Any negative findings will be immediately corrected. If unable to correct immediately, security will be enhanced in the interim. -The CNA and Nurse assigned to the resident received 1:1 in-service by the Staff Educator/Development on 5/1/24 for elopement, supervising residents, documentation, and notification to the supervisor when a resident is identified as missing. The assigned CNA was suspended on 5/2/24. The CNA resumed duty after 3 days of suspension without pay. The assigned Nurse was terminated on 5/2/24. -All residents can be affected by the alleged deficiency. A head count was done for all residents on 4/30/24 and all residents were accounted for within the facility. All residents were assessed for risk of elopement. This assessment was completed between 4/30/24 and 5/2/24 by licensed nursing personnel. The Unit Managers have verified the EMR [electronic medical record] that residents that triggered for Elopement risk had effective interventions in place. This was completed on 5/2/24. -Education was provided by the Staff Educator/Development on 5/1/24 with the security staff on security protocols to prevent resident elopement. Security protocol includes documenting when residents' leave the facility, rounding all exits at least every 4 hours, and gates are closed at all times. -All staff will be educated on Elopement Prevention, Elopement Protocols and the facility's Policy and Procedures on Elopement Prevention by the Staff Educator/Development. This education was implemented on 5/1/24 and will be completed by 5/4/24. The Staff Educator/Development will ensure that any staff that has not received their education by 5/4/24 will receive it before resuming work. -Deanwood's staff shall make a routine resident check at least every 2 hours. The licensed nurse makes the determination if the resident needs more frequent monitoring and will communicate any new change with the care team. Documentation of this will be maintained every shift in the Electronic Medical Record. Related policies will be revised to reflect the plan of action and updated periodically. Current staff will be trained each shift as they come in. -Licensed nurses will be educated by the Staff Educator/Development on ensuring all residents with interventions for monitoring are implemented as outlined in the Routine Resident Check/Supervision/Rounding Policy. This education was implemented on 5/2/24 and will be completed by 5/4/24. The Staff Educator/Development will ensure that any staff that has not received their education by 5/4/24 will receive it before resuming work. -The security staff will supervise residents in the parking lot area at least every 4 hours to ensure residents' safety. A log is maintained by the security staff for this supervision. Any issues found will be reported to the Nursing Supervisor immediately. Audit of this log on a weekly basis will be done by the QA [Quality Assurance] Nurse for the period of one month. -A new audit was implemented on 5/2/24 to ensure that security guards are monitoring the gates, and the gates are not left unattended. This audit will be completed by the front desk staff/night supervisor. This audit will be done at least every shift for one week. Any new issues will be addressed immediately. -An ongoing audit of the Security Gate Protocol will be done by the Administration to ensure that the Security Gate Protocol is followed by security staff. This audit will be conducted daily x 1 week, weekly x4, monthly x3. Any issues found will be addressed immediately upon discovery and will be reported to the QAPI [Quality Assurance Performance Improvement] committee. If negative patterns are found, the length of audit will be extended. -The results of the monitoring and care plan review completed under this action plan are submitted to the QA/QI [Quality Assurance Quality Improvement] Committee for review and follow-up monthly. -Date of compliance will be 5/6/24. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on May 8, 2024, at 4:36 PM 2. Facility staff failed to provide adequate supervision to prevent accidents, as a result, Residents' #64 and #79 had unwitnessed falls. A review of the facility's policy titled Fall and Fall Management with a revision date of 01/2024, revealed the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident -Centered Approaches to Managing Falls and Fall Risk -The staff with the input of the interdisciplinary team will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician and interdisciplinary team, the staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 2A. Resident #64 was admitted to the facility on [DATE] with multiple diagnoses that included: Monoplegia of Left Upper Limb following Cerebrovascular Accident (CVA) and Muscle Weakness. A facility policy Use of Assistive Devices and Equipment with a review date of 01/2024 documented: 4. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition - the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. A care plan dated 9/20/23 documented, Focus [Resident #64] had an actual fall with no injury r/t (related to) sliding off the wheelchair. Interventions: Continue interventions on the at-risk plan; For no apparent acute injury, determine and address causative factors of the fall, Therapy referral for wheelchair positioning and management 9/21/23. A Falls Risk assessment dated [DATE] documented, Quarterly - Falls risk score 11.0 Moderate Risk; Exhibits loss of balance while standing. Uses an assistive device, e.g. (such as) cane, walker, etc. (etcetera). A physical therapy Discharge summary dated [DATE] documented, Discharge Recommendations: Pt continues to require supervision for safe use of power W/C due to limitations in problem solving, visual field deficits, and memory/attention. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 15 indicating the resident was cognitively intact. The resident was also coded for being dependent on staff assistance for activities of daily living, chair/bed-to-chair transfers, and sitting to lying/lying to sitting on side of bed transfers. A nursing progress note dated 02/21/24, 10:10 PM documented, At 2200 (10:00pm), resident requested to go to bed. Resident went to room and a CNA (Certified Nursing Assistant) went to retrieve Hoyer lift to transfer resident. Upon CNA return resident was observed on the floor. Resident replied, I was trying to put my arm on the arm rest and fell out of the wheelchair. Head to toe assessment performed: Resident is alert and verbally responsive. Resident oriented to person, place, time, and situation. A SBAR (Situation, Background, Assessment, Response) note dated 02/21/24, 10:10 PM documented, Resident was observed on the floor; right shin and right knee abrasions; alert, and oriented to person, place, and time. A Facility Reported Incident (FRI), DC~12617, received by the State Agency on 02/23/24 documented, Resident had a fall on 2/21/24 without visible injury on assessment. The resident was observed on the floor in her room. The resident's wheelchair was evaluated by the maintenance team and found to be fully functional. During a face-to-face interview on 04/29/24 at 1:27 PM, Resident #64 stated, I was in my wheelchair and the CNA [Employee #31] was putting me in the bed and in the midst of putting me in the bed he took my seatbelt off. Then, he left the room to get the Lift. I tried to put my right arm on the arm rest, but it was not there. He had raised it up on that side, so I fell out of the chair and onto the floor on my right side. He came back about 5 to10 minutes later. He's not a regular on this floor, he floats here. The CNA's and Nurses, all got me up off the floor and back in bed. When they asked me what happened I told them, and they said I did it on purpose. During a face-to-face interview on 05/03/24 at 2:26pm, Employee #16 (Director of Rehab) stated, She has a power chair with a seat belt, and she has a hard time with the seat belt. If we put it on her she is not able to take it off, so someone has to be with her to take it off for her. She has a tilt where she leans to one side, and the seat belt is there for safety. During a face-to-face interview conducted on 05/03/24 at 4:00pm, Employee #31 (Certified Nursing Assistant, CNA) stated, I work another floor, but I float sometimes. I remember the incident when she fell, she rolled herself in her wheelchair to her room and I went with her then she backed herself up to the side of the bed, then I told her to wait here so I could get help because I can't transfer her by myself. I brought the Lift to the room and found her on the floor about 5 minutes later. During a face-to-face interview on 05/03/24 at 4:30pm, Employee #32 (Licensed Practical Nurse, LPN) stated, The CNA called me because [resident's name] wanted to go to bed. She was sitting in her wheelchair, and he (Employee #31) went to get help and when he went back, she was on the floor. She has a motorized wheelchair, and she goes around [the facility] by herself and she can go downstairs by herself, she goes and smoke. She only needs help to get in the wheelchair and out of the wheelchair. During a face-to-face interview on 05/07/24 at 3:38pm, Employee #2 (Director of Nursing) acknowledged the findings and stated, [Resident's name] know what she's doing, she will sometimes make herself fall out the wheelchair for attention, she's very manipulative. It should be noted that review of the resident's care plans lacked documented evidence of a care plan with goals and interventions to address the resident's behavior of falling out the wheelchair for attention. 2B. Resident #79 was admitted to the facility on [DATE] with multiple diagnoses that included: History of Falling, Personal History of Transient Ischemic Attack, and Dementia. Review of the resident's medical record revealed the following: A SBAR Note dated 03/31/24, documented the following, Describe the problem/symptom: Resident observed sitting on the floor at bedside . A care plan with a focus area of Fall with injury transfer to (Hospital name) ER with a date of revision of 03/31/24 documented the following interventions: Frequent monitoring of resident while in bed for fall prevention, keep routinely used items with reach for the resident. A Facility Reported Incident (FRI), DC~12611, submitted to the State Agency on 03/31/24 documented, Resident was observed by staff sitting on the floor at bedside with laceration on left side of head, slight bleeding, no hematoma .order given to transfer to nearest hospital ER for evaluation. A physician's order dated 04/09/24 directed, Send resident to the nearest ER (emergency room) due to fall and for CT (computed tomography) scan of the skull with head trauma. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the facility staff coded Resident #79 as having severely impaired cognition; no impairment of the upper or lower extremities; used a wheelchair for mobility; and had two or more falls with injury since the last admission or prior MDS assessment. A SBAR Note dated 04/13/24 documented, Fall . 04/09/24. Resident was noted sitting on floor, he was seen lying comfortably in bed during routine rounds at approximately 7:30 am. Upon assessment, moderate amount of blood with laceration to left scalp of head observed. Pressure applied and wound team alert. Order given to send Resident to the ER for head scan to evaluate for internal bleeding A SBAR Note dated 05/06/24 documented, Resident observed by staff sitting on the floor beside his bed. Head to toe assessment done and observed with skin tear to left leg of the shin. During a face-to-face interview conducted on 05/14/24 at 1:09 PM, Employee #26 (5 South Unit Manager) was asked to provide documented evidence of the frequent monitoring that was being conducted of Resident #79 while in bed, for fall prevention. The employee was unable to provide this surveyor with that information. Employee #26 stated that Certified Nurse Aide (CNA) do thirty-minute watch. When asked to provide documented evidence of the thirty-minute watch, employee #26 stated that there was no documentation. Employee #26 was further asked how they are ensuring that adequate supervision (frequent monitoring) of Resident #79 is being provided if there is no documentation, the employee did not answer. The evidence showed that facility staff failed to have documented evidence that they conducted frequent monitoring of Resident #79 after a fall with injury (laceration on left side of head) on 03/31/24. Subsequently, Resident #79 sustained two more falls with injury on 04/09/24 (laceration to left scalp) and on 05/06/24 (skin tear to shin of left leg).

Based on record review and staff interviews, for one (1) of 94 sampled residents, facility staff failed to ensure that Resident #463 received timely treatment and care after an unwitnessed fall with documented pain and swelling in her left arm. Subsequently, 23 hours lapsed before an order for x-ray was obtained that determined that the resident sustained a fracture to her left arm; and she was sent to the hospital 2 days later. These failures resulted in actual harm to Resident #463 who had unresolved pain for a minimum of 23 hours post fall. The findings included: Resident #463 was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease, Anemia and Hyperlipidemia. Review of the resident's medical record a physician's order dated 10/30/23 that directed, Assess resident for pain every shift on a scale from 0 to 10; Dialysis Tuesday, Thursday and Saturday; bed to the lowest position when resident is in bed every shift; call light and all commonly use articles within resident reach at all times, every shift. A physician's orders dated 10/31/23 directed, Evaluate for new onset or increase in edema every day, every shift for Congestive Heart Failure (CHF); Assess dialysis AV (arteriovenous) graft site on left upper arm for bleeding, redness, tenderness, and swelling every shift. A Quarterly Fall Risk Assessment/Evaluation dated 02/28/24 documented Moderate fall risk, score: 11.0. A care plan focus area: [Resident #463] is at risk for falls characterized by multiple risk factors related to unstable health condition reviewed 03/15/24 had interventions that included: Call bell pinned to gown when in bed; encourage resident to use handrails or assistive devices properly; ensure environment is free of clutter; have commonly used articles within easy reach; transfer and change positions slowly. A care plan focus area: [Resident #463] has a history of CVA (Cerebral Vascular Accident) with residual right-sided weakness reviewed on 03/15/24 had interventions that included: Assess fingers and toes for warmth and color. A care plan focus area: [Resident #463] has alteration in musculoskeletal status r/t (related to) history of Hand Steal Syndrome, Contracture (Left Hand) reviewed on 03/15/24 had interventions that included: Anticipate and meet needs; be sure call light is within reach and respond promptly to all requests for assistance; give analgesics as ordered by the physician; monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) or complications related to arthritis such as joint pain, joint stiffness, swelling, decline in mobility, and pain after exercise or weight bearing. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the resident as makes self-understood; able to understand verbal content; a Brief Interview for Mental Status (BIMS) summary score of 11, indicating moderately impaired cognition; no rejection of care; required extensive assistant of one person for bed mobility and toilet use; required total dependence of two persons for transfer; limitation in range of motion on one side for upper and lower extremity; no falls since admission/entry or reentry or the prior assessment. A physician's order dated 03/25/24 documented, Tylenol (pain medication) Oral Tablet 325 MG (milligrams), give 2 tablets by mouth every 6 hours as needed for pain. A Situation Background Assessment Request (SBAR) Communication Form created on 04/01/24 at 8:00 AM by Employee #20 (assigned Licensed Practical Nurse/LPN) documented: - Situation: Resident fell. - No reports or non-verbal indicators of pain. - During rounds, the resident was observed sitting on the floor by her bed in her room. Resident stated that she fell from the bed while trying to get out of the bed. - Head to toe assessment done no redness, bruises or open area noted. - MD notified; no new orders given at this time. A Fall Risk Assessment/Evaluation dated 04/01/24 at 8:24 AM documented: - Moderate fall risk, score: 11.0. A Post-Fall Huddle Form dated 04/01/24 at 8:27 AM documented: - Description of fall: Resident observed sitting by the side of her bed. - All fall precautions were in place at the time of the fall. - Recommendations/new interventions: will continue to remind the resident to use call light for assistance. A Nursing Progress Note dated 04/01/24 at 12:05 PM, created by Employee #21 (4 North Unit Manager) documented: - During rounds, the resident was observed sitting on the floor by her bed in her room. Resident stated that she fell from the bed, while trying to get out of the bed. Head to toe assessment done no redness, bruises or open area noted, neuro checks WNL (within normal limits). - Left AV graft site clean and dry intact no bleeding noted. - Resident denies pain, was assisted back to bed. Resident is non-ambulatory, observed bed in low position, call bell within reach. - Resident is non-compliant with the use of call light. Education provided for resident to call for assistance at all times, resident verbalized understanding. A SBAR Communication Form created on 04/01/24 at 12:37 PM by Employee #21 documented: - Situation: Slightly swollen left arm. - Pertinent medical history: recent fall. - Resident reports pain: yes. Location: left arm pain 3/10. - [Employee #22 (Resident #463's MD)] contacted on 04/01/24 at 12:38 PM; new orders to elevated left arm on pillow and to monitor and report any changes. - Resident has edema/slightly swollen of left arm [dialysis arm] with a pain score of 3/10 upon assessment, Tylenol given, and reassessment done within one-hour, resident verbalized effectiveness 0/10. - Assessment of left arm: no bruises, discoloration, or redness noted. - Per MD, continue to monitor or notify if there is any worsening of the condition. - Left arm immobilized and elevated on pillow. Review of the April 2024 Medication Administration Record (MAR) showed no documented evidence that Resident #463 was medicated for pain at the time the SBAR indicated. A care plan focus area: [Resident #463] has Alteration in musculoskeletal status r/t history of Hand Steal Syndrome, Contracture (Left Hand), swollen left arm on 04/01/24 revised on 04/01/24 had interventions that included: Elevate left [arm] as ordered. A Nursing Progress Note dated 04/01/24 at 11:17 PM documented, Resident has swollen left upper arm, and it is elevated on a pillow. [Medical Doctor's name] was notified and is due to visit to assess resident. Resident denies pain. A physician's orders dated 04/02/24 at 11:30 AM directed, X-Ray of the left upper [arm]; Immobilize left arm/shoulder every shift; Assess resident for pain every shift; Tylenol 325 MG, give 2 tablets by mouth every 8 hours for pain for 7 days. Please note that Resident #463 was documented as having pain and swelling in her left arm area four hours after an unwitnessed fall, however, an x-ray was not ordered until 04/02/24 at 11:30 AM, 23 and a half hours later, when facility staff documented that the resident was now unable to move her left arm. A SBAR Communication Form dated 04/02/24 at 2:26 PM documented: - Situation: Resident complain of left upper arm pain, unable to move arm, arm swollen. - Resident reports and has non-verbal indicators of pain in the left upper arm, 3/10. - Physician contacted on 04/02/24 at 11:00 AM; order given for X-Ray. X-Ray has been done, results pending. Tylenol 325mg PO (by mouth) given as per PRN order with relief. Radiology Results Report dated 04/02/24 at 4:23 AM documented: - Procedure: X-ray, humerus, minimum of 2 views. - Findings: There is a complete fracture of the humerus surgical neck with mild displacement of the shift with extension of the fracture into the greater tuberosity. A SBAR Communication Form dated 04/03/24 at 8:55 AM documented: - Situation: X-ray result received Acute humeral neck and greater tuberosity fractures, with mild displacement, Mild degree of Osteopenia. Moderate osteoarthritis. - Resident reports pain in left arm. - Physician notified on 04/03/24 at 8:00 AM; new orders to immobilize the left hand. Review of the April 2024 MAR showed no documented evidence that Resident #463 was medicated for pain on 04/03/24 when facility staff documented that the resident reported pain on the SBAR, even though staff had knowledge that the resident had multiple fractures in her left arm. A Nursing Progress Note dated 04/03/24 at 9:00 AM documented, Resident was observed [in] a sitting position on the floor beside her bed on 4/1/24. The resident stated she was trying to get out of bed, and she fell. Bed was in lowest position, call bell on the bed within reach. No discoloration, swelling, abrasion or skin tear was noted. The resident denied pain at the time. On 4/2/24, the resident complained of pain and swelling noted to the left arm. An X-ray of the left Humerus ordered. X-ray result received this morning with impression of acute humeral neck and greater tuberosity fractures with mild displacement. Mild degree of osteopenia. Moderate osteoarthritis. Fall precautions in place. Care plan updated. An investigation is in progress. The resident transferred to the ER for further evaluation. A physician's order dated 04/03/24 directed, Transfer resident to the nearest hospital ER (emergency room) via 911 for splinting and orthopedic for humeral neck greater tuberosity fractures. A SBAR Communication Form dated 04/03/24 at 11:00 AM documented: - Situation: Transfer to [Hospital name] ER for complete fracture of the humerus surgical neck with mild displacement. - Physician notified on 04/03/24 at 10:00 AM; new orders - send resident to the hospital. - Resident left the unit at 9:52 AM via 911 to ER. A Facility Reported Incident (FRI), DC~12612, submitted to the State Agency on 04/03/24 documented: - The resident was observed in a sitting position on the floor beside her bed on 04/01/24. - No discoloration, swelling, abrasion or skin tear was noted. The resident denied pain at the time. - On 04/02/24, the resident complained of pain and swelling noted to the left arm. - An Xray of the left Humerus was ordered. X-ray result received this morning with impression of Acute humeral neck and greater tuberosity fractures with mild displacement. - Care plan updated. An investigation is in progress. The resident transferred to the ER for further evaluation. A Nurses Note dated 04/03/24 at 9:57 PM documented: - The writer called the [Hospital Name] emergency department at 9:50 PM, was informed that the resident will be admitted . A Complaint, DC~12609, received by the State Agency on 04/08/24 documented: - [Resident #463] has been staying at [Facility name], receiving dialysis for over a year, recently went to [Hospital name] on 04/02/24 with multiple broken bones in her leg and arm. I visit [Resident #463] weekly with her granddaughter, she is very weak and unable to walk independently. - We are unable to find out what happened to put her in the hospital. When we went to the hospital, the doctors there did not even know what had happened and were asking us for information. - I am concerned about the quality of care she is receiving at this facility. I think an injury this extreme needs to be followed up on. The Hospital Discharge summary dated [DATE] documented: - admission date 04/03/24. - Discharge diagnoses and treatment plan: Left Coronoid Process (elbow) fracture, left proximal Humeral Fracture, present on admission. Manage non-operatively, removeable splint, apply ice pack and keep extremity elevated. Left distal femur fracture. Manage non-operatively, long leg splint, non-weight bearing, apply ice pack and keep extremity elevated. During a face-to-face interview on 04/19/24 at 2:10 PM, Employee #20 (assigned LPN) stated, [On 04/01/24] I made rounds after I started my shift and observed the resident on the floor. The resident stated, 'I fell from the bed.' I called for help. The Unit Manager (Employee #21) came, and we put her (Resident #463) back in bed. A head-to-toe assessment was done, and no injury was noted at the time. I called the doctor, and no new orders were given. The next day, there was complaints of pain in the left arm. I called the MD, and he ordered x-rays. The results came back and showed a fracture. MD was called with the results and gave order to send [Resident #463] to the hospital. When asked if she medicated Resident #463 on 04/01/24 for pain, the employee stated that she did not remember. During a face-to-face interview on 04/19/24 at 3:01 PM, Employee #21 (4 north Unit Manager) stated, [Employee #20] found the resident on the floor during rounds. I assisted to get her (Resident #463) back in the bed. A head-to-toe assessment was done by myself and Employee #20. [Resident #463] did not complain of pain in the left arm or in the legs. The doctor was called. The x-ray was ordered on the next day (04/02/24). When asked who medicated Resident #463 on 04/01/224 at 12:37 PM as documented in the SBAR that she created and signed, Employee #21 stated, The assigned nurse (Employee #20) was responsible for medicating the resident. During a face-to-face interview on 05/03/24 at 10:00 AM, Employee #22 (Primary Care Physician) was asked his expectations for treatment of a resident who has documented pain and swelling of a limb after an unwitnessed fall. The employee stated, In elderly patients who fall, there's a great risk of a fracture. X-rays should be done immediately. When asked why x-rays were not ordered for Resident #463 when facility staff reported that the resident had pain and swelling of a limb after an unwitnessed fall, the employee stated, There must've been some miscommunication in this case because an x-ray should've been done immediately. During a face-to-face interview on 05/16/24 at 3:30 PM, the findings were brought to the attention of Employee #2 (Director of Nursing/DON) and Employee #3 (Medical Director). Employee #3 stated, Whether the x-ray was done right after the fall or the next day, it wouldn't have made a difference in the management of her care, it would not have changed. I see no problem that the x-ray was done the next day. (over 24 hours after the resident's unwitnessed fall with documented pain and swelling in her left arm). The Medical Director (Employee #3) was then informed that because the management of Resident #463's care changed when she was transferred to the emergency room for further evaluation, it was then discovered that the resident also sustained a fracture to her left femur as a result of the fall on 04/01/24, which required a hard cast. Employee #3 responded, [Resident #463] is a dialysis patient, which automatically makes her a fall and fracture risk. It's expected that a dialysis site would have some swelling and tenderness. It (getting an xray on 04/01/24 after the fall occurred and the resident complained of pain and had observed swelling) wouldn't have changed the management of care for the patient. I feel that the staff did what a reasonable person should've have done.

Based on observations, residents and staff interviews, facility staff failed to make information on how to file grievances available to the residents. The census on the first day of the survey was 265. The findings included: Review of the facility's Resident Grievance/Concerns policies and procedures dated January 2024 documented: - The facility must make information on how to file a grievance or complaint available to the resident. During observations on 04/19/24, 04/22/24 and on 04/23/24 on the second, third, fourth and fifth floors, the following was noted: - Each floor had a black lock box, with a small opening labeled Grievance Box; there was a compartment behind the box that was noted to be empty. During a Resident Council Meeting on 04/24/24 at 2:00 PM, multiple residents stated that grievance forms were not readily available to them and were not sure of where to find them. During a face-to-face interview on 04/25/24 at 12:00 PM with the Social Services Department, the surveyor asked them where the grievance forms are kept/located. Employee #14 (Social Worker) stated that the Social Workers are the keepers of the grievance forms and that the forms supposed to be in the compartment right behind the grievance box, by the elevator, on each unit. The employee further stated that the Social Services Department is responsible for ensuring that grievance forms are always available at the grievance box locations. It was brought to the attention of the Social Services Department that during observations of each unit, on three different dates, there were no grievance forms observed. The Social Services Department acknowledged the findings and Employee #14 stated that the social workers would ensure that the grievance box on each floor has grievance forms. The evidence showed that facility staff failed to make information on how to file a grievance or complaint available to the residents. Cross Reference 22B DCMR Sec. 3233.2

Based on review of facility reported incidents, medical records, facility documentation/policies, resident, and staff interviews, for two (2) of three (3) sampled residents, facility staff failed to implement safeguards to protect and prevent further potential abuse of residents by Employee #3 (Maintenance Worker/alleged perpetrator) as evidenced by allowing ongoing, unrestricted, and unsupervised access to residents by the alleged perpetrator. Residents' #1 and #2. Due to these failures, an Immediate Jeopardy situation was identified on January 12, 2023, at 10:00 AM. The facility submitted a Plan of Action to the survey team that was on onsite at 8:14 PM on January 12, 2023, and the plan was accepted. The survey team returned on January 17, 2023, to validate the facility's plan, and the Immediate Jeopardy was lifted on January 18, 2023, at 4:39 PM. After removal of the immediacy, the deficient practice remained at a potential for harm and the scope and severity was lowered to a D. The findings included: Review of the policy Prohibition of Abuse (not dated) showed, .depending on the facts of the investigation, appropriate action will be taken against the offender and documents relevant to the offense and action taken will be appropriately filed . all records shall be retained for 5 years under the safekeeping of the Administrator . Review of the policy Investigation Process (not dated), showed, [Facility name] will continue to ensure the safety of our residents .procedures and implementation .if allegation of wrongdoing is found to be unsubstantiated/substantiate (depending on the type of allegation) the staff will be transferred from the floor/unit where the allegation occurred to another floor/unit to prevent recurrence of allegation . The Human Resource Director/Designee will file both initial and outcome of investigation document that involve employees in their files. Background information: Allegation #1: Employee #3 and Resident #2: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Human Immunodeficiency Virus (HIV) and Anemia. Review of Resident #2's record revealed the following: Resident #2 resided on Unit 5 South, room [ROOM NUMBER]-B as of 03/04/22 to the start of this survey. The Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive response; no potential indicators of psychosis; no behavioral symptoms or refusal of care; required limited assistance with one person physical assist for bed mobility, transfer, walking in room, toilet use and personal hygiene; required supervision for walking in the corridor and off the unit; no impairment in range of motion; and received antipsychotic medications. A Facility Reported Incident (FRI), DC00010928; received by the State Agency on 08/08/22, showed that Employee #3 (Maintenance Worker/Alleged Perpetrator) was involved in an alleged employee-to-resident incident of inappropriate touching. The incident documented, Resident (#2, female) alleged that she was touched inappropriately by one of the facility employees (Employee #3's name), with maintenance department . facility investigation was completed with the following .The alleged employee file was pulled from HR (human resources) and reviewed, no history of any kind of abuse was found in his file. Therefore, facility investigation was unable to substantiate the allegation of inappropriate touching of [Resident #2] by the employee, however the employee will be sent to staff development for a refresher training on sexual harassment prior to returning to work. Review of Employee #3's Time and Labor Time Card for August 2022 showed that on 08/08/22, the employee was in at 8:15 AM and out at 1:00 PM. The next documented time in was 08/25/22 at 5:15 AM. A review of Employee #3's (Maintenance Worker/Alleged Perpetrator) HR file was conducted on 12/01/22 at 10:00 AM that showed: 1. One Employee Discipline Report dated 11/25/22 that documented, Level of offense - Group III Offense, Type of offense left blank, Current action - suspension pending termination, . Employee is suspended pending investigation alleged (sp) resident abuse, Previous warnings left blank, a check mark where it stated, Employee declined to sign this form, Employee, Supervisor, Administrator signature left blank, HR signature [Employee #18] followed by the date 11/25/22 2. There was no documented evidence related to the allegation of sexual abuse/inappropriate touching made on 08/08/22 3. No documented evidence that Employee #3 was provided a refresher training on sexual harassment prior to returning to work as per the incident report sent to the State Agency 4. No documented evidence that corrective measures were implemented to prevent recurrence of the allegation During a face-to-face interview conducted on 12/01/22 at 10:29 AM, Employee #1 (Former Administrator), Employee #4 (Regional Director of Human Resources) both acknowledged the findings from review of Employee #3's personnel record. Employee #1 stated, The previous Maintenance Director [at the time of this survey, was no longer employed by the facility] was made aware that the plan was for Employee #3 to not be alone in any resident rooms. He [Employee #3] was supposed to always be supervised. When asked how Employee #3, the Maintenance Director, other department heads and unit staff were made aware of this plan, Employee #1 stated, This was discussed in our daily morning meetings with all the department heads. They were made aware and were to relay the information to their staff. Myself, the previous Maintenance Director and Employee #3 signed a document that said that. When asked to provide this document, Employee #1 stated, I am not sure where it is. It was given to the previous Maintenance Director and I am not sure what he did with it. When asked why there was not an Employee Discipline Report from the 08/08/22 allegation in Employee #3's personnel record, Employee #4 stated, I was not involved with this, I am not sure. On 12/01/22 at 5:09 PM, Employee #2 (Director of Nursing/DON) handed this surveyor two forms. The first form was an Employee Discipline Report for Employee #3 dated 08/08/22 that documented, Level of offense left blank; Type of offense left blank; Current Action - suspension; a check mark where it stated, I disagree with the employer's description of the violation; Previous warnings left blank; a check mark where it stated, Employee declined to sign this form. The second form was an Educational Consult Referral dated 08/24/22 that documented, . alleged resident abuse/sexual inappropriateness . Referred by [DON's name] .8/24/22 . Employee was educated on all the various types of abuse and sexual inappropriateness/harassment .[Employee #3's signature] 8/24/22 [Employee #15's (Educator) signature] 8/24/2022. Employee #2 was asked why these documents were in his possession and not filed in Employee #3's personnel record. Employee #2 stated, I keep some stuff in my office and that neither Employee #1 (Former Administrator) or Employee #4 (Regional Director of HR) were aware of this. Allegation #2: Employee #3 and Resident #1: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Hypertension, and Muscle Weakness. Review of Resident #1's medical record revealed the following: Since 09/07/22 to present, Resident #1 has resided on Unit 5 South, room [ROOM NUMBER]-A. From the aforementioned date to the start of this survey (3 months), no other resident has resided in that room other than Resident #1. A Quarterly MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 03, indicating severe cognitive impairment; no potential indicators of psychosis; no behavioral symptoms; required limited assistance with one person physical assist for bed mobility, transfer, walking in room, dressing, and personal hygiene; no impairment in range of motion; frequently incontinent of urine and occasionally incontinent of bowel. Care plan focus area, [Resident #1] exhibits the following behavior symptoms as evidenced by falsely alleging that she was assaulted related to confusion/Dementia initiated on 07/02/20 and revised on 11/07/22 had interventions of, . Observe for changes in behavior/side effects .Assess physical and/or environmental changes that may precipitate behavioral changes . Psych referral as needed . Care plan focus area, [Resident #1] has impaired cognitive function or impaired thought processes r/t (related to) Dementia revised on 11/07/22 had an intervention of, . Keep [Resident #1's] routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . Care plan focus area, [Resident #1] has ADL (activities of daily living) self-care deficit as evidenced by inability to care for self related to Dementia revised on 11/07/22 had an intervention of, Assist with daily hygiene, grooming, dressing, oral care and eating as needed . Care plan focus area, [Resident #2] needs for communications AEB (as evidenced by) inability to express emotion, listen and share information due to decline in cognitive status revised on 11/07/22 had an intervention of, .Provide reassurance and patience when communicating with resident. A FRI, DC00011266, submitted to the State Agency on 11/25/22 documented, Today at about 11:30 am we received allegation from CNA (Certified Nurse Aide): 'I went to walk into [Resident #1's] room wanting to take her vitals. I witness the maintenance man (Employee #3/Alleged Perpetrator) coming up off his knees in front of [Resident #1]. Then act like he was doing something to the curtain in front of her . Maintenance staff was interviewed and said he went to resident room the repair bottom drawer. On his way out, he met the CNA at the door. Maintenance staff denies touching resident inappropriately or sexually abuse her .Resident has been transfer to ER (emergency room) for further evaluation related to the allegation . Submitted On: [DATE], 05:58PM EST (Eastern Standard Time) . Facility initiated investigation into the issue, and based on statements, interviews on both residents and employees, facility was unable to substantiate the allegation of sexual abuse . Review of the Quality Assurance and Performance Improvement 24 Hours Report Audit form dated 11/23/22 showed, . [Room number] 525 A Broken cabinet . Although, the form showed there was a broken cabinet in room [ROOM NUMBER]A, there was no evidence provided by the facility to indicate that this repair had been assigned or completed by Employee #3. On 11/25/22, the Time and Labor Time Card for Employee #3 showed, in - 5:45 AM .out - 9:15 AM . 11/25/22 at 11:49 AM [Situation Background Assessment Request (SBAR) Communication Tool] .Situation: It was alleged that a male staff members was found in a suspicious position alone with resident in resident's room .Alleged staff has been suspended pending investigation. 11/25/22 at 4:48 PM [Social Work Progress Note] This social worker spoke to [Resident's representative] and shared with her that there has been an allegation of abuse toward her sister. This social worker informed her that her sister will be transferred to the hospital, and a staff member may contact her again this evening. She was grateful for the information .care plan meeting has been scheduled for Monday 11/28/22 at 12pm. 11/25/22 at 5:19 PM [Nurses Note] 911 left the facility at 5:17pm 11/25/22 at 9:45 PM [Hospital Discharge Summary] .The forensic nurse examiner's (examine prospective victims of all ages who have suffered abuse, neglect, sexual assault, trauma, or any other crime-related injuries as part of the investigation) did see you in the ER . 11/26/2022 at 1:45 AM [Nurses Note] Resident is back from the hospital to the unit [at] 11:40pm. Report given on the phone . there was no signs and symptoms regarding to the resident's complained . During an observation and interview of Resident #1 on 12/01/22 at 10:51 AM, the resident was noted standing in the doorway of room [ROOM NUMBER]. Resident #1 appeared well groomed, wearing a red tee-shirt with gray pants. The resident was not able to tell the surveyor the time or place. The resident was asked if she could show me her bed area. Resident #1 stated, Yes and walked with the surveyor inside the room. Resident #1 sat on the bed closest to the door (bed A). The bed was locked and in the lowest position, the bedside curtain was clean, no damage or missing rods were noted, the floor area around her bed was clean and intact. No broken drawers or cabinets noted. It should be noted that room [ROOM NUMBER] bed B was unoccupied. Resident #1 was asked if anyone comes inside her room, to which she replied, The people who work here always come in and out. The resident was then asked had any staff ever touched her inappropriately or attempted to have any kind sexual contact with her. Resident #1 was unable to recall and stated, I don't think so. Face-to-face staff interviews: 12/01/22 at 11:18 AM, Employee #7 (CNA who reported) stated, I came on my shift [7:00 AM - 3:00 PM] and around 7:15 AM, I did rounds and then started to take the vital signs. I walked by [room [ROOM NUMBER]] and saw the maintenance (Employee #3/Alleged Perpetrator) fixing the door [of Resident #1's room]. I walked by again and saw him messing with the drawer. I thought that was odd because the drawer had already been fixed. A couple of minutes later, I walked into room [ROOM NUMBER] with the vital signs machine and saw him (Employee #3) on his knees, in front of the resident (#1), as she was pulling her shirt down. It's the same red shirt she is wearing today. The vital signs machine made a sound that startled him and he began to nervously mess with the floor area in front of where the resident was sitting. I asked him what he was doing and he said 'I was just fixing something' and left the room very quickly. After he left, the resident said to me, 'I don't have on any underwear; I don't have on any underwear.' I left and went to tell another CNA what I just saw. I also told the charge nurse (Employee #13/Licensed Practical Nurse). I am not sure what he did after I told him which was around 7:25 [AM]. I was very shaken up by what I saw and it really bothered me. Around 10:30 [AM], when I realized nothing had been done to address what I reported, I went to HR and spoke to [Employee #18/HR Director), reported it and that's when the ball started rolling. Employee #3 (Maintenance Worker/Alleged Perpetrator) was called by this surveyor on 12/01/22 at approximately 12:15 PM; however, he did not answer the phone or return the call. On 12/02/22 at 10:00 AM, a face-to-face interview was held with Employees #1 (Former Administrator), #2 (Director of Nursing/DON), #4 (Regional Director of HR), #5 (Regional Director of Maintenance), #6 (new Maintenance Director), #13 (Charge Nurse/LPN from unit 5 south), #14 (Social Worker), #16 (Social Services Director), #17 (Quality Assurance/QA) and #18 (HR Director). The following statements were made by the interviewees: Employee #1 (Former Administrator) was asked about what actions were implemented from the 08/08/22 allegation against Employee #3, the employee stated, [Employee #3] was supposed to be supervised when in resident's rooms. Employee #1 was again asked to provide documented evidence of said plan to which she responded, I don't have it. I am still looking through the documents of the previous maintenance director. It was discussed in our morning meetings for the department heads to pass that information to their staff. Employee's #4 and #18 were asked to detail the facility's process after a resident makes an allegation against an employee. Employee #4 stated, Once nursing makes HR aware, the employee involved is asked to write a statement and HR fills out the form [Employee Discipline Report]. 'Current action' is what the facility does based on the type of offense [attendance, performance, discipline, other]. The employee either agrees or disagrees; any previous warnings are also documented to include the date, type of warning (attendance, performance, discipline, other), the level of warning (oral/written/suspension/other), and any and all actions taken as a result. Employees' #4 and #18 were shown the Employee Discipline Report dated 11/25/22 that was sent to the State Agency by the facility on 11/29/22 at 5:58 PM as part of the facility's conclusion to the investigation regarding Resident #1and Employee #3 (Maintenance Worker/Alleged Perpetrator). Employee #18 was asked why this Employee Discipline Report dated 11/25/22, that she completed, failed to document any previous warning when Employee #3 had an allegation on 08/08/22. Employee #18 reviewed the form and made no comment. Employee #4 then stated, She (Employee #18) is on orientation and does not know how to complete the form. Employee #4 was then shown the Employee Discipline Form dated 08/08/22 for Employee #3 that was completed and signed by Employee #18, attesting to being the HR representative who completed that form. Employees' #4 and #18 reviewed the Employee Discipline Report dated 08/08/22 and made no comments. Both Employees' #4 and #18 acknowledged that Employee #3's personnel file failed to have: no documentation of the previous offense [08/08/22] or the safeguards/corrective actions implemented. Employee #6 (Maintenance Director) was asked if he was aware or had any knowledge that Employee #3 was not allowed to be in any resident's room unsupervised. The employee stated, No. I was not aware of this from August [2022] until now. This is the first I've heard of this. Employee #6 was then asked how the maintenance workers whereabouts get tracked in the facility. The employee stated, We don't track where they work in the facility. The work orders are not assigned. We have an electronic system where things get reported that need fixing but most tasks that we do don't get reported in the system. The nurses will report it directly to the maintenance [worker] that they see on the unit and that worker fixes the problem. Employee #6 was asked about the broken cabinet in room [ROOM NUMBER] A that was reported on the 24 hours report on 11/23/22. Employee #2 interjected to say that the cabinet had been fixed. Employee #6 explained, I can't tell you which maintenance worker fixed it or on what date. Employee #5 (Regional Director of Maintenance) was asked what his role was in the implementation of any measures that were taken or put in place to prevent recurrence of the allegation of Employee #3. The employee stated, I am not involved in the day-to-day operations. I knew he [Employee #3] was being dealt with. [Employee #3] wasn't supposed to be in anyone's room. [Previous Maintenance Director's name] reported to me that he talked to his staff about this. Employee #1 interjected to say, We monitored for compliance during rounds and told the department heads to do so as well. The other staff should've been made aware by them [department heads]. On 12/02/22 at 10:25 AM, the surveyor asked the employees who were present in the conference room if they were aware or had knowledge that Employee #3 was not supposed to be any resident rooms or unsupervised in resident's rooms: Employee #13 (LPN/Charge Nurse, unit 5 South), Employee #14 (Social Worker) and Employee #16 (Social Services Director). All three employees denied ever being informed by their department head, managers/supervisors, or anyone in administration that Employee #3 was not allowed to be alone and unsupervised in resident's rooms. During a face-to-face interview conducted on 12/02/22 at 11:08 AM, Employee #12 (Housekeeping Supervisor) stated, I attend the morning rounds with the other department heads and sometimes the maintenance workers round with us. I've never heard of Employee #3 not being allowed to enter or be alone in a resident's room. During a face-to-face interview conducted on 12/02/22 at approximately 11:30 AM, Employee's #1 and #2 acknowledged that from 08/08/22, the facility failed to have any safeguards implemented to protect and prevent further potential sexual abuse/inappropriate touching of residents by Employee #3 (Maintenance Worker/alleged perpetrator). Follow-up interview with Employee #7: During a follow-up face-to-face interview on 01/10/23 at 10:30 AM, Employee #7 stated, [Resident #1] was seated on the bed when she was pulling her shirt down from her thigh area. I could not see that she didn't have on any underwear. Employee #7 was asked could she see the resident's private parts/area. She was unable to validate if the resident had on underwear. During a face-to-face to face interview on 01/12/23 at 9:35 AM with Employee #1 (Former Administrator) stated, He was the only painter. His primary job was to paint. He never had an assigned floor, he worked all over the building. Through observations, record reviews, and staff interviews, it was determined that the facility failed to: 1. Establish a tracking/monitoring system for Employee #3's whereabouts in the facility after the allegation on 08/08/22. Subsequently, on 11/25/22, Employee #3 was observed on unit 5 South, putting Resident #2 (room [ROOM NUMBER] bed B) at an increased risk for the likelihood of recurrence of allegation (inappropriate touching). 2. Have Employee #3 supervised while in resident's rooms. Subsequently, on 11/25/22, another employee observed Employee #3 alone and unsupervised in Resident #1's room, on his knees, directly in front of the resident, who was sitting on her bed. 3. Have documented evidence that the employee received the refresher training on sexual harassment prior to returning to work on 08/25/22 or any time thereafter. 4. Provide documentation to support a rationale for Employee #3 being in Resident #1's room unsupervised. Additionally, the facility's failure to transfer Employee #3 to another unit/floor after the 08/08/22 allegation from Resident #2, allowing him to have continued, unrestricted access to the resident and gave way to the likelihood for further abuse from her alleged perpetrator; and 5. When the facility's Administration was aware of the first allegation against Employee #3 (08/08/22), there was no documented evidence that they implemented any systematic changes or completed a plan of action to protect Resident #2 or address the allegation against Employee #3, or that they followed their policy that outlined that the employee would be transferred from the floor/unit where the allegation occurred to another floor/unit to prevent recurrence of allegation . Based on these findings, on January 12, 2023, at 10:00 AM, an Immediate Jeopardy (IJ)-J situation was identified. On January 12, 2023, at 8:14 PM the facility's Administrator provided a corrective action plan to the State Agency Survey Team, which included: 1. The incident was reported on 11.25.22. Employee#3 was suspended on 11.25.22 and has not worked since 11/25/22. A head-to-toe assessment was done for Resident #1 by the licensed nurse on 11.25.22 with no visual signs of abuse, no discoloration, or bruising noted. Resident#1 was also interviewed by the ADON, Clinical Coordinator and Unit Manager .Resident#1 was sent to the ER for further evaluation and returned to the center the same day. No signs of potential physical or sexual abuse were noted per the hospital records. The Police were notified about the sexual allegation immediately and began their investigation. The facility has provided all documents to the Police for the investigation. 2. Employee#3 has been suspended immediately until and unless he is cleared of the sexual allegation by both internal (facility) and external agency (Police). In the event that the employee#3 is cleared by both internal (facility) and external agency (Police), of the alleged abuse, the employee will no longer be allowed to work on the unit of the 5th floor in which the resident resides . 3. A house wide audit was done by the Administrator on 1.12.23 for any sexual allegations in the past 3 months (9.1.22 to 1.12.23). There were no other allegations of sexual abuse found from this audit. 4. Education will be done for the Administrator and Director of Nursing by the Governing body who in turn will educate all the Department heads (Managers, Directors and Supervisors) who will then ensure that all staff are educated on Abuse which would include but not limited to sexual abuse, how to interpret sexual abuse, report timely and measures to be taken to prevent sexual abuse as per facility's Abuse policy. 5. All department heads and supervisors will be notified during the daily clinical meeting if there is a particular staff that should not work on a particular unit or with a particular resident due to an abuse allegation. The department head/supervisor will be responsible to supervise the alleged employee to ensure that they are not within the complainant resident's room. Documentation of this notification during the clinical meeting will be maintained by the QA Director. 6. For allegations of abuse, the alleged employee involved in the incident. will be notified immediately in writing by the HR (Human Resource) manager/designee of work restrictions [which include but is not limited to: not working with a particular resident that has the allegation towards them, or a change to another unit (as applicable to the allegation or the employee's position)]. A copy of this notification to the employee will be placed in the employee's personnel file. 7. Maintenance Director will be educated by the Administrator to ensure that when an employee has an abuse allegation against them by a resident, the employee will no longer work with that resident or in that resident's room. 8. Maintenance Director will also be educated by the Administrator to ensure that if an employee is suspended, completed paperwork (suspension, termination or targeted education) is submitted to HR with all sections of the paperwork filled out. 9. A representative from the governing body will provide education to the HR Manager to ensure that the employee's personnel file will have completed disciplinary documents with all sections properly filled out, to include but limited to suspension, termination, and targeted education for the employees. The education to the HR Manager will include ensuring all employee personnel files are stored within the HR department appropriately in a specified designated area and are accessible at all times. 10. In the event that an employee is accused/suspected of sexual abuse the employee will be suspended immediately. The Department head/scheduler will ensure that an employee that had an abuse allegation would not be scheduled to work directly with the resident or in that resident's room that had any abuse allegation toward the employee. 11. An audit will be done by the HR Manager for (1) the alleged employee's personnel file, to ensure that for any abuse allegation toward an employee, there has been evidence of written communication with that employee regarding work restrictions and (2) evidence of communication with the Department heads, scheduler and supervisors to ensure that the alleged employee will no longer work with the resident In question and (3) for employee files that have suspension, termination or targeted education to ensure that all the paperwork has been completed in its entirety. 12. These three audits mentioned will be done weekly for four (4) weeks and monthly for three (3) months to ensure that the facility's systemic failure thoroughly investigates, implements timely plans of action to mitigate the likelihood of further abuse or adverse event. And will prevent to place other residents at risk for abuse as per facility policy. Any negative findings will be addressed immediately. Results of finding will be forward to QA Committee for review and recommendations. Date of Compliance: 01/16/2023. The State Agency Survey Team returned to the facility on January 17, 2023, to verify that the plan of correction was in place. On 01/18/2023, at 4:39 PM, the Immediate Jeopardy was removed. DCMR - 3269.1(l)

Based on observation, record review, resident and staff interviews, for seven (7) of 105 sampled residents, facility staff failed to ensure residents were free from abuse (willful infliction of injury) and neglect as evidenced by: failure to prevent the willful infliction of serious injury of Resident #404 by Resident #82; failure to implement person center care measures for Resident #151 who had incidences of aggressive behavior towards Resident #71 and willful infliction of injury to Resident #67; failure to ensure staff received training to provide person-centered care to Resident #409 post hip replacement, subsequently the resident sustained a dislocated hip; failure to ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently, the resident to be transferred to the emergency room (ER) for dislodgment; and failure to have available [NAME]-tube and HME (medical equipment) for treatment and care of Resident #3's stoma subsequently, the resident was transferred to the ER a second time for replacement of the [NAME]-tube. Actual harm was determined to be present for Residents #404, #71, #67, #409, and #3. The findings include: Review of the facility policy entitled, Prohibition of Abuse [not dated], documented, Abuse is the willful infliction of injury . resulting in physical harm, pain or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Neglect, is failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Review the facility policy entitled, Resident-to-Resident Altercation/Incidents revised on ,d+[DATE] documented, . When a resident is observed or identified as being aggressive to having aggressive behavior or has the potential for abusing other residents, an assessment of strategies to prevent such incidents from occurring will be provided by the Interdisciplinary Team (IDT) . Review the facility policy entitled, Your Rights and Protections as a Nursing Home Resident revised on ,d+[DATE] documented, .You have the right to be free from verbal, sexual, physical, and mental abuse . 1. Facility staff failed to prevent the willful infliction of serious injury of Resident #404 by Resident #82 evidenced by failure to adjust Resident #404's plan of care resulting in a resident-to-resident altercation. Review of a Facility Reported Incident (FRI) dated [DATE], documented, .The charge nurse observed [Resident 404] sitting on the floor besides his roommate's . bed #420A; the charge nurse noticed blood on [Resident #404's] left ear and mouth. The nurse assessed [Resident #404's] left ear and mouth and there was no skin tear or abrasion including his face . [Resident #82] was interviewed he said, that man keeps coming over to my bed side and when I asked him to go back to his side of the bed, he punched me on my stomach and chest and I punched him on the chin and he fell . Review of a Complaint dated [DATE] documented, .family is hoping for answers after they say their father was brutally beaten at a nursing home in the District. [Representative's Name] . in an interview that his father [Resident #404] was attacked while living at the [Facility Name]. [Resident #404] died from his injuries on [DATE] (2022) . Review of a Complaint dated [DATE] documented, .Avoidable death. Comments: Patient assaulted in nursing home. Beneficiary was assaulted [DATE] in skilled nursing facility by another resident. He sustained blunt head trauma with bleeding noted on his left ear and mouth. He was transferred to an acute hospital and later died . Resident Background Information: A. Resident #82 was admitted to the facility on [DATE]with multiple diagnoses that included: Schizophrenia, End Stage Renal Disease and Sensorineural Hearing Loss. Resident #82's Quarterly Minimum Data Set (MDS) dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognitive response, no physical or behavior symptoms directed towards others, required supervision with one person physical assist for activities of daily living (ADLs), used a walker for mobility and received antipsychotic medications. B. Resident #404 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia without Behavioral Disturbances, Vascular Dementia without Behavioral Disturbances and Transient Cerebral Ischemic Attack. Review of Resident #404's medical record revealed the following: [DATE] [Quarterly MDS] showed facility staff coded a BIMS summary score of 03, indicating severe cognitive impairment. In Section E (Behavior), no potential indicators of psychosis, no physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred 1 to 3 days, wandering behaviors occurred daily In Section G (Functional Status), walk in room (how resident walks between locations in his/her room), Supervision with one person physical assist and no functional limitation in range of motion In Section P (Restraints and Alarms), wander/elopement alarm, Used daily Care Plan: [DATE] (Revision date) [Resident #404] is at risk for Elopement: cognitive impairment, dementia . Observed wondering at the adjacent unit on [DATE]. Wandering to the adjacent unit on [DATE]. Redirected easily. Wandering to the adjacent unit on [DATE]. Easily redirected. Wondering on [DATE]. Redirected. Wondering to the adjacent unit [DATE], Easily redirected . Avoid leaving unattended or unobserved for long periods of time. Hourly elopement/wandering monitoring and location. Review of the Daily Behavior Documentation showed the following: [DATE] at 2:12 PM . Elopement attempts. Wandering sleeping in other people's bed . Behaviors are constant. [DATE] at 1:12 PM . sleeping in other people bed. Behaviors are constant. [DATE] at 1:52 PM . sleeping in other people's bed. Behaviors are constant. [DATE] at 1:47 PM .sleeping in other peoples bed. Behaviors are constant. [DATE] at 12:17 PM .sleeping in other peoples bed .Behaviors are constant. [DATE] at 11:16 AM . sleeping in other people bed. Behaviors are constant. [DATE] at 12:32 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 2:10 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 1:28 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 2:19 PM .sleeping on other people's bed .Behaviors are constant. [DATE] at 1:18 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 12:23 PM .sleeping on other peoples bed .Behaviors are constant. Skin Observation Tool dated [DATE] at 2:40 AM documented, Observations . face . Blood was coming from his mouth, we managed to stop it by applying cold compress and ice . Situation Background Assessment Request (SBAR) dated [DATE] at 4:00 AM showed, Situation . The resident got hit by his roommate . Background: Altered mental status . Resident Reports Pain? 'No'. Non-verbal indicators of pain evident? 'No'. Functional Status unchanged . Skin/Wound Status- (area was left blank) . Assessment . (area was left blank) . Additional comments . At approximately 02:30 am . The writer observed [Resident #404] sitting on the floor near roommate's bed (420 bed A) with blood coming out of his left ear, face. The writer immediately notify the supervisor and called 911. DC (District of [NAME]) police. I saw [Resident #82] also sitting on his walker facing [Resident #404]. The writer asked [Resident #82] what happened, resident stated 'I hit him because he came to my bed.' DC fire department arrived at the unit at 3:10 am and left with [Resident #404] in a stretcher accompanied by two ambulance attendants to [Hospital Name]. [Physician Name] and RP (representative) was made aware. [DATE] at 4:16 AM [Nursing Supervisor Progress Note] The Charge Nurse reported that While making routine rounds, Resident [#404] was observed sitting on the floor beside room [ROOM NUMBER] A. Resident was noted with some blood on the left side of his face, a quick assessment was made, he was assessed for pain and discomfort. Resident could not describe what happened. This is his base line. A quick assessment was done, Range of motion exercise was done, ice was applied to the left side of the face, vital signs was monitored T. (temperature) 96.5, P. (pulse) 82, R. (respirations) 18, B.P. (blood pressure) ,d+[DATE], Spoe (sp) (oxygen saturation) 97% on Room Air. [DATE] at 1:43 PM [Nurses Note] A call was placed to [Hospital Name] to know about the status of the resident [#404] in the ER, spoke with nurse [Registered Nurse's Name] who stated Resident (#404) is critically ill, he has been intubated and about to be transferred to ICU (intensive care unit). RP . made aware. During a tour conducted on [DATE] at approximately 3:00 PM of unit 4 south, a facility document was observed taped to a partition at the nurses station that stated, . Updated on [DATE] 4 South List of Residents for Daily Behavior Documentation. room [ROOM NUMBER]D [Resident #404] Common behavioral traits confusion, wondering, elopement, sleeping in other peoples bed . Review of this evidence showed that facility staff had knowledge of and documented Resident #404's intrusive behavior of going into other resident's rooms and sleeping in other resident's beds. a. Although the facility had a care plan in place to address Resident #404's wandering on to other resident units; there was no evidence that the care plan was updated/revised to address the residents intrusive behavior (wandering into other resident rooms and sleeping in their beds). b. Facility staff failed to document the names, room numbers of residents who were affected by Resident #404's behavior; and failed to assess how Resident #404's behavior impacted other residents such as putting himself or others at risk for physical injury, intrusion on their privacy or activity, upset that he in their room and sleeping in their bed. c. Although the staff record that Resident #404 was being monitored hourly, he was still found wandering into other resident rooms and sleeping in their beds. There is no evidence that monitoring the resident was readjusted to manage the residents behavior. During a face-to-face interview conducted on [DATE] at 12:48 PM, Employee #7 (Clinical Coordinator) stated, I am responsible for care plan updates, creating and updating interventions. During care plan reviews, I do a 30-day look back at orders, nurse's notes, psych notes and make updates as needed. When asked if he was aware that Resident #404 had documented behaviors of going into other resident's rooms and sleeping in other resident's beds, Employee #7 stated, I was never made aware by the nurses on the unit. I knew him [Resident #404] as a wanderer, I was not aware that he was going into rooms or else his [Resident #404] care plan would have been updated to reflect that behavior and have specific interventions. When asked about the, 4 South List of Residents for Daily Behavior Documentation . that stated Resident #404's behavior, Employee #7 stated, I didn't see it. 2. Facility staff failed to provide adequate supervision and implement the plan of care interventions for Resident #151 to protect and prevent Residents #71 and #67 from incidences of aggressive behavior (resident-to-resident altercations) and willful infliction on injury. Review of Facility Reported Incidences showed the following altercations involving Resident #151: Review of the FRI dated [DATE] documented, . At 0730AM, the security officer . observed [Resident #151] assaulting another resident [Resident #71] at the front of the building . Review of the FRI dated [DATE] documented, .At 2030 on [DATE] ([DATE]), [Resident #67] alleged to the receptionist that [Resident #151] hit him on his chest x 2 in the lobby . Resident Background Information for Residents' A.Resident #151 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Psychosis, Epileptic Syndrome and Benign Prostatic Hyperplasia. Review of Resident #151's medical record revealed: [DATE] [Admission MDS], facility staff coded a BIMS summary score of 07, indicting severe cognitive impairment. In Section E (Behavior): E0100. Potential Indicators of Psychosis - Delusions (misconceptions or beliefs that are firmly held, contrary to reality) - yes E0200. Behavioral Symptoms: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) - Behavior of this type occurred 1 to 3 days, verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) - Behavior of this type occurred 4 to 6 days, Impact on Resident . Put the resident at significant risk for physical illness or injury? yes; impact on others . put others at significant risk of physical injury? yes; significantly intrude on the privacy or activity of others? yes; significantly disrupt care or living environment? yes In Section G (Functional Status): Activities of Daily Living (ADL) Assistance - bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, Resident #151 required supervision and one person physical assist Review of the Care Plan revealed: [DATE] (Revision date) As evidenced by a positive PASARR (Preadmission Screening and Resident Review) Level I screen and Level II evaluation, it was determined that the resident needs Specialized Services while in the Nursing Facility. Related to: schizophrenia .Inform the MD (medical doctor) if the Individual has a serious health decline and services previously agreed to may need to be modified or deleted. Inform the MD of any significant changes may require additional evaluation to add, modify or remove services . [DATE] (Revision date) [Resident #151] at risk for changes in behavior problems related to: agitation . [DATE] (Revision date) [Resident #151] has problematic manner in which resident acts characterized by inappropriate behavior; resistive to treatment/care related to: Cognitive Impairment (Dementia, Schizophrenia). Non compliant with taking medications, non compliant with vital signs, non compliant with shaving and showers. Non compliant with Wader guard placement kicking and hitting . [DATE] (Revision date) [Resident #151] has impaired cognitive function or impaired thought processes r/t (related to) Dementia . [DATE] (Revision date) [Resident #151] uses psychotropic medications r/t behavior management, Paranoid Schizophrenia . Monitor/record occurrence of for target behavior symptoms . violence/aggression towards staff/others) and document per facility protocol . [DATE] (Revision date) Resident #151] has behavior problem r/t (Combative, Spilling water on the entire floor, disrobing) r/t Schizophrenia. Non-compliant letting roommate into the room, moving chair into another room and refusing to stop . Combative, agitation, hitting multiple staff members, trying to break down doors in the Administration area and rolling on the floor . 1:1 staff monitoring for safety until seen by psych or sitter is available . B. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included Schizoaffective Disorder, Unspecified Dementia without Behavioral Disturbance and Hypertension. Review of Resident #71's medical revealed, a Quarterly MDS dated [DATE]where facility staff coded a BIMS summary score of 09, indicating moderate cognitive impairment, no potential indicators of psychosis and no physical or verbal behavioral symptoms, limited assistance with one person physical assist for ADLs, no limitations in range of motion and no skin conditions. C. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included Unspecified Intellectual Disabilities, Psychotic Disorder with Hallucinations, and Unspecified Dementia without Behavioral Disturbance. Review of Resident #67's medical revealed, a Quarterly MDS dated [DATE] where facility staff coded a BIMS summary score of 14, indicating intact cognitive response, no potential indicators of psychosis, no physical or verbal behavioral symptoms, limited to extensive assistance with one person physical assist for ADLs and no limitations in range of motion. Altercation #1 involving Residents #151 and #71: [DATE] at 11:18 AM [Nurses Note] . At 0730AM, the [Security Officer's Name] and the [Receptionist's Name] observed resident [#151] assaulting another resident [Resident #71] at the front of the building. The security officer and the receptionist ran to the residents and separated both residents . [Resident #71] was interviewed. He said, 'the man jumped on me in front of the building for no reason. I have never spoken to him. I don't know where this came from today' . asked [Resident #151] why he assaulted [Resident #71]. He said, 'he raped my daughter' . The MPD (Metropolitan Police Department) was called . took [Resident #151] because of his aggressive behavior and transported him to [Hospital Name] at 0809 (AM) for evaluation. [Resident #71] was assessed and small scratch mark observed on the back of his left hand . Altercation #2 involving Residents #151 and #67: [DATE] at 11:30 AM [Nurses Note] . At 2030 (8:30 PM) on [DATE] ([DATE]) , Resident #67] alleged to the receptionist that [Resident #151] hit him on his chest x 2 in the lobby; the receptionist notified the supervisor; the supervisor assessed [Resident #67] and he denied any pain . At 2040 (8:40 PM) [Resident #151] was observed at the gate trying to exit. He was redirected back to the building . stood by the building entrance trying to grab and hit staff exiting the building . will not let staff exit or enter the building. The DC Police Department was called and notified at 2340 (11:50 PM). 2 MPD . responded at 2345 (11:45 PM). During interview with [Resident #151], he was not cooperating; he made attempts to hit one of the Police Officers. [Resident #151] was taken into custody . [Resident #67] . was assessed this AM (morning). He alleged being hit on the lateral abdomen over his previous surgical site. No swelling, discoloration or open area observed during assessment. He denied pain . Review of Resident #151's medical record showed documented aggressive behaviors and a resident-to-resident altercation on [DATE]. There was no documented evidence that facility staff revised Resident #151's plan of care to protect other residents; and then on [DATE], Resident #151 attacked another resident at the facility. In both instances the resident was removed from the facility due to his aggressive behaviors towards other residents. During a face-to-face interview conducted on [DATE], Employee #7 (Clinical Coordinator) acknowledged the findings and stated that Resident #151 has been on 1:1 since he was admitted back to the facility in ,d+[DATE] and has not had any resident-to-resident altercations. 3. Facility staff failed to ensure staff received training to provide person centered care (related to hip precautions) for Resident #409 after she had left hip surgery. Review of an intake form for a complaint received by the State agency on [DATE] documented .after having hip surgery on [DATE], was observed two days later on [DATE] with leg positioned like the letter 'K' Resident #409 was sent to the hospital for a dislocated hip and hip surgery. Resident #409 was admitted to the facility on [DATE] with diagnoses that included: Encounter for Orthopedic Aftercare, Presence of Left Artificial Hip Joint, Alzheimer's Disease (Unspecified), Repeated Falls, Muscle Weakness (Generalized), and Other Abnormalities of Gait and Mobility. Review of Resident #409's medical record revealed the following: A Quarterly Minimum Data Set (MDS) for Resident #409 dated [DATE] revealed that facility staff coded the following: In Section C (Cognitive Patterns), the Brief Interview for Mental Status (BIMS) Summary Score was 99, indicating severe impaired cognition. In Section G (Functional Status), ADL assistance: for transfers, toilet use, and personal hygiene, the resident was totally dependent and required two or more person's physical assistance from two or more staff. For bed mobility, the resident required limited physical assistance from one staff member. For dressing, the resident required extensive physical assistance from one staff member. In Section H (Bowel and Bladder) - Always incontinent for bladder and bowel In Section J (Health Conditions), Yes to: resident have a fall any time in the last month prior to admission /entry or reentry; resident have fracture related to a fall in the last 6 months prior to admission /entry or reentry; resident have major surgery during the 100 days prior to admission; resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay. In Section O (Special Treatments, Procedures, and Programs), start date for Occupational and Physical Therapy [DATE]. [DATE] at 12:10 PM [Hospital Discharge Summary] .Hospital Course Patient presented with left hip fracture; status post Arthroplasty (hip replacement). With no postoperative complications .Discharge Procedure Orders .Weight Bearing as Tolerated (WBAT); Laterally; Left .Restrictions as follows: Posterior hip precautions . [DATE] at 8:29 PM [Admission Note] .Resident was admitted from [Name of Local Hospital] for rehabilitation post left hip Arthroplasty .Resident has hip abduction with pillow and WBAT. Fall and safety precautions initiated: resident location close to nurses' station with close monitoring, call light and commonly used items within close reach . [DATE] (3:00 PM-11:00 PM) [CNA Documentation], facility staff documented that Resident #409 was given a bath, assisted with bed mobility and provided incontinent care for bowel and bladder. [DATE] [Physician's Order] Left hip: monitor left hip for inflammation, pain, and drainage. [DATE] at 2:18 PM [Physical Therapy Evaluation and Plan of Treatment Note] .referred to skilled therapy after having a L (left) hip hemiarthroplasty that resulted from a fall . Precautions . (no flexion past 90 degrees, abduction past midline, or internal rotation, WBAT . [DATE] (7:00 AM-3:00 PM) [CNA Documentation], facility staff documented that Resident #409 received a bath/shower and assistance with dressing, assistance with bed mobility, and provided incontinent care for bowel and bladder. [DATE] (3:00 PM - 11:00 PM) [CNA Documentation], facility staff documented that Resident #409 received assistance with bed mobility, and provided incontinent care for bowel and bladder. [DATE] (11:00 PM-7:00 AM) [CNA Documentation], facility staff documented that Resident #409 received assistance with bed mobility, and provided incontinent care for bowel and bladder. [DATE] [Physician's Order] Place a pillow between lower extremities after care, turn and reposition when resident is in bed. [DATE] [Physician's Order] Wedge resident appropriately after care, turn and reposition when [the] resident is in bed. [DATE] (7:00 AM-3:00 PM) [Treatment Administration Record (TAR)], showed that facility staff documented that they placed a pillow between Resident #409's lower extremities after care, and wedged resident appropriately turning and repositioning when the resident was in bed. [DATE] (7:,d+[DATE]:00 PM) [CNA Documentation], facility staff documented that Resident #409 received a bath/shower and assistance with dressing and bed mobility. [DATE] at 3:29 PM [Physician's Progress Note] Patient seen at the request of Nurse Manager and the family. Patient reportedly has increasing pain at the site of surgery, worse with movement .added oxycodone (narcotic pain reliever) prn (as needed) for 14 days for breakthrough pain . [DATE] at 5:40 PM [SBAR] .Resident transfer to [Hospital Name] . Date problem or symptom started: [DATE] . Background . S/P (status post) left hip Arthroplasty done on [DATE] . A-Assessment . Resident is alert and verbally responsive, no apparent distress noted. No change in mental status noted .R-Request - Person contacted: [Name of Resident Representative] was at bedside. Communicated in person. Notes: She [Representative] requested her mom to be transfer[ed] to the Hospital . [DATE] at 6:20 PM [Nurses Note] .Family was at bedside visiting today from 11:45 AM Resident was seen by the medical director at 12:30 PM, . At about 4 PM daughter requested that she (Resident #409) needed an X-ray to be done because she want[ed] to make sure her mothers' leg was not dislocated. Writer explains[ed] to the daughter that [the] resident has been seen by the doctor in her present (sp) just a few hours ago. If there was any concern note[d] the doctor would have order[ed] an X-ray. She insisted that she want[ed] her mom to be sent to the hospital immediately because she need[ed] an X-ray to be done and read right [away]. Writer told her that an X-ray can be gotten from the doctor, but it will take b/n (between) ,d+[DATE] hours for the X-ray to be done .[Physician's Name] was notified and the doctor said an X-ray will take about ,d+[DATE] hours to be done so the resident should be transfer[red] to the hospital via non-emergency transport for further evaluation per family request .Resident was taken out from the facility at 5:50 [PM] to [Hospital Name]. [DATE] at 6:34 PM [Hospital Discharge Summary] The patient presents from [Name of Facility], where she has been staying for the past few days . Her daughter and son-in-law went to visit her . looked under her covers, and found that her left leg was significantly inwardly rotated. They were concerned something is going wrong with the surgery at the left hip, and they requested transportation to the hospital ED (Emergency Department) Course/Critical Care .2:30 AM: The patient's hip was reduced (a procedure for treating a hip dislocation without surgery) .tolerated the procedure well .Narratives: 02:27 PM . plan to discharge back to [Name of Facility]. 03:51 PM . cleared for discharge. Request knee immobilizer for discharge . A review of the Resident #409's medical record lacked documented evidence that the facility staff that cared for Resident #409 from [DATE] to [DATE], provided her with adequate supervision, assistance and hip precautions to ensure that Resident #490's hip was not dislocated. During a telephone interview conducted on [DATE], at approximately 12:30 PM, Resident #409's daughter/representative stated, On [DATE], I noticed that my mother looked out of it and flinched when I pulled back the cover to see what was wrong. I didn't see the knee immobilizer on her leg. Her leg was positioned like the letter 'K'. I spoke with the unit manager and told her I wanted to see the doctor. They finally brought in the doctor, who said he wasn't my mother's primary doctor, and he ordered oxycodone for pain. I insisted that my mother get an X-ray for her hip. I was told the X-ray would take a long time (,d+[DATE] hours), so I asked the nurse to call 911. She told me she did not have a doctor's order, and I can call 911, so I did. 911 showed up and said it wasn't a medical emergency, so they [911] called a non-emergency vehicle, and my mother was transported to [Hospital Name]. During a face-to-face interview on [DATE], at approximately 3:30 PM, Employee #4 (Educator) stated, I told the daughter how long it would take (x-ray). She insisted we call 911 to have [Resident #409's] hip X-rayed and evaluated at the hospital. Per the daughter's request, with the doctor's permission, a non-emergency ambulance was called. The resident [ was transferred out to [Hospital Name]. I did an SBAR of the incident. During a face-to-face interview on [DATE] at approximately 4:00 PM, Employee #8 (2nd Floor Unit Manager) stated that training for residents with hip precautions usually occurs with physical therapy or by the unit managers when the resident is admitted . For [Resident #409], Employee #8 stated, I did the impromptu training in the resident's room. I trained the ,d+[DATE] CNAs and two (2) nurses who worked the day and evening shifts on this unit. I reviewed how to put the pillow/wedge between the resident's legs, how to put the hip immobilizer on the resident, and how to roll the resident on her side to prevent her from crossing midline. I reminded staff to keep the bed in the lowest position and keep the call light near the resident. Employee #8 was not able to provide a copy of the impromptu training sign in sheet or the handouts that he said were provided to the staff. There was no evidence that facility staff provided the necessary staff training and staff supervision to meet Resident #409's needs status post hip surgery. 4. The facility's staff failed to ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently, causing the resident to be transferred to the emergency room (ER) for dislodgment, keep a supply of respiratory medical equipment in the facility that was necessary to care for and treat Resident #3's laryngectomy and stoma subsequently, the resident had to be transferred to the ER for a replacement; and obtain/provide Resident #3's with HMEs. These failures resulted in actual harm to Resident #3. 4A.Review of a complaint received by the DC Department of Health on [DATE] from the resident's family member alleged that Resident #3 was rushed to theER on [DATE], which could have been fatal .because there was an HME put into his (Resident #3) neck stoma (airway). According to [NAME] Hopkins Medicine, HME is a humidifying filter that fits onto the end of the trach tube and comes in several shapes and sizes. Also known by several other terms including: Thermal Humidifying Filters, Swedish nose, Artificial nose, Filter, Thermovent T. https://www.hopkinsmedicine.org/tracheostomy/resources/glossary.html#Tracheotomy Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Malignant Neoplasm of Larynx, Carcinoma of Larynx, Acquired Absence of Larynx, and Tracheostomy Status. The resident was discharged to the hospital on [DATE]. Review of an Admission Minimum Data Set, dated dated dated [DATE] revealed that the Brief Interview Mental Summary Score section was blank. Additionally, the resident was coded for receiving Tracheostomy care and speech therapy services. Continued review showed that Resident #3 was not coded for receiving respiratory therapy services. Review of the resident's medical record revealed the following: [DATE] at 19:54 [admission nursing progress note]- Resident underwent awake tracheostomy with direct laryngoscopy and biopsy on [DATE] .upon assessment, resident alert and oriented to person and place.Resident has a [NAME] tube with cap [HME] in place . [DATE] at 20:29 [physician assistant physician progress note]- Pt. (patient) seen at bedside appears alert and stable .Pt. also has tracheostomy and doing well .vitals: ,d+[DATE] (blood press [TRUNCATED]

Based on observation, record review, resident, family and staff interviews, for 11 of 105 sampled residents, the facility's staff failed to ensure that residents received adequate supervision as evidenced by failure to 1. ensure that Resident #404 received adequate supervision to prevent an altercation with Resident #82, resulting in serious injury, 2. provide adequate supervision for Resident #56 who sustained a fall outside in front of the facility resulting in serious injury, 3. provide Resident #409 who was status post hip surgery with adequate supervision to prevent an injury of unknown origin (dislocated hip), 4. provide adequate supervision of Resident #151 to prevent altercations with Residents #71 and #67, 5. properly secure Resident #183's wheelchair during a van transport, resulting in a fall with injury, 6. provide adequate supervision of Resident #61 to prevent multiple falls with an injury, and 7. provide adequate supervision and monitoring of Resident #72 to prevent an altercation with Resident #188. Actual harm was determined for residents #404, #56, #409, #67, and #183. The findings include: Review of the facility policy entitled, Resident-to-Resident Altercation/Incidents revised in ,d+[DATE] documented, . When a resident is observed or identified as being aggressive to having aggressive behavior or has the potential for abusing other residents, an assessment of strategies to prevent such incidents from occurring will be provided by the Interdisciplinary Team (IDT) . These immediate actions may include . monitor and adjust care to reduce negative outcomes . aggressor placed on 1:1 monitoring . the care plan will be updated with the interventions in place to prevent and deescalate behaviors by the licensed nurses/manager . 1. Facility staff failed to ensure Resident #404 received adequate supervision to prevent an altercation with Resident #82, resulting in serious injury. Review of a Facility Reported Incident (FRI) dated [DATE], documented, .The charge nurse observed [Resident 404] sitting on the floor besides his roommate's . bed #420A; the charge nurse noticed blood on [Resident #404's] left ear and mouth. The nurse assessed [Resident #404's] left ear and mouth and there was no skin tear or abrasion including his face . [Resident #82] was interviewed he said, that man keeps coming over to my bed side and when I asked him to go back to his side of the bed, he punched me on my stomach and chest and I punched him on the chin and he fell . Review of a Complaint dated [DATE] documented, .family is hoping for answers after they say their father was brutally beaten at a nursing home in the District. [Representative's Name] . in an interview that his father [Resident #404] was attacked while living at the [Facility Name]. [Resident #404] died from his injuries on [DATE] (2022) . Review of a Complaint dated [DATE] documented, .Avoidable death. Comments: Patient assaulted in nursing home. Beneficiary was assaulted [DATE] in skilled nursing facility by another resident. He sustained blunt head trauma with bleeding noted on his left ear and mouth. He was transferred to an acute hospital and later died . Resident Background Information: A. Resident #82 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, End Stage Renal Disease and Sensorineural Hearing Loss. Resident #82's Quarterly Minimum Data Set (MDS) dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognitive response, no physical or behavior symptoms directed towards others, required supervision with one person physical assist for activities of daily living (ADLs), used a walker for mobility and received antipsychotic medications. B. Resident #404 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia without Behavioral Disturbances, Vascular Dementia without Behavioral Disturbances and Transient Cerebral Ischemic Attack. Review of Resident #404's medical record revealed the following: [DATE] [Quarterly MDS] showed facility staff coded a BIMS summary score of 03, indicating severe cognitive impairment. In Section E (Behavior), no potential indicators of psychosis, no physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred 1 to 3 days, wandering behaviors occurred daily In Section G (Functional Status), walk in room (how resident walks between locations in his/her room), Supervision with one person physical assist and no functional limitation in range of motion In Section P (Restraints and Alarms), wander/elopement alarm, Used daily Care Plan: [DATE] (Revision date) [Resident #404 is at risk for Elopement: cognitive impairment, dementia . Observed wondering at the adjacent unit on [DATE]. Wandering to the adjacent unit on [DATE]. Redirected easily. Wandering to the adjacent unit on [DATE]. Easily redirected. Wondering on [DATE]. Redirected. Wondering to the adjacent unit [DATE], Easily redirected . Avoid leaving unattended or unobserved for long periods of time. Hourly elopement/wandering monitoring and location. Review of the Daily Behavior Documentation showed the following: [DATE] at 2:12 PM . Elopement attempts. Wandering sleeping in other people's bed . Behaviors are constant. [DATE] at 1:12 PM . sleeping in other people bed. Behaviors are constant. [DATE] at 1:52 PM . sleeping in other people's bed. Behaviors are constant. [DATE] at 1:47 PM .sleeping in other peoples bed. Behaviors are constant. [DATE] at 12:17 PM .sleeping in other peoples bed .Behaviors are constant. [DATE] at 11:16 AM . sleeping in other people bed. Behaviors are constant. [DATE] at 12:32 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 2:10 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 1:28 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 2:19 PM .sleeping on other people's bed .Behaviors are constant. [DATE] at 1:18 PM .sleeping on other peoples bed .Behaviors are constant. [DATE] at 12:23 PM .sleeping on other peoples bed .Behaviors are constant. Skin Observation Tool dated [DATE] at 2:40 AM documented, Observations . face . Blood was coming from his mouth, we managed to stop it by applying cold compress and ice . Situation Background Assessment Request (SBAR) dated [DATE] at 4:00 AM showed, Situation . The resident got hit by his roommate . Background: Altered mental status . Resident Reports Pain? 'No'. Non-verbal indicators of pain evident? 'No'. Functional Status unchanged . Skin/Wound Status- (area was left blank) . Assessment . (area was left blank) . Additional comments . At approximately 02:30 am . The writer observed [Resident #404] sitting on the floor near roommate's bed (420 bed A) with blood coming out of his left ear, face. The writer immediately notify the supervisor and called 911. DC (District of [NAME]) police. I saw [Resident #82] also sitting on his walker facing [Resident #404]. The writer asked [Resident #82] what happened, resident stated 'I hit him because he came to my bed.' DC fire department arrived at the unit at 3:10 am and left with [Resident #404] in a stretcher accompanied by two ambulance attendants to [Hospital Name]. [Physician Name] and RP (representative) was made aware. [DATE] at 4:16 AM [Nursing Supervisor Progress Note] The Charge Nurse reported that While making routine rounds, Resident [#404] was observed sitting on the floor beside room [ROOM NUMBER] A. Resident was noted with some blood on the left side of his face, a quick assessment was made, he was assessed for pain and discomfort. Resident could not describe what happened. This is his base line. A quick assessment was done, Range of motion exercise was done, ice was applied to the left side of the face, vital signs was monitored T. (temperature) 96.5, P. (pulse) 82, R. (respirations) 18, B.P. (blood pressure) ,d+[DATE], Spoe (sp) (oxygen saturation) 97% on Room Air. [DATE] at 1:43 PM [Nurses Note] A call was placed to [Hospital Name] to know about the status of the resident [#404] in the ER, spoke with nurse [Registered Nurse's Name] who stated resident (#404) is critically ill, he has been intubated and about to be transferred to ICU (intensive care unit). RP . made aware. During a tour conducted on [DATE] at approximately 3:00 PM of unit 4 south, a facility document was observed taped to a partition at the nurses station that stated, . Updated on [DATE] 4 South List of Residents for Daily Behavior Documentation. room [ROOM NUMBER]D [Resident #404] Common behavioral traits confusion, wondering, elopement, sleeping in other peoples bed . This evidence showed that facility staff had knowledge of and documented Resident #404's intrusive behavior of going into other residents rooms and sleeping in other resident's beds. a. Although the facility had a care plan in place to address Resident #404's wandering on to other resident units; there was no evidence that the care plan was updated/revised to address the residents intrusive behavior (wandering into other resident rooms and sleeping in their beds). b. Facility staff failed to document the names, room numbers of residents who were affected by Resident #404's behavior; and failed to assess how Resident #404's behavior impacted other residents such as putting himself or others at risk for physical injury, intrusion on their privacy or activity, upset that he in their room and sleeping in their bed. c. Although the staff record that Resident #404 was being monitored hourly, he was still found wandering into other resident rooms and sleeping in their beds. There is no evidence that monitoring the resident was readjusted to manage the residents behavior. During a face-to-face interview conducted on [DATE] at 12:48 PM, Employee #7 (Clinical Coordinator) stated, I am responsible for care plan updates, creating and updating interventions. During care plan reviews, I do a 30-day look back at orders, nurse's notes, psych notes and make updates as needed. When asked if he was aware that Resident #404 had documented behaviors of going into other resident's rooms and sleeping in other resident's beds, Employee #7 stated, I was never made aware by the nurses on the unit. I knew him [Resident #404] as a wanderer, I was not aware that he was going into rooms or else his [Resident #404] care plan would have been updated to reflect that behavior and have specific interventions. When asked about the, 4 South List of Residents for Daily Behavior Documentation . that stated Resident #404's behavior, Employee #7 stated, I didn't see it. 2. Facility staff failed to provide adequate supervision for Resident #56 while in the front of the building in the non-smoking area, resulting in injury. Review of the facility incident report submitted to DC Department of Health dated [DATE] read as follows: [Resident Name] .with a BIMS score of 15 who presents with COPD, Diabetes, Heart Failure, [Hypertension], and [End Stage Renal Disease]. On [DATE], around 17:15, resident was observed outside, in the parking lot, and on the floor. Upon the initial assessment, resident was observed with a hematoma to the left side of her forehead. When asked what occurred, she informed the staff that she was attempting to get something off the floor and slid out of her wheelchair. She was assessed and did not have any complaints of pain. She was then assisted back into the wheelchair and taken up to her room for further interventions and assessments. Neuro check was conducted, and everything was within normal limits .CRNP (Certified Registered Nurse Practitioner) was made aware of the fall and an order was obtained to transfer the resident to the hospital for further evaluation. 911 was called .arrived at the facility .to take the resident to the hospital. Resident was transferred to [Name of Hospital] .Care plan updated for resident to seek assistance with retrieving items from the floor while in the wheelchair and she was educated on the importance of not bending over while in the chair for safety . Resident #56 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Hypertension, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Acquired Absence of Right and Left Leg Below the Knee. The Quarterly MDS dated [DATE] under section C0500 BIMS Score showed Resident #56 was coded as a 15 indicating that she was cognitively intact. Under Section E Behavior, the resident was coded as no behaviors exhibited. Under Section G Functional Status, the resident was coded as requiring extensive assistance with one-person physical assist under bed mobility, locomotion on and off unit, dressing and personal hygiene. Under Section G0400 Functional Limitation in range of motion, the resident was coded as having impairment on both sides of lower extremities. Under G0600 Mobility Devices, the resident was coded as using a wheelchair. Review of the nursing progress notes read as follows: [DATE] at 12:19 PM . [Employee #22 (Activities Aide)] was coming from the patio when she observed resident's wheelchair suddenly rolling into the parking lot. The Security chased after the wheelchair and resident, but resident ran into a car and fell . Resident said during interview, 'My wheelchair suddenly started rolling from the building into the parking lot, I was unable to stop it and into a car and hit my head. Head to toe assessment done; A hematoma was observed on the left forehead. No skin tear, no bleeding, no discoloration observed. Denied pain .NP (Nurse Practitioner) .was notified and she gave an order to transfer to the nearest ER . [DATE] at 11:04 AM [Nurse Practitioner Progress Note] .seen today for assessment s/p fall and f/u (follow up) ER visit .While in the ER, she had a negative head scan and negative right knee X-R (Xray), and she was sent back to the facility this morning to continue rehab and acute care. [DATE] at 11:40 AM Resident returned from [Hospital Name] at 10:15 AM in stable condition S/P (status post) fall. On assessment, swelling remains on left forehead with discoloration noted. Nose bleeding observed. Resident is alert and responsive. Denied pain. Able to communicate. Per hospital transfer records, a head CAT (computed tomography) Scan was don which demonstrated no evidence of brain injury. A face-to-face interview with Resident #56 was conducted on [DATE], at approximately 10:30 AM. She stated that someone from Activities Department was helping her outside (pushing her wheelchair). The staff member did not put the brakes on the wheelchair. The wheelchair rolled down and she hit her head on the concrete after the wheelchair hit a car and she fell over. During a face-to-face interview with Employee #22 (Activities Aide) on [DATE], at approximately 2:15 PM. He stated, I am the staff member who helped [Resident #56] with her wheelchair on [DATE] (date of the incident). Employee #22 and I (writer) proceeded outside the facility, and he showed me where he left [Resident #56], on the day of the incident ([DATE]). Employee #22 and I turned left at the front door of the facility and walked a few steps past the guardrails, towards the smoking area. He stopped between the fourth and fifth guardrail and pointed to an area with a yellow arrow on the ground and identified it as the spot where le left the resident. He said that the resident told him she had it from there. He left and went inside and within minutes, he turned around and saw [Resident #56's] wheelchair rolling down the parking lot. He ran to try to catch her and her wheelchair, but it was too late. [Resident #56's] wheelchair hit a car that was parked at the far-right corner (third row of the parking lot), and she fell out of the chair onto the concrete. During an interview with Resident #56 on [DATE] at 11:30 AM, she stated, I can lock and unlock the wheelchair. I can roll myself outside. I was coming from Bingo. I asked to go outside. They pushed me outside in front of the building. He (Employee #22) did not put the locks on the wheelchair, and he took his hands off the wheelchair. He did not push me when he let go of the wheelchair. I know how to put the locks on the wheelchair. I was outside when the incident happened. During an interview with Resident #56 on [DATE] at 11:40 AM, she stated, I did not turn the wheelchair around after the staff member left. During an interview on [DATE] at 12:20 PM, Employee #22 said that he normally locks the wheelchair before he leaves a resident but did not lock [Resident #56's] wheelchair on [DATE], because she was heading to the smoking area, they had not gotten to that area when she told him . I got it from here. He said that he thinks [Resident #56] turned her wheelchair around after he left her to head to the other side of the building where her friend [Resident #80] was. At the time of the incident, there was no evidence that facility staff provided adequate supervision for Resident #56 and other residents who were in the front of the building in the non-smoking area. Subsequently, Resident #56 was observed seated in her wheelchair, rolling through the parking lot, hit a parked car (approximately 40 feet away from the sloped sidewalk at the entrance of the building), fell out of her wheelchair and sustained a hematoma to the left side of her head. Additionally, there was no evidence that facility assessed the seating device (wheelchair) used by Resident #56 to determine if it was personal fit and safe for the resident to use. Lastly, although the facility staff states that Resident #56 is a smoker, she was not identified as a smoker and there was no smoking assessment or care plan in place to address the resident smoking. During a face-to-face interview with Employee #30 (Director of Rehabilitation Department) on [DATE], at 2:20 PM, she confirmed a wheelchair assessment was not completed for Resident #56 and provided documentation to show that a wheelchair referral was initiated on [DATE]. During a face-to-face interview with Employee #7 on [DATE] at 10:28 AM, he stated, Prior to this incident, Resident #56 was not assessed for a wheelchair. Prior to this there was no escort. I didn't know she was going outside and the facility staff said they didn't know she was going outside. The resident is free to go outside. So we put interventions in place so this doesn't happen again. During a face-to-face interview with Employee #2 (Director of Nursing) on [DATE] at 10:28 AM, she stated, She [Resident #56] was wheeling herself to smoke. He [Employee #22] was trying to wheel her to go smoke. When she turned around to go back she loss control of her wheelchair. He [Employee #22] saw her two minutes later and chased after her. 3. Facility staff failed to provide adequate supervision as specified in Resident #61's care plan resulting in the resident having multiple falls. Review of the FRI received on [DATE] documented, Writer was notified at 1405 (2:05 PM) by the receptionist at the front desk that resident is observed lying face down at the entrance of the facility . Resident reported to writer that 'I hit the wheel of my wheelchair against a surface and fell off my wheelchair and hit my head on the ground and my head hurts.right side of his forehead noted with an abrasion with no bleeding/swelling observed at this time . transfer resident to the nearest ER via 911 for further assessment . Resident #61 was admitted on [DATE] with multiple diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Anemia, Hypertension, Acute Kidney failure, Systemic Inflammatory Response Syndrome and Anxiety. Review of Resident #61's medical record revealed the following: A Quarterly Minimum Data Set (MDS), with an Assessment Reference dated [DATE] that documented the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderate cognitive impairment. In Section E (Behavior), no indicators of psychosis, rejection of care, or wandering. In Section G (Functional Status), supervision with the assistance of one person for locomotion on the unit (how the resident moves, between locations in his/her room and an adjacent corridor on the same floor. If in a wheelchair, self-sufficiency once in the chair) and locomotion off the unit (how the resident moves to and returns from off unit locations (e.g. areas set aside for dining, activities, or treatments). In Section J (Health Conditions), one (1) fall with injury (skin tears, abrasions, lacerations. Superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain) since admission/entry/reentry ([DATE]). A care plan with a start date of [DATE] showed, At risk for fall due to history of falls, unsteady gait, cognitive impairment, unstable health condition, pain, poor coordination, Diseased process .and impaired balance. Goal: Resident will remain free of injury from falls through the next review date. Interventions: Assess for fall risk on admission quarterly and as needed. Bed in low position. [DATE] at 7:11 PM [Progress Note] Writer was notified at 1405 (2:05 PM) by the receptionist at the front desk that resident is observed lying face down at the entrance of the facility. Writer rushed outside and observe resident lying face down. Resident is alert and verbally responsive. Resident reported to writer that 'I hit the wheel of my wheelchair against a surface and fell off my wheelchair and hit my head on the ground and my head hurts. Resident denies any other distress at this time .resident verbalized pain on his head on a scale of (,d+[DATE]) ,d+[DATE] . resident's right side of his forehead noted with an abrasion with no bleeding/swelling observed . MD (medical doctor) made aware . transfer resident to the nearest ER (emergency room ) via 911 for further assessment. [DATE] at 11:36 PM [Nurses Note] At about 10:10 pm staff heard a loud noise at the hall in front of room [ROOM NUMBER]. When staff went to check, they observed resident on the floor in laying position on his left side in front of his wheelchair . Resident c/o (complained of) of having severe pain to the left [side of] forehead, no discoloration or swelling noted to the site . DC (District of [NAME]) EMS (emergency medical services) called non-emergency ambulance to transport resident . [DATE](Revision date) [Care Plan with focus area] Actual fall on [DATE] with a right forehead abrasion, [DATE] fall with no injury, [DATE] fall with no injury at the front lobby. Goal: Resident will not speed when moving around in his wheelchair through the next review date. Interventions: Staff will make frequent rounds to resident's room to constantly remind resident to use the call button to call staff for assistance. Increased staff supervision with intensity based on residents' needs. Bed alarm in place. PT (physical therapy) consult for strength and mobility. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bed-bound . [DATE] at 1:55 PM [Nurses Note] Resident alert and verbally responsive. He returned from ER . at 1:35pm (1:35PM) in stable condition . Resident denied pain. CT (computed tomography) scan of the head and face indicated no acute fracture . Review of Resident #61's the medical record from [DATE], through [DATE], showed there was no documented evidence that there was an increase in staff supervision with intensity based on residents' needs as directed in the care plan (created dated [DATE]). Resident #61 sustained another fall on [DATE] with minor injury. During a face-to-face interview conducted on [DATE] at 9:30 AM, with Employee #8 (2nd Floor Unit Manager) acknowledged the finding and stated, He [Resident #61] is not supervised or monitored. He [Resident #61] goes off the unit by himself and always returned with no problem. 4. Facility staff failed to provide adequate supervision and monitoring of Resident #72's location, resulting in a resident-to-resident altercation with Resident #188. Review of a facility reported incident dated [DATE] documented, .according to the Charge nurse on the unit and the CNA, When the two of the residents got close to each other,[Resident #72] punched [Resident #188] in his face with his right hand ., Subsequently [Resident #188] fell to the floor . no injuries were noted . Resident Background Information A. Resident #72 was admitted to the facility on [DATE] with the following diagnoses: Non-Alzheimer's Dementia, Ventricular Tachycardia, Chronic Kidney Disease, Depression, and Generalized Muscle Weakness. A review of the Quarterly Minimum Data Set (MDS) for Resident #72 dated [DATE] revealed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) Summary Score was 99, indicating that the resident had severely impaired cognition. In Section E (Behavior), Wandering - Presence and Frequency. For the question, Has the resident wandered. Staff answered, Behavior of this type occurred 4 to 6 days, but less than daily. B. Resident #188 was admitted to the facility on [DATE] with the following diagnoses: Non-Alzheimer's Dementia, Altered Mental Status, Visual Hallucinations, Restlessness and Agitation. A review of the Quarterly Minimum Data Set (MDS) for Resident #188 dated [DATE] revealed that facility staff coded a Brief Interview for Mental Status (BIMS) Summary Score was 99, indicating that the resident had severely impaired cognition and wandering that occurred daily. During a tour conducted on [DATE] at approximately 9:52 AM of unit 4 south, a facility document was observed taped to a partition at the nurses station that stated, . Updated on [DATE] 4 South List of Residents for Daily Behavior Documentation. room [ROOM NUMBER] [Resident #72] Common behavioral traits, wondering, elopement, med., test refusal . Resident-to-resident altercation #1 [DATE] [Physician's Progress Note]: Patient seen because of altercation with another resident. Patient not injured. He is confused and he was separated from the other resident. He needs redirection as the other resident is in a room he used to occupy . Resident-to-resident altercation #2 [DATE] at 6:13 PM [Situational, Background, Assessment and Request (SBAR) Communication Tool]: . Resident #72 then punched Resident #188. 2. Date problem or symptom started: [DATE] .Psych consult and initiate behavior monitoring . Additional Comments. [Resident #72] was walking in the hall and [Resident #188] was walking in the hall as well. When the two of them were close, [Resident #72] then punched Resident #188 in his face with his right hand, to the left side of face. Subsequently, [Resident #188] fell to the floor as a result of the punch. The charge nurse saw the incident and then went to separate the residents immediately. [Resident #72] has been placed on 1 on 1 monitoring at this time. The mobile crisis center was updated and will be out to evaluate the resident .MD aware . Resident's care plan has been updated to reflect the incident. RP .made aware of the incident as well. [DATE] to [DATE] [Daily Behavior Documentation] showed that facility staff documented, Resident exhibits the following: Going through other people. Elopement attempts. Wandering . Behaviors are constant. Behavior problems led to issues with care 16 times in Resident #72's medical record. [DATE] [Physician's Order]: Psych (Psychiatric) consult secondary to resident-to-resident altercation. [DATE] [Physician's Order]: Provide resident with 1 on 1 sitter until cleared by psych Prior to [DATE], there was no evidence of an active care plan to address Resident #72's physically aggressive behavior. The evidence showed that the facility's staff failed to revise Resident #72's plan of care to address his aggressive behaviors resulting in another altercation with Resident #188 resulting in minor injury. During a face-to-face interview [DATE] at approximately 3:30 PM, Employee #7 acknowledged the finding and stated that Resident #72 was no longer a wanderer. 5. Facility staff failed to provide adequate supervision of Resident #151 to protect and prevent two residents (Residents' #71 and #67) from incidences of aggressive behavior (resident-to-resident altercations). Review of the FRI dated [DATE] documented, . At 0730AM, the security officer . observed [Resident #151] assaulting another resident [Resident #71] at the front of the building . Review of the FRI dated [DATE] documented, .At 2030 on [DATE] ([DATE]), [Resident #67] alleged to the receptionist that [Resident #151] hit him on his chest x 2 in the lobby . Resident Background Information A. Resident #151 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Psychosis, Epileptic Syndrome and Benign Prostatic Hyperplasia. Review of Resident #151's medical record revealed: [DATE] [Admission MDS], facility staff coded a BIMS summary score of 07, indicting severe cognitive impairment. In Section E (Behavior): E0100. Potential Indicators of Psychosis - Delusions (misconceptions or beliefs that are firmly held, contrary to reality) - yes E0200. Behavioral Symptoms: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) - Behavior of this type occurred 1 to 3 days, verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) - Behavior of this type occurred 4 to 6 days, Impact on Resident . Put the resident at significant risk for physical illness or injury? yes; impact on others . put others at significant risk of physical injury? yes; significantly intrude on the privacy or activity of others? yes; significantly disrupt care or living environment? yes In Section G (Functional Status): Activities of Daily Living (ADL) Assistance - bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, Resident #151 required supervision and one person physical assist Review of the Care Plan revealed: [DATE] (Revision date) As evidenced by a positive PASARR (Preadmission Screening and Resident Review) Level I screen and Level II evaluation, it was determined that the resident needs Specialized Services while in the Nursing Facility. Related to: schizophrenia .Inform the MD (medical doctor) if the Individual has a serious health decline and services previously agreed to may need to be modified or deleted. Inform the MD of any significant changes may require additional evaluation to add, modify or remove services . [DATE] (Revision date) [Resident #151] at risk for changes in behavior problems related to: agitation . [DATE] (Revision date) [Resident #151] has problematic manner in which resident acts characterized by inappropriate behavior; resistive to treatment/care related to: Cognitive Impairment (Dementia, Schizophrenia). Non compliant with taking medications, non compliant with vital signs, non compliant with shaving and showers. Non compliant with Wader guard place [TRUNCATED]

Based on observation, record review and staff and family interviews, for two (2) of two (2) sampled residents with laryngectomies, the facility's staff failed to: 1. ensure Resident #3's airway (stoma) was not occluded by a medical device Heat Moisture Exchanger (HME) subsequently, the resident to be transferred to the emergency room (ER) for dislodgment, 2. keep a supply of respiratory medical equipment in the facility that was necessary to care for and treat Resident #3's laryngectomy and stoma, resulting in the resident being transferred to the ER for a replacement 3. obtain/provide Resident #3 with HMEs, 4. change and clean respiratory equipment in accordance with the physician's orders for Resident #304, and 4. obtain an order for the use of a button (HME) for Resident #304 with a Tracheostomy. These failures resulted in actual harm for Resident #3, example #1. The findings include: 1. The facility's staff failed to ensure Resident #3's airway (stoma) was not occluded by a medical device HME subsequently, causing the resident to be transferred to the emergency room (ER) for dislodgment. According to [NAME] Hopkins Medicine (https://www.hopkinsmedicine.org/tracheostomy/resources/glossary.html#Tracheotomy) a HME is a humidifying filter that fits onto the end of the trach tube and comes in several shapes and sizes. It is also known by several other terms including Thermal Humidifying Filters, Swedish nose, Artificial nose, Filter, Thermovent T. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Malignant Neoplasm of Larynx, Carcinoma of Larynx, Acquired Absence of Larynx, and Tracheostomy Status. Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview Mental Summary Score section was blank, indicating the resident had not been assessed. Additionally, the resident was coded for receiving Tracheostomy care and speech therapy services. A continued review showed that Resident #3 was not coded for receiving respiratory therapy services. Review of the resident's medical record revealed the following: -12/01/21 at 19:54 [admission nursing progress note]- Resident underwent awake tracheostomy with direct laryngoscopy and biopsy on 10/27/27 .upon assessment, resident alert and oriented to person and place.Resident has a [NAME] tube with cap [HME] in place . -12/01/21 at 20:29 [physician assistant physician progress note]- Pt. (patient) seen at bedside appears alert and stable .Pt. also has tracheostomy and doing well .vitals: 126/81 (blood pressure), 86 (pulse, 18 (respiration), 97.6 (temperature), 95% RA (oxygen saturation rate on room air) . -12/02/21 [physician order]- Change HME daily day shift. -12/02/21 at 13:15 [respiratory therapy assessment]- Type- initial assessment, Resident was alert and oriented with [NAME] tube and holder in place with an HME. [NAME] tube cleaned, tube holder changed. HME changed. Pre-treatment assessment respiratory rate 18, SPO2 98% [on] room air, lung sounds clear . Post-treatment assessment respiratory rate 18, SPO2 (peripheral capillary oxygen saturation) 99% on room air, lung sounds clear . -12/03/21 [physician order] - transfer resident to the nearest ER (emergency room ) for further evaluation related to stuck HME in stoma. -12/03/21 at 14:42 [nursing progress note] - The respiratory therapist notified writer that resident has an HME stuck in the stoma (airway). Resident has a [NAME]-tube. Resident was assessed and no respiratory distress noted. Resident denied pain. No bleeding noted. O2 (oxygen) Sat (saturation) checked immediately and was 99% RA (room air). [Doctor's name] notified. He gave instruction to transfer resident to nearest ER (emergency room ) for further evaluation. Resident's granddaughter notified and wanted to know what happened. The respiratory therapist explained .when she did care for [NAME]-tube and changed HME on yesterday 12/2/21, the stoma (airway) was clear but today she observed that there was an HME stuck in the stoma. The therapist explained to the granddaughter that maybe the HME initially stuck down in stoma (airway) and the resident coughed it up .Resident's daughter .called and spoke with Respiratory Therapist .wanted to find out if resident was alive, in distress or pain and asked .how she determine that since resident is non-verbal . 911 called at 1345 and they arrived at 1400 . v/s (vital signs): 121/80 (blood pressure), 63 (pulse), 18 (respirations), 97.8 (temperature), O2 Sat (saturation) 99% RA (room air). -12/04/21 [hospital discharge summary]- Diagnosis-tracheostomy malfunction. Diagnostic radiology XR (x-ray) neck soft tissue, XR chest PA (posterior-anterior) and LAT (lateral) 2 view. Call for follow-up appointment with physician within 2 to 4 days [provided education tool] for How to Clean a Tracheostomy Tube, Adult. -12/04/21 at 07:54 [nursing progress note] - Resident came back from the hospital .on arrival 129/89 (blood pressure), 18 (respiratory rate) 98% (oxygen saturation rate) on room air. -12/04/21 [physician order] - Do not occlude stoma in neck. The [patient] is an obligate neck breather. -12/06/21 at 16:13 [physician assistant progress note] - Re-admission follow-up, pt (patient) was hospitalized for tracheostomy malfunction. Pt. seen at the bedside appears alert and stable .vitals: 130/67 (blood pressure), 71 (pulse), 17 (respirations), 97% RA (oxygen saturation rate on room air) .resp (respiration): lung CTA (Clear to auscultate), BL (bilaterally). However, further review of progress notes lacked documented evidence that Employee #31 (Respiratory Therapist) assessed or provided care for Resident #3 from 12/03/21 to 12/06/21 (post being sent to the emergency room ). Review of the December 2021 Treatment Administration Record showed the following: Change HME daily day shift (start date 12/03/21). The facility's nurse initialed on 12/03/21 indicating that she changed Resident #3's HME on dayshift Review of the comprehensive care plan with an initial date of 12/04/21 showed the following: Focus Area- [resident's name] has [NAME] tube r/t (related to) laryngeal cancer. Goal- [resident's name] will have no abnormal drainage around trachea site through the review date. Will have no s/sx (signs/symptoms) of infection through the review date. Interventions- [NAME]-tube care daily, change HME daily, assist with cough as needed . Further review of Resident#3's comprehensive care plans lacked documented evidence of interventions to address care for Resident #3's use of a [NAME]-tube and HME from 12/01/22 to 12/03/22. Review of a complaint received by the DC Department of Health on 01/26/22 from alleged that Resident #3 was rushed to theER on [DATE], because there was an HME put into his (Resident #3) neck stoma (airway). Resident #3 was unable to be interviewed at the time of the survey because he was discharged to the hospital on 03/29/2022. During a telephone interview on 04/12/22 at 11:35 AM, the resident's responsible party (granddaughter) stated that the clinical coordinator and the respiratory therapist called her informing her that the HME was stuck in her grandfather's stoma. When asked if they informed her what happened, she said, No, neither one of them could explain, but [name of clinical coordinator] said sometimes there are things that happened that we can't explain. During a face-to-face interview on 04/12/22 at approximately 5:00 PM, Employee #32 (LPN) stated, I cleaned something in his neck two times a shift. Respiratory sees him (Resident #3) all the time. I had training from respiratory, but I don't remember when. The employee also stated, I don't remember the resident (Resident #3) using a HME. During a face-to-face interview on 04/13/22 at 2:25 PM, Employee #7 (Clinical Coordinator) reported that when the respiratory therapist informed him that an HME was stuck in the resident's stoma (airway), he had Resident #3 transferred to the emergency room for evaluation. The employee then shared that Resident #3 was not in any distress when the HME was lodged in his stoma (airway). When asked if an investigation was conducted to determine how the incident of the HME being lodged in Resident #3's stoma (airway) happened, Employee #7 stated, No. The employee also said the respiratory therapist was responsible for changing the resident's HME. During a telephone interview on 04/14/22 at 2:35 PM, Employee #31 (Respiratory Therapist) stated that she informed the staff that Resident #3's HME was stuck in his stoma (airway). I'm not sure how the HME got stuck in his stoma. If he (Resident #3) did not get the HME out of his stoma it would have been detrimental. The employee stated that she worked three to four days a week, and on the days, she was not in the facility nursing staff was responsible for cleaning Resident #3's [NAME]-tube and changing the HME. Also, Employee #31 said that she provided nursing staff education on how to care for Resident #3's [NAME]-tube and HME and documented the training on a clipboard in her office. The employee also said she required nursing staff to do a return demonstration to ensure competency. During a face-to-face interview on 04/14/22 at approximately 3:00 PM, Employee #33 (RN) stated that respiratory therapy provided her with training on tracheostomy care, but they did not provide education on laryngectomy's, [NAME]-tubes, or HMEs. The employee said that although she regularly worked on the floor where Resident #3 resided, she could not remember working with him. A review of in-service training documents lacked documented evidence that staff was provided education on the [NAME]-tubes or HMEs. During a face-to-face interview on 04/14/22 at approximately 3:30 PM, Employee #4 (Educator) stated that the respiratory therapist was responsible for providing staff education on the [NAME] tube and HME. The employee said that the respiratory therapist was to provide her with written documentation of education provided to staff. However, she said, I don't have any records of education provided by the respiratory therapist. There was no evidence that facility staff developed a person-centered approach to care for and provide necessary services to Resident #3 who had a laryngectomy. Subsequently, Resident #3's airway (stoma) was occluded by a medical device HME, causing him to be transferred to the ER for dislodgment of the device. 2. The facility failed to keep a supply of respiratory medical equipment in the facility that was necessary to care for and treat Resident #3's laryngectomy ([NAME]-tube) and stoma (airway). Subsequently, the resident had to be transferred to the ER for a replacement. According to the University of Arkansas for Medical Science, a [NAME] tube is a flexible silicone tube designed to maintain the stoma right after the laryngectomy surgery. A [NAME] tube is used to maintain the airway and can be following a laryngectomy. (https://patientslearn.uams.edu/wp-content/uploads/sites/95/2018/03/Lary_Tube_Care.pdf) Review of Employee #31's (Respiratory Therapist) signed and dated 06/03/19 job description, showed that she was responsible for providing necessary material and equipment for resident (sp) to perform required therapy. Review of an Admission MDS assessment dated [DATE] revealed that the Brief Interview Mental Summary Score section was blank, indicating the resident was not assessed. Additionally, the resident was coded for receiving Tracheostomy care and speech therapy services. Review of the resident's medical record revealed a physician's order dated 12/02/21that stated, Cleanse [NAME]-tube daily on day shift. Further review of Resident #3's medical record revealed the following nursing progress notes: -01/07/22 at 4:51 PM: It was observed today that resident Laryn [[NAME]] tube is out. He was assessed by the respiratory therapist and recommended to send resident out to the ER for laryn [[NAME]] tube replacement. 911 arrived .left at 4:40 PM. -01/07/22 at 6:10 PM: [MD's Name] called from [Name of Hospital] need to know the size laryngectomy tube. RT (respiratory therapy) note said size was gathered at admission. -01/08/22 at 6:32 AM: Resident returned from [Name of Hospital] at 2:30 AM in stable condition . O2 SAT (oxygen saturation) 95% RA (room air).; and -01/08/22 at 4:02 PM: Resident alert and oriented .Resident observed with difficult breathing with the new [NAME] tube placed from hospital 1/7/22. Resident's family took him to [Name of Hospital] for follow-up and possible change of [NAME] tube .resident . O2 sat (oxygen saturation) 98. Review of the comprehensive care plan with an initial date of 12/04/21 and revision date of 1/7/22 showed the following: Focus Area- [resident's name] has [NAME] tube r/t (related to) laryngeal cancer, 01/07/22 sent out for laryn (sp) tube placement, taken to ER for laryn (sp) tube replacement. Goal- [resident's name] will have no abnormal drainage around trachea site through the review date. Will have no s/sx (signs/symptoms) of infection through the review date. Interventions- [NAME]-tube care daily, change HME daily, assist with cough as needed . Review of a respiratory therapy assessment/infection screener progress note lacked documented evidence the respiratory therapist assessed or provided care for Resident #3 from 01/05/22 to 01/12/22. Review of complaint #DC00010525 showed the complainant alleged that Resident #3 was sent to theER on [DATE] for a [NAME] tube replacement due to facility throwing out the one ([NAME]-tube) he had. During a telephone interview on 04/12/22 at 11:35 AM, the resident's granddaughter stated that the facility made her aware of the [NAME]-tube missing. She stated, I told them that my grandfather's [NAME] tube was missing when I visited him 5 days prior. I asked them why it took them so long to get his [NAME]-tube replaced. During a telephone interview on 04/14/22 at 2:35 PM, Employee #31 (Respiratory Therapist) stated that when the resident's [NAME] tube was misplaced (01/07/22) she had the resident sent out the ER for replacement. The employee then reported that while Resident #3 was in the emergency room the emergency room staff called her to inquire about the size of the resident's [NAME]-tube, but she could not give the physician the size because she did not know the size of the resident's [NAME]- tube. When asked if it was her responsibility to order respiratory supplies, Employee #31 said, Yes but she could not order Resident #3's [NAME]-tube because she did not know the size. When asked if she made the resident's physician or medical director aware, the employee stated, No, I don't talk the doctors. I made [Administrator's name] and [Clinical Director's name] aware several times. Through interview with Employee #31 there was no evidence that facility staff knew the size of Resident #3's [NAME] Tube to order replacements, therefore, none were available in the facility for use. Subsequently, Resident #3 was sent to the emergency room for replacement of the [NAME] tube. 3. Facility staff failed to obtain/provide Resident #3 with HMEs that were necessary to help reduce mucus production and coughing by humidifying and filtering the air breathed through his stoma from 01/08/22 to 03/02/22. According to [NAME] University Hospital, it is important to keep your mucus thin so that it is easy to cough up [mucous]. You should always wear a stoma protector such as a .Heat Moisture Exchange (HME: baseplate and cassette). These are available on prescription and will moisten mucous . https://www.ouh.nhs.uk/patient-guide/leaflets/files/11587Pstoma.pdf Review of complaint #DC00010525 revealed allegations that the facility did not have [NAME]-tubes and HMEs for Resident #3. Review of Resident #3's medical record showed the following Physician's orders: 12/02/21 [Physician's Order] Change HME daily Day shift. 12/02/21 [Physician's Order] Change [NAME]-Tube daily Day shift. The medical record also contained the following nursing notes: 01/07/22 at 4:51 PM [nursing progress note]- It was observed today that resident larynx tube is out. He was assessed by the respiratory therapist and recommended to send resident out to the ER for larynx tube replacement. 911 arrived .left at 4:40 PM. However, review of respiratory therapy assessment / infection screener progress notes lacked documented evidence the respiratory therapist assessed or provided care for Resident #3 from 01/05/22 to 01/12/2022. -01/07/22 at 6:10 PM [nursing progress note] - [MD's Name] called from HUH ([NAME] University Hospital) need to know the size laryngectomy tube. RT (respiratory therapy) note said size was gathered at admission. -01/08/22 at 6:32 AM [nursing progress note] - Resident returned from HUH at 2:30 AM in stable condition .vs (vital signs): 144/75 (blood pressure), 18 (respiration), 70 (pulse), 96.8 (temperature), O2 SAT (oxygen saturation) 95% RA (room air). -01/08/22 at 4:02 PM [nursing progress note] - Resident alert and oriented. Resident tolerated -feeding and all medications. Resident observed with difficult breathing with the new [NAME] tube placed from hospital 1/7/21. Resident's family took him to [Name of Hospital] for follow-up and possible change of [NAME] [laryngectomy] tube .resident .O2 sat (oxygen saturation) 98. Review of Treatment Administration Records from 01/08/22 to 03/02/22 showed that the facility's nurses initialed they changed Resident #3's HME daily on dayshift. However, it should be noted that per the respiratory therapist (Employee #31) the HME could not be changed from 01/08/22 to 03/02/22 because the facility did not have HMEs compatible to connect with Resident #3's [NAME]-tube. Review of the comprehensive care plan with an initial date of 12/04/21 showed the following: Focus Area- [resident's name] has [NAME] tube r/t (related to) laryngeal cancer, 01/07/22 sent out for laryn (sp) tube placement, taken to ER for laryn (sp) tube replacement. Goal- [resident's name] will have no abnormal drainage around trachea site through the review date. Will have no s/sx (signs/symptoms) of infection through the review date. Interventions- [NAME]-tube care daily, change HME daily, assist with cough as needed . Further review of Resident#3's comprehensive care plans lacked documented evidence of interventions to address care for Resident #3's use of a [NAME]-tube and HME from 12/01/22 to 12/03/22. Review of the of an invoice dated 03/02/22 showed the facility ordered one box of 30 cassette HMEs and 1 laryngectomy ([NAME]) tube. Further review of the invoice showed handwritten entry received [on] 03/03/22. Review of emails from Resident #3's responsible party to Employee #11 (Social Worker) showed the following: 02/22/22 at 9:30 AM -On February 7th and February 8th, I emailed [Employee #31's name- respiratory therapist] in reference to Resident #3's name [NAME]-tubes and HME's being ordered. In prior conversation she (Employee #31) stated that she needed to know the size of tube so that she (Employee #31) could order his (Resident #3) supplies. I gave her the information on the 7th (02/07/22). Checked back with her the following Monday 02/14/22) and she stated she order the belonging ([NAME]-tubes and HMEs) .She (Employee #31) has the information and the items ([NAME]-tubes and HMEs) need to ordered ASAP. 03/07/22 at 12:54 PM- Has anyone looked into his (Resident #3) [NAME] tubes and HMEs being ordered. I gave the needed information, and he still hasn't received those supplies that [Employee #31's name- respiratory therapist] ordered on February 7th of 2022. She stated that she would get back with me and never did. Theses supplies are important necessities to his current state he is in. 03/25/22 at 12:47 PM -It was told to me that the HME's and [NAME]-tubes were ordered for [Resident #3's name] back in February. Medicaid is requesting the invoices for said orders .Can you send me any and all documentation in reference to these invoices? During a telephone interview on 04/12/22 at 11:35 AM, the resident's emergency contact (granddaughter) stated, He was without a [NAME]-tube several times and they ([NAME]-tube) had to be replaced by the treatment (chemo infusion center) center. She further stated, I emailed [Employee #31; respiratory therapist] on 02/07/22 and 02/08/22 size for supplies ([NAME]-tube, collar, and straps) but she never responded. I called her (Employee #31) a week later (02/14/22) and she said [Employee #7-Clinical Coordinator] approved the supplies and she (Employee #31) ordered them. During a face-to-face interview on 04/13/22 at 2:25 PM, Employee #7 (Clinical Coordinator) stated, We had a problem with supplies one time, and I told the respiratory therapist (Employee #31) and she ordered them. During a face-to-face interview on 04/14/22 at approximately 2:00 PM, Employee #11 (Social Worker) stated that Resident #3's granddaughter emailed him on 02/22/22, 03/22, and 03/29/22 inquiring about order for supplies (HMEs and [NAME]-tubes). During a telephone interview on 04/14/22 at 2:35 PM, Employee #31 (Respiratory Therapist) stated that Resident # 3 did not a have HME to connect to his [NAME]-tube from 01/08/22 to until they were ordered and received by the facility [03/03/22]. When asked why it took so long for Resident #3 to get the HME, Employee #31 said I did not know the size of the resident's [NAME]-tube. And the HMEs we had in house was not compatible with the [NAME]-tube his family provided on 01/08/22. The employee then said she reached out to the granddaughter on 01/12/22 or 01/13/22 to get the name of the [NAME]-tube so she could order an HME, but the granddaughter said, The doctor told me (granddaughter) that the HME is not important, and she did not send me the size of the [NAME]-tube until 02/07/22. Employee #31 said that she did call the resident's physician once to get the size of his [NAME]-tube once, but he did not call her back. However, she made Employee #1 (Administrator) and Employee #7 (Clinical Coordinator) aware multiple times that Resident #3 did not have HMEs. It should be noted that nursing staff documented in Treatment Administration Records that they changed the resident's HME on the following dates: 01/09/22 to 01/25/22 01/27/22 to 02/02/22, 02/04/22 to 02/08/22, 02/11/22 to 02/14/22, 02/18/22 to 02/22/22 02/24/22 to 03/01/22. However, it should be noted the invoiced provide by the facility with an order date of 03/02/22 showed the facility did not receive HMEs until 03/03/22, at which time they received 30. During a face-to-face interview on 04/20/22 at approximately 2:00 PM, Employee #44 (Admission Director) stated that newly admitted residents' medical supplies are ordered and in the facility before the resident's admission. When asked if Resident #3's [NAME]-tubes and HME were ordered and in the facility before his admission (12/01/22), she stated, I don't know because I was not in the facility at that the time he was admitted . It should be noted that the one (1) invoice the facility provided to the surveyor had a date of 03/02/22, which documented that the facility received one (1) [NAME]-tube and 30 HMEs on 03/03/22. 4. Facility staff failed to change and clean respiratory equipment in accordance with the physician's orders and failed to obtain an order for the use of a button (HME) for Tracheostomy Status and failed to develop a care plan with goals and approaches to address the use of an HME for Resident #304. Resident #304 was admitted to the facility on [DATE] with diagnoses that included: Tracheostomy Status, Personal History of Malignant Neoplasm of Larynx, Peripheral Vascular Disease, Muscle Weakness (Generalized), and Other Abnormalities of Gait and Mobility. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was coded as follows: Section C (Cognitive Patterns), the Brief Interview for Mental Status (BIMS) Summary Score was 15, indicating that the resident was cognitively intact. Section G (Functional Status) G0110 Activities of Daily Living (ADL) Assistance: for bed mobility, transfers, and personal hygiene, the resident required extensive physical assistance from one staff member; and for eating the resident required limited physical assistance from one staff member. Section O (Special Treatments, Procedures, and Programs): O0100 Special Treatments. Respiratory Treatments resident receives oxygen therapy, suctioning, and tracheostomy care. The number of days this therapy was administered for at least 15 minutes a day in the last seven days was 0. A review of Resident #304's medical record revealed: 10/17/2019 [Hospital Discharge Summary]: .PMH (past medical history) of laryngeal cancer with laryngectomy with permanent tracheostomy ([AGE] years ago) . Laryngeal Cancer: stable. s/p (status post) laryngectomy with trach (2004). Does not need O2 (oxygen) at baseline but needs humidification of the stoma. SpO2 (oxygen level) goal >90%. SLP (speech-language pathologist) was consulted about a replacement speaking valve. 11/30/2019 [Physician Orders]: .Ensure tracheostomy kit is at resident bedside at all times. 01/17/2020 [Physician's Order]: Oxygen at 3L/min continuously via trach mask every shift. 11/30/2020 [Physician's Order]: Change trach set-up weekly every Monday & PRN . Change O2 tubing and humidifier bottle weekly & PRN one time a day every [Monday] 02/18/2022 [Respiratory Therapy Assessment]: . Resident alert and oriented in no distress on trach collar. Humidification set-up changed and dated. Voice prosthesis cleaned. Small tan secretion expectorated. 02/14/2022 [Physician's Order]: .Clean concentrator and air compressor filters weekly and PRN as needed.' 04/04/2022 [Physician's Order]: Check Spo2 every shift to maintain above 92%. Notify MD (medical doctor/RP (representative) if noted below (2% every shift. According to the March 2022 Treatment Administration Record, facility staff were signing in the designated spaces to indicate that they: Changed the O2 tubing and humidifier bottle weekly and PRN one time a day every [Monday] on 3/7/2022, 3/14/2022, 3/21/2022 and 3/28/2022.; and they cleaned [oxygen] concentrator and air compressor filters weekly and PRN as needed on 3/07/2022, 3/14/2022, 3/21/2022 and 3/28/2022. According to the April 2022 Treatment Administration Record, facility staff were signing in the designated spaces to indicate that they: Changed the O2 tubing and humidifier bottle weekly and PRN one time a day every [Monday] on 04/04/2022 and 04/11/2022; and they cleaned [oxygen] concentrator and air compressor filters weekly 04/04/2022 and 04/11/2022. During a second-floor tour on 04/04/2022 at 12:31 AM, Resident #304 was observed in his room lying on his bed and watching television. He was receiving humidified oxygen via corrugated tubing connected to his trach collar on one end and connected to a humidifier bottle of sterile water that had oxygen filtered into it on the other end. The corrugated tubing had no label to indicate when facility staff last changed it, and the sterile water bottle had a label dated 03/06/2022. On 04/04/2022 at 3:30 PM, during a face-to-face interview with Employee #2, Director of Nursing (DON), she stated that usually, the nurses and the respiratory therapist are responsible for providing care to the residents, but the facility currently had no respiratory therapist. She reported that the facility had a part-time respiratory therapist (RT) who stopped showing up after the last shift on 3/20/2022, from 7: 00 AM to 4:30 PM. When asked if the nurses were trained to order tracheostomy supplies, suctioning equipment, adjust settings on CPAP (Continuous positive airway pressure), etc. She said, No, that was done by the respiratory therapist in the past. She reported that she was in the process of contacting an agency RT and should have one confirmed by the end of the day. She also stated that she would check Resident #304 and make sure the resident's tubing and humidification bottle were changed and dated. During observation and interview on 04/07/2022 at 4:18 PM, Resident #304 was observed lying in his bed. The resident was wearing a trach collar and was receiving humidified oxygen. The oxygen tubing and the humidified oxygen bottle had labels dated 04/05/2022. When asked who is responsible for suctioning and providing his trach care, the resident stated, I do not get suctioned. I cough up sputum myself. I do not have a trach; I have a laryngectomy with a valve. I use humidified oxygen to keep my stoma moist and help me breathe. The respiratory therapist used to come in once a week to clean my stoma and change out everything, but I haven't seen the RT in a few weeks. There was no evidence of a tracheostomy kit at the resident's bedside per the physician's orders and no evidence of the resident's button that he uses to breathe outside of the facility. During a second-floor tour on 04/18/2022 at 9:23 AM, Resident #304 was observed wearing his trach collar and was receiving humidified oxygen. The oxygen tubing and the humidifier bottle had labels from 04/05/2022 on them. The oxygen concentrator was beside the resident's bed. The concentrator and the air filters to the concentrator were dirty. On 04/18/2022 at 9:30 AM, during a face-to-face interview with Employee #39 (Registered Nurse), she stated that Resident #304 does not have a tracheostomy and does not require suctioning. She added that she had recently provided him with stoma care (cleaned the stoma), but the respiratory therapist changed the trach set-up (trach collar, tubing, and humidification bottles). She also knew nothing about the resident's button. On 4/18/22 at 9:49 AM, Employee #8 (Unit Manager/Registered Nurse), present at the time of the observation, when asked who was responsible for cleaning the concentrator at the resident's bedside, he responded the nurses were responsible. He acknowledged the resident's dirty oxygen concentrator and air filters and said he would clean them. During a face-to-face interview on 04/18/2022 at 11:30 AM with Employee #42 (Newly hired Respiratory Therapist), he stated he was contract staff for the facility, and he had just started yesterday. He said he was not provided an orientation to the facility and had just met the residents requiring respiratory care. He said he would have to schedule a meeting with the DON to determine what supplies were needed. He explained that the clear button Resident #304 referred to is an HME like a nose; it helps the resident breathe. He noted that Resident #304 could not find his HME and stated he would follow up. Through observation, review of Resident #304's medical record, review of facility documents, and resident and staff interviews, facility staff documented that they were changing the O2 tubing and humidifier bottle weekly and cleaning the concentrator and air compressor filters weekly, however through observation and staff interview it was noted that it did not occur. Also, through review of Resident #304's medical record did not show an order for the use of an HME for the resident, and no care plan with goals and approaches to address the use of an HME for the resident. 45104

Based on clinical record review, resident interview, and staff interviews for one (1) of 51 sampled residents, it was determined that the facility staff failed to prohibit neglect of the resident, as evidenced by the staff's failure to provide Activities of Daily Living (ADL) care to Resident #259. The findings include: A review of the admission record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) dated January, 1, 2015 revealed under Section G (Functional Status), that the resident required extensive assistance with at least one (1) person assistance in personal hygiene, dressing, and toileting. The resident also required extensive assistance in bathing, bed mobiltiy and transfering, with two persons physical assist. The resident had functional limitations in range of motion to bilateral lower extremities. In Section H (Bladder and Bowel) the resident was coded as frequently incontinent of urine and bowel. A review of the care plans dated December 24, 2014 revealed the resident had an ADL self-care performance deficit that required one (1) staff participation with bathing. On February 20, 2015 at approximately 2:45 PM, a face-to-face interview was conducted with Resident # 259, regarding a complaint that was made on February 15, 2015. The resident stated, On Sunday (February 15, 2015) it was only two (2) Certified Nursing Assistants (CNA's) on the floor. The only time I saw a CNA is when they brought my tray in for lunch. I waited after lunch for someone to service me. At 2:55 PM, a CNA came in the room. I don't know (his/her) name, and it's not my job to give names. The CNA said, (resident's sir name), because of the workload we have, I'm not able to get to you on this shift. I will relay this to the next shift to take care of you. A little after 3:00 PM, the charge nurse came in the room, and I told the charge nurse. The charge nurse said, I know. I just don't have the people to work the floors. I apologize. I will let the next shift know to definitely clean you up. These nurses are so frustrated and they don't want to confront management because they are afraid their jobs are in jeopardy. I got cleaned up after 4:00 PM. I told the social worker on February 17, 2015 that I wanted to speak to administration (named personnel). On February 18, 2015, they both (facility and nursing administration) came up to my room. I explained the situation. I didn't bite my tongue. I told them that management is doing a poor job providing us quality service. I told them it's no way to give quality service with two CNA's covering 35 people. I told (administration) that the blame is on them. I told them that we are paying residents and we demand quality services and I'm tired of hearing excuses. When asked what happened thereafter, he/she stated they (administration) apologized. On February 20, 2015 at approximately 3:15 PM, a face-to-face interview was conducted with Employee #34. When asked who provided ADL care to the resident, he/she stated, I gave (resident's name) a complete bath, at approximately 4:00 PM or so. He/she stated, The CNA that was assigned on the day shift gave shift report that he/she (CNA) wasn't able to get to (resident's name) because they only had two CNA's that morning. He/she was giving care to the resident in the 'D bed', when I came in. On February 20, 2015 at approximately 3:35 PM, a face-to-face interview was conducted with Employee #19 regarding the complaint. He/she stated, I am aware of a complaint about the floor only having two CNA's. I received a grievance form from the nurse manager. It was a complaint by (resident's name). I spoke to (resident's name) on the 17th (February 17, 2015) to see what happened. He/she reported that they only had two) CNA's on the day shift this weekend. He/she stated that management doesn't care about the residents, its poor management, and he/she was going to report this to the state (State Agency), when they come in tomorrow. He/she asked to speak to administration. I met with him/her on February 18, 2015. I spoke to him/her the day before yesterday. He/she told me that (administration) came to talk to him/her. On February 20, 2015 at approximately 3:55 PM, a face-to-face interview was conducted with Employee #28. He/she acknowledged the aforementioned findings. He/she stated, We know that (Employee #37's name) did not bathe the resident, and he/she was suspended for five days. A review of the Certified Nursing Assistants (CNA's) assignment(s) for February 15, 2015 revealed that Employee #37 was assigned to care for Resident #259 from 7:00 AM - 3:00 PM. A review of Employee #37's written statement revealed the following: I was floated to 5S (5 South) from 4S (4 South) over the weekend. We working 2 (two) CNA's. I realized (resident's sir name) did not get ADL care. I informed (resident) I will let the next shift know because I didn't have enough time, I still had 2 (two) other residents to care for. According to 3211.5 of the District of Columbia Municipal Regulations, Nursing personal and required daily average staffing levels are as follows: Registered Nurses 0.6 Total Staffing 4.1 A review of the facility staffing on February 15, 2015 revealed the following: Registered Nurses 0.42 Total Staffing 2.82 The staffing results listed above reveal that the facilty failed to provide sufficient numbers of personnel to provide nursing care to the resident. Subsequently, facility staff neglected to provide ADLs care such as, personal hygiene, dressing, bathing, toileting for Resident #259. On February 20, 2015 at approximately 5:00 PM, a face-to-face interview was conducted with Employee #2 regarding the aforementioned findings and staffing. He/she acknowledged the aforementioned findings. The clinical record was reviewed on February 20, 2015.

A. Based on observations, record review and interviews for two (2) of 51 sampled residents, it was determined that the facility staff failed to implement measures to safeguard the integrity of one (1) resident ' s central venous catheter (Permacath) from unintentional dislodgement and trauma. For the same resident, facility staff failed to develop a coordinated interdisciplinary Hospice plan of care that guides both providers (hospice and the nursing facility) to meet the assessed needs for the resident. Facility staff failed to effectively manage pain and a chronic disorder of the Central Nervous System ([MEDICAL CONDITION]) for one (1) resident. Residents' #286 and 177. The findings include: 1. Facility staff failed to implement measures to safeguard the integrity of one (1) resident ' s central venous catheter (Permacath) from unintentional dislodgement and trauma. For the same resident, facility staff failed to develop a coordinated interdisciplinary Hospice plan of care that guides both providers (hospice and the nursing facility) to meet the assessed needs for Resident #286. A. Facility staff failed to implement measures to safeguard the integrity of Resident #286's central venous catheter (Permacath) from unintentional dislodgement and trauma. A venous catheter is a tube inserted into a vein in the neck, chest, or leg near the groin, usually only for short-term [MEDICAL TREATMENT]. The tube splits in two after the tube exits the body. The two tubes have caps designed to connect to the line that carries blood to the dialyzer and the line that carries blood from the dialyzer back to the body, (National Kidney and Urologic Diseases Information Clearinghouse). http://kidney.niddk.nih.gov/KUDiseases/pubs/vascularaccess/index.aspx Resident #286 was admitted to the facility on [DATE] with no known allergies and a past medical history that included: Candidiasis, Unspecified Pruritic Disorder, [MEDICAL CONDITION], End Stage [MEDICAL CONDITION], Secondary Parkinsonism, and Essential Hypertension. The quarterly Minimum Data Sets dated November 25, 2014 and January 19, 2015 were reviewed. Under Section B (Hearing, Speech and Vision) the resident was coded as having no speech. Under Section C (Cognitive Skills) the resident was coded as being severely impaired. Under Section E (Behaviors) the resident was coded as having no behavioral issues. Under Section G (Functional Status) the resident was coded as totally dependent in bed mobility, transfers, dressing, eating, personal hygiene and toilet use. The resident was coded as having no impairment in upper extremity range of motion, (shoulders, elbow wrist and hand) in Section G0400 (Functional Limitation in Range of Motion). Under Section O (Special Treatments, Procedures, and Programs) the resident was coded as receiving [MEDICAL TREATMENT]. A review of the nursing notes revealed: December 8, 2014 at 15:19 (3:19 PM) Resident alert and responsive. Left chest permacath dry and intact, no bleeding noted. December 9, 2014 at 08:19 (AM) Resident ' s left chest permacath observed coming out, no bleeding noted. Nursing supervisor made aware, said to send resident to [MEDICAL TREATMENT]. Call placed to (physician) and message left. [MEDICAL TREATMENT] nurse (sent) resident back to the floor and said to(send) (him/her) to (the) hospital. (Physician) returned call and spoke with the supervisor and ordered to send resident to (Outpatient Medical Center) for permacath replacement. (Outpatient Medical Center) was called and not open till 8:00 AM. Next shift handed over to observe resident for bleeding and follow up with appointment . December 9, 2014 at 11:47 (AM) Resident alert and responsive. No bleeding noted from old access site left upper chest. V/S (vital signs) 98.0 (temperature), 78 (pulse), 20 (respirations), 160/90 (blood pressure). Call placed to (physician at the Outpatient Medical Center) for appt (appointment) for permacath replacement. Resident needs a referral from [MEDICAL TREATMENT] to go to (Outpatient Medical Center), [MEDICAL TREATMENT] made aware. December 9, 2014 at 14:01 (2:01 PM) Resident responsive to stimuli, V/S (vital signs) 97.9 (temperature), 60 (pulse), 18 (respirations), 130/60 (blood pressure). Resident left the unit at 1:50 PM via 911 to (hospital name) for left chest permacath replacement . December 9, 2014 at 22:41 (10:41 PM) Resident admitted at (hospital name) . December 10, 2014 at 01:03 (AM) Late entry note for 12/9/14: Supervisor was called at 6:45 AM that resident permacath was dangling, resident was assessed and noted that the permacath was out (more) than usual and was dangling, no bleeding noted at the site. Resident is (non) verbal and unable to explain .resident was put in (geri) chair and took down to [MEDICAL TREATMENT] to also co-assessed by the charge nurse, the change nurse was not available, and at 7:05 AM the charge call supervisor that the permacath was completely out, but no bleeding or drainage noted. Supervisor immediately (covered) the site with 4x4 (guaze) and opsite (dressing cover) to prevent air embolism . On December 11, 2014 at 15:14 (3:14 PM) Resident #286 was (readmitted ) from the (hospital) . S/P (status [REDACTED]. January 7, 2015 at 19:58 (7:58 PM) Resident alert and responsive. Left chest permacath intact no bleeding noted or swelling noted . January 8, 2015 at 08:39 (AM) The writer was called to resident room at 7:15 AM, left chest permacath was dislodged and observed on (his/her) body. No bleeding observed, no distress noted. Supervisor made aware, site covered with dry dressing. (Attending physician) paged and message left. 911 was called and came in at 7:31 AM. Resident left the unit at 7:41 AM . January 13, 2015 at 16:19 (4:19 PM) Resident readmitted from (hospital) .patient had newly placed permacath on the right thigh (groin) which is double lumen and properly secured .skin is warm to touch, dry, and noted with multiple scars on the left neck, bilateral upper chest, right ankle, and scratch marks all over the body .Peri-wound is noted with discoloration and multiple scratch wounds, right buttocks noted with scratch wound measuring (1.0 cm x 0.5 cm x 0.1 cm) .Resident was seen scratching self, fingernails trimmed . January 13, 2015 at 20:14 (8:14 PM) Left buttock scratch wound instead of right. January 14, 2015 at 00:30 (12:30 AM), Resident is readmitted from (hospital name) permacath replaced to right femoral . February 7, 2015 at 13:38 (1:38 PM) Resident is responsive. Right femoral catheter is dry and intact, no bleeding noted . February 7, 2015 at 18:19 (6:00 PM) Supervisor call by Safety for a resident being sent out of [MEDICAL TREATMENT] center. Supervisor went to 1st floor to find a resident (on) a stretcher in ambulance. [MEDICAL TREATMENT] staff narrated that resident pulled (his/her) right femoral [MEDICAL TREATMENT] access and therefore 300 ml (milliliters) of blood in the dialyzing line was unable to return to the system and therefore wasted. Per [MEDICAL TREATMENT] staff, this event occurred and hour towards the end of treatment. Resident taken to (hospital name) at 15:00 (3:00 PM) by ambulance .charge nurse call (hospital) at 6:22 PM to verify resident ' s status and (he/she) was informed that resident will be admitted . The [MEDICAL TREATMENT] Communication forms from November 2014 through February 7, 2015 were reviewed. It was noted that sections of the forms were incomplete/or left blank. For example: Part I- comments or questions , glucose (level) , did the patient eat before [MEDICAL TREATMENT] , time taken , problems noted and/or resident complaints , nurse signature ; Part III- patient status , glucose (level) . It was determined that facility staff failed to consistently complete sections of the forms, to communicate pertain information regarding the resident ' s clinical status and care needs. A review of the care plan section of the active clinical record revealed that there was no care plan initiated with goals and approaches to address the resident ' s dislodging of the perm-a-cath. In addition there was no evidence that facility staff initiated a care plan to address the residents scratching of his/her skin until January 4, 2015, however this concern was first observed in July 2014. Interviews: A face-to-face interview was conducted on February 11, 2015 at approximately 11:00 AM with Employee #56 Occupational Therapist. He/she stated, The resident did not participate in therapy. (He/she) did not show purposeful movement, but (he/she) could not follow commands. The resident ' s fingers were not contracted but both of (his/her) wrists were stiff. The resident was receiving occupational therapy for positioning and range of motion. A face-to-face interview was conducted on February 11, 2015 at approximately 4:20 PM with Employee #11. He/she stated, The resident has a [DEVICE] and a permacath on (his/her) left side. The resident did not have any behavioral issues. (He/she) itches. He/she took the permacath out twice (from the chest). After the second time (the catheter was pulled out) it was put in (his/her) thigh (groin) and (he/she) took it out. (He/she) is at the hospital now and (he/she) is Hospice. The resident ' s nails were short. Employee #11 was asked if the resident had dermatology consult due to the resident itching. He/she replied, No. The employee was then asked what measures were put in place to address the resident's scratching. He/she replied, The resident was prescribed [MEDICATION NAME] (anti-itch medicine) cream and Hospice nurse ordered something for the itching. We also monitored the resident and checked (his/her) vitals. (He/she) pulled at (his/her) clothes and scratched. In addition, the employee acknowledged that the communication forms were not consistently completed and there was no information recorded on the forms regarding the resident pulling on his/her clothing and scratching him/herself. In summary, Resident #286 dislodged his/her chest permacatheter on December 9, 2014. The resident was first transported to the first floor to the [MEDICAL TREATMENT] center to seek assistance. The resident was then returned to the nursing unit. The facility staff attempted to make an appointment with an Outpatient Medical Center to have the permacatheter reinserted. Approximately five (5) hours later the resident was sent from the facility to the hospital via 911. The resident was admitted to the hospital. On December 11, 2014 Resident #286 was readmitted to the facility from the (hospital). During the resident ' s stay, a left upper chest permacatheter replacement occurred. There was no evidence that facility staff implemented measures to help prevent future removal or dislodgement of the catheter. January 8, 2015 the resident was observed with his/her left chest permacatheter dislodged and observed on his/her body. The resident was sent to the hospital via 911. January 13, 2015 the Resident was readmitted from (hospital) .patient had a newly placed permacatheter on the right groin. The resident also presented with scratch marks all over his/her body and the peri-wound was noted with multiple scratch wounds, right buttocks noted with scratch wound measuring (1.0 cm x 0.5 cm x 0.1 cm). It was also recorded that the resident was seen scratching his/herself and the resident ' s fingernails were trimmed. Through record review and staff interview, there was no evidence that the facility staff communicated with the [MEDICAL TREATMENT] staff on the communication forms regarding the resident's itching, scratching and the resident dislodging the permacatheter. After the second occurrence of the permacatheter being dislodged, there was no evidence that facility staff implement approaches to help prevent the resident from dislodging/removing the permacatheter or the femoral catheter. Subsequently, on February 7, 2015 it is recorded that while receiving a [MEDICAL TREATMENT] treatment the resident pulled (his/her) right femoral [MEDICAL TREATMENT] access and therefore 300 ml (milliliters) of blood in the dialyzing line was unable to be return to the resident resulting in blood loss. The Resident was taken to the hospital and admitted . The record was reviewed on February 11, 2015. 1B. Facility staff failed to develop a coordinated interdisciplinary Hospice plan of care that guides both providers (hospice and the nursing facility) to meet the assessed needs for Resident #286. A review of the physician's order [REDACTED]. The quarterly Minimum Data Sets January 19, 2015 was reviewed. Under Section O (Special Treatments, Procedures, and Programs) the resident was coded as receiving Hospice. Review of the Hospice care plan dated January 23, 2015 under Focus states, Resident family agree for resident to be hospice due to (his/her) prognosis. Resident was admitted into hospice care on 01/23/2015 (January, 23, 2015). The Goal states, Residents family wishes will be respected with regards to hospice care through the review date. The Interventions include Continue quarterly care conference with all members of the team to address resident/family need, and Coordinate care with (Outside provider) hospice. Resident #286 ' s electronic record and paper chart revealed that there were no hospice notes/information related to care of the resident (i.e. the initial and ongoing assessments, the interdisciplinary plan of care) available for review. A face-to-face interview was conducted with Employee #11 on February 11, 2015 at 12:45 PM. He/she stated, I will call Hospice and ask them for the notes. Employee #11 the picked up the phone and called the hospice organization in the presence of the surveyor. Employee #11 then stated, The notes will come within an hour per hospice. Employee #11 further acknowledged the findings. There was no evidence that a coordinated interdisciplinary Hospice plan of care that guides both providers (hospice and the nursing facility) to meet the assessed needs for Resident #286 was not readily available in the active clinical record. A face-to-face interview was conducted with Employee #11 on February 11, 2015 at 12:45 PM. He/she acknowledged the findings. The record was reviewed on February 11, 2015. 2. Facility staff failed to implement an effective pain management regimen and address the neurologist ' s recommendations in a timely manner for Resident #177. A family interview with Resident #177 ' s Responsible Party (RP) was conducted on February 11, 2015 at approximately 2:00 PM. The Responsible Party voiced the following concerns: · Regarding Resident #177 ' s medication- This is extremely pressing for me. (Resident #177) had an appointment with the neurologist secondary to swallowing issues. He/she (the nurse) was unable to administer the medication (Tecifidera- medication for [MEDICAL CONDITION]) secondary to resident ' s swallowing deficit. The RP found out within the last month or so that the resident ' s old medication had been discontinued. · Regarding Resident #177's pain - The RP verbalized that (he/she) is unsure if the pain medication is strong enough because the resident moves from side to side and/or grips the bedrail when (he/she) is in pain. Visited Resident #177 four (4) days ago in the evening. When I arrived, (he/she) was in pain. (He/she) was holding the side rails. I asked the evening nurse about (his/her) pain medication. He/she looked at the medication record and nothing was recorded that (he/she) received anything for pain. · Regarding nursing staffing - The RP stated that at times there are only two (2) CNA ' s (Certified Nursing Assistants) on evenings and weekends. An annual physician history and physical dated January 31, 2015 revealed Resident #177 ' s medical [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) dated October 12, 2014 revealed that Under Section G (Functional Status) the resident was coded as totally dependent in bed mobility, transfers, dressing, eating, personal hygiene and toilet use. The resident was coded as having bilateral lower extremity impairment and impairment to one side in the upper extremity (shoulders, elbow wrist and hand) in Section G0400 (Functional Limitation in Range of Motion). Under Section J (Health Conditions) revealed that Resident #177 was on a scheduled pain medication regimen and receiving PRN pain medications. The resident was also coded as having a numeric rating scale of 06 (the Numeric Rating Scale was from 0-10 for pain intensity. During an observation conducted on February 11, 2015 at approximately 4:45 PM, the resident was observed lying on (his/her) back in the bed and covered with a white sheet. (His/her) head was positioned towards the left of the bedside rail. He/she was instructed to blink (his/her) eyes once for yes and twice for no. When queried if (he/she) was in pain, (he/she) nodded (his/her) head and blinked (his/) eyes one time. The writer informed Employee # 67 that the resident was in pain. An annual physician history and physical dated January 31, 2015 revealed Resident #177 ' s medical [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) dated October 12, 2014 revealed that Under Section G (Functional Status) the resident was coded as totally dependent in bed mobility, transfers, dressing, eating, personal hygiene and toilet use. The resident was coded as having bilateral lower extremity impairment and impairment to one side in the upper extremity (shoulders, elbow wrist and hand) in Section G0400 (Functional Limitation in Range of Motion). Under Section J (Health Conditions) revealed that Resident #177 was on a scheduled pain medication regimen and receiving PRN pain medications. The resident was also coded as having a numeric rating scale of 06 (the Numeric Rating Scale was from 00-10 for pain intensity. During an observation conducted on February 11, 2015 at approximately 4:45 PM, the resident was observed lying on (his/her) back in the bed and covered with a white sheet. (His/her) head was positioned towards the left of the bedside rail. He/she was instructed to blink (his/her) eyes once for yes and twice for no. When queried if (he/she) was in pain, (he/she) nodded (his/her) head and blinked (his/) eyes one time. The writer informed Employee # 67 that the resident was in pain. A review of the signed physician's order [REDACTED]. October 6, 2014 - [MEDICATION NAME] (man-made form of cannabis- also known as marijuana) 5mg capsule- 1 (one) cap (capsule) twice a day for pain control. October 6, 2014 - Tecfidera ( medication used for the treatment of [REDACTED]. October 6, 2014 -Tylenol ( [MEDICATION NAME]- pain reliever) -650 mg tablet enteral pain - (route) rectum prn for pain. October 20, 2014- 3:00 PM- [MEDICATION NAME] (narcotic -like pain reliever) 50mg via GT (Gastrostomy Tube) Q (every) six (6) hours prn (as needed) pain. (Please) assess resident for pain and medicate as prescribed. December 21, 2014- 1520 (3:20 PM) - Hold Tecfidera until pharmacy gives an alternative (medication) (to be given) IM (Intramuscular injection). January 3, 2015 Monthly physician's order [REDACTED].> Assess resident for pain every shift on a scale from 0 to 10 every shift; Diet Orders: Aspiration Precaution: Hold Tecfidera until pharmacy gives an alternative every shift; [MEDICATION NAME] (Tylenol- [MEDICATION NAME]- pain reliever) 650mg rectal- prn pain every 6 (six) hours; [MEDICATION NAME] ([MEDICATION NAME])- (therapeutic class: Anticonvulsant, also used for migraine [MEDICATION NAME] and tremor associated with [MEDICAL CONDITION]) capsule 400mg three times a day- 1 cap via [DEVICE] tid (three times a day) for neuropathic pain; [MEDICATION NAME] HCL ([MEDICATION NAME]) - ([MEDICATION NAME])-tablet 50mg - Give 1 (one) tablet via [DEVICE] every 6 (six) hours as needed for pain . A review of the October, November and December, 2014, January and February 2015 MARs revealed that Resident #177 did not receive [MEDICATION NAME]. A review of the October, November and from December 1 - 21, 2014 the resident was administered the Tecfidera. From December 22, 2014 to February 19, 2015 the resident did not receive the Tecfidera. Notes: A review of the Physician ' Progress Notes revealed the following: October 9, 2014- 16:10 (4:10 PM) - Resident was assessed by speech and pleasure feeding discontinued. Resident is NPO (nothing by mouth) MD (medical doctor) was notified and [MEDICATION NAME] held until NPO status is discontinued . RP aware . October 20, 2014- 15:07- (3:07 PM) - Type: SOAP (Subjective, Objective, Assessment, Plan) Note-Nurse Practitioner- Resident with history of [MEDICAL CONDITION] bladder, MS ([MEDICAL CONDITION]) and advanced immobility, and depression seen today for evaluation. (His/her) (Responsible party named), (his/her) (responsible party) states resident is having pain and would like (him/her) to have pain medication because Tylenol is not working for (him/her). Resident nods when asked if (he/she) is having pain. Plan: [MEDICATION NAME] 50mg (milligram) q (every) 6 (six) prn (as needed). November 3, 2015- 15:12 (3:12 PM) - Type: SOAP Note- Nurse Practitioner- Subjective: Resident with history of . MS and advanced immobility . seen today for evaluation. (Relative named) reported that resident was not getting pain medication as needed, (he/she) saw that (he/she) was gripping the bed rail which shows that (he/she) is in pain, explained to (him/her) that the nurses assess the resident for pain which (he/she) is able to nod yes or no. Plan: Continue plan of care. Nurses to assess for pain and offer pain medication. November 18, 2014- 15:45 (3:45 PM) - Type: SOAP Note- Nurse Practitioner- . Resident is currently on tube feedings. Unit manager states (he/she) was evaluated about a month ago, with results being unsafe for resident to have food by mouth. Plan: SLP (Speech Language Pathology) evaluation and treatment for [REDACTED]. November 25, 2014 - Physical Examination- Attending Physician - Have Pain: N , Plan/Recommendations- Hold Tecfidera, Continue current management, Aspiration Precautions December 11, 2014- 15:56 (3:56 PM) - Type: Nurses Note- .Tecfidera 240mg was not given because medication cannot be crushed. A call was placed to the MD (Medical Doctor) and MD instructed that a call be placed to pharmacy to get a substitute for the medication. MD said (his/her) phone number (will) be sent to pharmacy for them to call (him/her) so that they can come out with a cheaper substitute. MD suggested [MEDICATION NAME] (medication used to treat relapsing [MEDICAL CONDITION]) MCG (microgram) IM Q (every) week. A call was placed to pharmacy and all information given, MD number. December 21, 2015 15:25 (3:25 PM), Nurses Notes: .Resident was seen by (attending physician) and new order to hold Tedfidera 240 mg until MD talks to the pharmacy . January 5, 2015 at 16:16 (4:16 PM) - Nurses Notes:.Tecfidera to be discontinued due to resident is unable to swallow. Medication cannot be crushed .Pleasure feeding discontinued by the speech therapist. Responsible party informed . January 31, 2015- Physical Examination- Physician ' s Note: Have Pain: N ; Plan/Recommendations: Neurology f/u (follow up) for MS ([MEDICAL CONDITION]) meds (medications) and start via [DEVICE] (Gastrostomy Tube) or IM. February 16, 2015- 15:12 (3:12 PM)- Type: SOAP Note- Subjective: .seen today for evaluation- states (he/she) had pain, tried to point to (his/her) head. Nurse administered pain medication right away. Plan- [MEDICATION NAME] (Atypical anti-psychotic) decreased to 50mg q hs (hour of sleep) - On [MEDICATION NAME] 600mg (milligram) tid (three times a day). Neurology Consultation: A neurology consult dated January 20, 2015 revealed: From Wellness notes, patient is on Tecfidera 240mg twice per day along with adjunct medications of [MEDICATION NAME] and [MEDICATION NAME] (drug for urinary tract anti-spasmodic). Off [MEDICATION NAME] of which (resident ' s responsible party) is not sure why. According (to) (Responsible Party), patient has verbalized pain sensation as well as observed non-verbal cues. (He/she) points to (his/her) headache and body. (He/she) does receive as needed APAP (Tylenol- pain [MEDICATION NAME]). (He/she) is off [MEDICATION NAME]. Most pressuring issues today to (his/her) (Responsible Party) are: (1) worsening dysphagia- (patient) can no longer swallow Tecfidera (oral delayed-released capsules used for the treatment of [REDACTED]. Patient Instructions: Problem #1: (History) of [MEDICAL CONDITION], Progressive/Relapsing- The patient has presented with chronic progressive MS. (He/she) has been on Tecfidera for several months. Unfortunately, because the Tecfidera capsules cannot be crushed and given to (him/her) via [DEVICE], we have to switch the patient to AUBAGIO (teriflunomide)- (used to reduce flare-ups in people with relapsing [MEDICAL CONDITION]) at an initial dose of 7mg once a day daily for about 3 months, then switch to the 14mg/day dose( enrollment form was completed today). TB ([MEDICATION NAME]) test will be required. Liver function will have to be checked monthly for the first 6 (six) months of therapy. (2) We suggest increasing the daily dose of [MEDICATION NAME] ([MEDICATION NAME]) from 400 up to 600mg three times a day (for pain, including headache). Problem #2: Headache- Since the patient has presented with apparent headache, we ordered a CT to rule out [DIAGNOSES REDACTED] or subdural hematoma. Order- CT Head (Computerized Tomography) or Brain without Contrast. A review of the Pain Management Flow sheets for November 2014 through February 11, 2014 revealed the following: Pain Rating Scale Legend: 0- No Hurt; 2- Hurts Little Bit; 4- Hurts Little More; 6- Hurts Even More; 8- Hurts Whole Lot and 10- Hurt Worst. Location of Pain was general with a behavior of restlessness exhibited prior to med (medications) for some of the occurrences. The Resident ' s pain scale prior to the administration of [MEDICATION NAME] 50mg PRN revealed the following quantitative pain intensity assessments: During the month of November 2014 the resident ' s experienced pain daily that ranged from four (4) to seven (7) out of 10 as follows: 4/10- 1 time 5/10- 5 times 6/10- 34 times 7/10- 3 times During the month of December 2014 the resident ' s experienced pain daily that ranged from five (5) to eight (8) out of 10 as follows: 5/10- 5 times 6/10- 37 times 7/10- 1 time 8/10- 1 time During the month of January 2015 the resident ' s experienced pain daily that ranged from four (4) to six (6) out of 10 as follows: 4/10- 1 time 5/10- 29 times 6/10- 23 times On January 20, 2015 the resident ' s [MEDICATION NAME] was increased from 400mg to 600mg three (3) times a day. During the month of February 2015 the resident ' s experienced pain daily that ranged from five (5) to six (6) out of 10 as follows: 5/10- 8 times 6/10- 15 times The Medication Administration Records (MARs) for December 2014 through February 2015 revealed that the nurses signed their initials in the allotted spaces, which indicated that (Resident #177) was assessed for, pain every shift and was administered [MEDICATION NAME] 50mg every six (6) hours as directed for pain prn. Also, Neurotin 600mg was administered three times a day for [MEDICAL CONDITION] pain, including headache. A review of the Nurse Practitioner ' s Communication book located on the unit revealed the following entry: December 19, 2014- Don ' t think the pain medication is working. Have nurse practitioner review medication. There was no evidence that the nurse practitioner addressed the aforementioned nursing communication. The following interviews were conducted regarding Resident #177 ' s pain management and [MEDICAL CONDITION] medication: A face-to-face interview was conducted on February 12, 2015 at approximately 2:45 PM with Employee #58 in regards to Resident #177 ' s pain management and the initiation of the new drug. (He/she) stated, they (medical doctors) have to be very careful with switching research drugs and it takes time to get them approved. (He/she) further stated the neurologist increased the resident's [MEDICATION NAME] and (he/she) would talk to the attending doctor regarding the resident ' s pain. A face-to- face interview was conducted on February 12, 2015 at approximately 3:30 PM with Employee #4 regarding Resident #177 ' s [MEDICAL CONDITION] and pain management medication. (He/she) called Employee #55 regarding the granules of Tecfidera - having difficulty administering through the resident ' s GT (Gastrostomy tube) instructed by Employee #55 to ask the Pharmacist to get an alternate medication. Employee #55 recommended [MEDICATION NAME] IM. Employee #4 was informed by the pharmacist that there was no alternate medication for Tecfidera and the doctor was informed. (He/she) further stated that the physician wanted to talk to the pharmacist. The pharmacist telephone number was given to the doctor to call. Also, Employee #4 stated that the resident ' s pain was assessed and (he/she) can verbalize or nod if (he/she) is in pain. We look at facial expressions and grimaces. In September 2014 (he /she) seem like (he/she) was in more pain. They only wanted to prescribe [MEDICATION NAME]. On December 21, 2014, I was transferred to another floor to assume another position . A face-to-face interview was conducted on February 12, 2015 at approximately 3:10 PM with Employee # 6. He/she stated when (he/she) was looking at the MAR (Medication Administration Record), (he/she) noticed that the medication (Tecfidera) was circled in red and immediately informed the nurse that we cannot hold medication. Employee #6 proceeded to tell the nurse to call the mother and inform (him/her). The (responsible party) made the appointment for the resident to see the neurologist. An order was written on December 21, 2014 to hold the medication. A face-to-face interview was conducted on February 12, 2015 at approximately 3:15 PM with Employee #14 regarding the Purified Protein Derivative (PPD) results. He/she stated he/she faxed the first PPD results to the neurologist nurse practitioner on January 23, 2015 and the second one on February 5, 2015. (He/she) called on February 6, 2015 to follow up on if the fax was received. However, did not get a voicemail. So (he/she) left a message for (him/her) to return (his/her) call. Further stated, he/she made a follow-up call on February 9, 2015; left another message for a return call. Another call was placed on February 12, 2015; informed he/she was not available. I then asked to speak to the next person in charge. At that time, the nurse practitioner picked her line up to talk. When queried about the resident ' s pain; Employee #14 stated, I go in frequently to assess (him/her). All the nurses are aware of this. Also, Employees #2 and #6 had in-services with the nurses on all three shifts regarding frequent monitoring (every two hours) of resident. On December 19, 2014, I documented in the NP ' s (Nurse Practitioner ' s) communication book about the resident ' s pain medica

Based on observation, record review and interviews for seven (7) of 51 sampled residents, it was determined that facility staff failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being as evidenced by failure to: consistently assess, monitor and report to the physician the respiratory status of one (1) resident who subsequently expired; consistently conduct skin assessments for one (1) resident who subsequently developed a facility acquired dry gangrene of the toe; consistently assess, monitor and manage a peripherally inserted central catheter (PICC) for one (1) resident who subsequently sustained an infection at the site; act with timeliness on physician's order [REDACTED]. [REDACTED]. Residents' # 402, 290, 316, 180, 303, 399, 401 The findings include: 1. Facility staff failed to consistently assess, monitor and report to the physician, the status of Resident #402 ' s condition at the time admission.. The resident was assessed with [REDACTED]. He/she was assessed with [REDACTED]. Resident #402 was admitted to the facility on [DATE] at 7:15 PM from an acute care hospital. According to the " Discharge/Transfer Summary " from the hospital, the resident ' s discharge [DIAGNOSES REDACTED]. " According to the Certificate of Death noted in the clinical record, the resident expired on [DATE]. 2014 at 6:20 AM; cause of death " Fatal Cardiac Arrhythmia due to or as a consequence of Non Valvular [MEDICAL CONDITION] Fibrillation. " Nursing Notes: The Admission Note written on February 18, 2014 at 23:49 (10:49 PM) revealed, " (Resident #402) arrived at the facility from an area hospital at 7:15 PM on February 18, 2014 ... " On admission resident is alert and oriented x 3(times), on (continuous) oxygen for SOB (Shortness of Breath), no acute distress or discomfort noted ...Lung sounds noted with expiratory wheezing, noted with barrel chest, resident is hyperventilating and (he/she) was using accessory muscles to breathe with respiration of 22. Resident is on oxygen 3l/min (three liters per minute) via NC (nasal cannula) for SOB. Skin is warm to touch skin is tinted, bi lateral hand and all fingers are cyanotic, both feel are shinny (and) toes are cyanotic. All meds (medications) clarified with (attending physician) and faxed to pharmacy. Emergency contact was in the unit. V/S (vital signs) ,[DATE] (blood pressure), Pulse 94, temp (temperature) 98.8, rr (respiratory rate) 22, SPO2 (Saturation Percentage of Oxygen) 97% with 02 (oxygen) 3l/min and wt (weight) 110 lbs (pounds). " The nursing note dated February 19, 2014 at 02:55 AM revealed, " Writer went to give the resident PPD (Purified Protein Derivative). Resident was sleeping. Writer attempt(ed) to wake (the) resident. (The) roommate stated, 'Do not wake (him/her) up. ' Supervisor made aware. Will follow up in the morning." The nursing note dated February 19, 2014 at 08:44, revealed, " Writer called to the room ... to find the resident unresponsive with the charge nurse performing CPR (Cardiopulmonary resuscitation). The EMS (Emergency Medical Services) team came to the resident's room (and) performed EKG (electrocardiogram) with result showing asystole (that the resident expired). (He/she) was pronounced dead at 06:20 AM ... " A face-to-face interview was conducted with Employee #35 on [DATE] at approximately 3:30PM. During the interview the employee acknowledged writing the aforementioned statement (nurse ' s note February 19, 2014 at 2:55 AM). He/she also stated that the resident was awake and verbally responsive while the supervisor was admitting (him/her). The employee also stated that the resident was asleep when he/she was attempting to administer the PPD. The employee was queried at what time (he/she) had attempted to administer the PPD. He/she stated, " It was around 2:00AM. " A face-to-face interview was conducted with Employee #34 at approximately 9:00AM on [DATE]. The employee stated that he/she was the supervisor on duty when the resident expired. The employee was queried regarding the events that led up to the resident ' s death. He/she stated that the report he/she received was that there were two admissions to the facility. One admission had been completed by the evening supervisor and one needed to be completed by him/her. He/she became involved with the admission of the assigned resident and was unaware of the expired resident ' s respiratory problems until he/she was called to the unit at around 6:00AM on February 19, 2014. A face-to-face interview was conducted with Employee #33 at approximately 4:30PM on February 27, 2014. The employee was queried whether he/she was the nurse who documented the following information (nurse ' s note February 18, 2014 at 10:49 PM): " Lung sounds noted with expiratory wheezes, barrel chest, hyperventilating and using accessory muscles to breathe; utilizing O2 at 3l/min (three liters per minute) via NC (nasal cannula) for SOB (Shortness of Breath.) Bilateral hands and all fingers were cyanotic, both feet were shiny and toes cyanotic. " The employee was asked whether the resident ' s condition (as described by him/her) warranted immediate medical attention. The employee did not respond to the question. A review of the record lacked documented evidence of an assessment for the resident between the time of admission 7:15 PM on February 18, 2014 and the time that the resident was pronounced dead at 6:20AM on February 19, 2014. The Admission Assessment documented by the nurse revealed that Resident #402 was experiencing respiratory difficulty upon arrival to the facility as evidenced by the following note: " Lung sounds noted with expiratory wheezes, barrel chest, hyperventilating and using accessory muscles to breathe; utilizing O2 at 3l/min via NC for SOB. Bilateral hands and all fingers were cyanotic, both feet were shiny and toes cyanotic. " The nurse ' s note also indicated that the nurse spoke with the attending physician regarding the resident ' s medication regimen; however, there was no evidence that the resident ' s condition, assessed at the time of admission was conveyed to the primary care provider. The only vital signs recorded in the clinical record prior to assessing the resident as unresponsive were obtained at the time of admission at 7:15 PM on February 18, 2014. There was no evidence that facility staff consistently assessed and monitored Resident #402 once he/she was assessed with [REDACTED]. The primary care physician was not informed regarding the respiratory status of the resident. The record was reviewed on February 27, 2014. 2. Facility staff failed to consistently conduct skin assessments on Resident #290, who subsequently developed a facility acquired dry gangrene of the toe; failed to obtain a nephrology consultation with timeliness and failed to turn and reposition the resident in accordance with the comprehensive plan of care. A. Facility staff failed to consistently conduct skin assessments on Resident #290, who was subsequently diagnosed with [REDACTED]. The Facility ' s Procedure Policy: " Skin and Wound Management " (no date indicated) stipulates: " Each resident is evaluated by the interdisciplinary team to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. Procedure: 3. Residents will be monitored weekly for skin integrity and documentation will be completed on the Weekly Skin Assessment form. " According to a re-admission history and physical dated [DATE], Resident #290 ' s [DIAGNOSES REDACTED]. " MDS: According to the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], Resident #209 was coded in Section G as being totally dependent requiring one person physical assist in personal hygiene. Under Section M (Skin Conditions) the resident was coded as having no venous and arterial ulcers and no foot problems; however, he/she was coded as being at risk of developing pressure ulcers. Care Plan: The care plan entitled ADL (Activities of Daily Living) Self Care Performance Deficit (related to) stroke, Musculoskeletal Impairment, Limited Mobility last updated on [DATE] revealed: Interventions: Skin Inspection- The resident requires skin inspection (every) shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. The care plan entitled Diabetes Mellitus Type II last updated [DATE] revealed... Inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness. Physician ' s Orders: The physician's order [REDACTED]. Interim order dated February 7, 2014 at 3:30 PM, directed, " Arterial Doppler- (Rule out) PAD/BLE ([MEDICAL CONDITION] - Bilateral Lower Extremities). " Interim order dated February 10, 2014 directed, "Apply skin prep to left 2nd toe gangrene. " Interim order dated February 14, 2014 at 2:46 pm, directed, " Schedule vascular consult with a vascular doctor for a plan of treatment to lt (left) foot 2nd toe gangrene. " A radiology report dated February 10, 2014 revealed the following: Procedure: Arterial Duplex Doppler to lower extremities- " Impression: No evidence of significant stenos is within either lower extremity arterial tree. " Skin Reports: The "Bath (and) Skin Report" revealed the following: [DATE]- Bed Bath Given- Skin intact-No documentation on the sheet. No charge nurse signature [DATE]- Bed Bath Given- Skin intact- No charge nurse signature. " The " Skin Sweeps" sheets revealed the following: " [DATE]- No new skin impairment- signed by licensed practical nurse [DATE]- No new skin impairment- signed by licensed practical nurse [DATE]- No new skin impairment- signed by licensed practical nurse [DATE]- No new skin impairment- signed by licensed practical nurse [DATE]- No new skin impairment-signed by licensed practical nurse. " The " Non-Pressure Ulcer Skin Conditions Sheet " dated February 10, 2014 at 13:01 revealed, " Date of Onset: February 8, 2014, Origin of Wound: Facility Acquired, Type of Evaluation: Initial Onset, Site of Skin Condition: Left 2nd (second) toe, Type of Skin Condition: Other: Dry Gangrene, Document Measurement in centimeters: Length: 3.6, Width: 4.9, Depth: 0, Presence of Pain: No, Progress: A dry gangrene. Black and dry with no drainage. Treatment: - Apply skin prep daily, Physician Notified of Change: - Yes. Vascular consult was scheduled for February 19, 2014; resident refused to go. Guardian made aware. Appointment rescheduled for [DATE]. " The clinical record lacked evidence that skin assessments were consistently conducted on shower days in accordance with the physician's orders [REDACTED]. Additionally, there were no skin sweep sheets nor bath and skin report sheets in Resident #209 ' s record for the month of February 2014. The Physician's Progress Notes revealed the following: [DATE]- Section C: Physical Examination: Check below (check mark) if normal and (+) if abnormal. Under Skin: check mark was placed after no rash. Extremities: No [MEDICAL CONDITION]. Under skin care section - there was no documentation indicating there was no skin alteration. [DATE]- Skin-check mark (no rash); Extremities: no [MEDICAL CONDITION], no documentation under skin care section. Plan/Recommendations: IV (Intravenous Fluids) - Continue (water) through PEG, Repeat electrolytes. [DATE]- Skin- check mark placed- (no rash), no documentation under skin care section. Plan/Recommendations: IV fluids. February 7, 2014 at 3:15 PM- Resident (with) Diabetes Mellitus, [MEDICAL CONDITION] Disorder, Hypertension, (status [REDACTED]. Assessment/Plan: (Left) foot 2nd toe necrotic- Arterial Doppler- (Rule out) PAD- ([MEDICAL CONDITION].) " According to a " Patient Podiatric Service report " dated [DATE] revealed: " Assessment, Procedures Performed & Plan of Treatment: Professional treatment is required of (check in box for) toe nails to prevent exposing patient to medically significant risk related to wound healing, complications and possible loss of limbs, due to : Diabetic and/or [MEDICAL CONDITION]; Follow-Up- Patient should be treated in 60 days for foot care due to systemic conditions or sooner should complications arise. " There was no evidence that the physician included the podiatrist follow-up recommendations in his/her plan of care prior to February 7, 2014, when the " gangrene toe " was discovered. Nursing Notes: [DATE]-12:53 PM - ADL (Activities of Daily Living) care provided by assigned CNA (Certified Nursing Assistant). Skin assessment done, no new skin issue. February 5, 2014 at 12:18 PM - Skin warm and dry to touch. February 6, 2014 at 07:35 AM - ADLs- total care given. February 7, 2014 at 09:19 AM- ADLs, total care given. February 7, 2014 at 19:50 PM- Resident has an order for [REDACTED]. February 8, 2014 at 16:52 PM - Arterial Doppler study to (rule out) PAD (Peripheral Artery Disease) of bilateral lower extremities. Skin warm and dry to touch. February 9, 2014 at 08:06- Skin dry and warm to touch. AM ADL care given. February 10, 2014 at 12:20- Note Text- Resident was transferred from (unit and bed named). Was noted with black dry gangrene on left 2nd toe- 3.6 x 4.9 x 0 x 0 cm. This was reported to (attending doctor named) on February 8, 2014 who ordered arterial Doppler to rule out peripheral artery disease. Doppler was scheduled for (February 10, 2014) by (radiology company). In the meantime skin prep to left 2nd toe daily. February 10, 2014 at 17:05- Note Text- Late entering for resident. On February 7, 2014, resident was noticed with darkness on left second toe. (Nurse Practitioner) was notified and an order for [REDACTED]. February 10, 2014 17:10- Note Text: Resident was transferred from (room number written) to (room number written) at 14:00 (2:00 PM). No sign of distress noted. (Vital Signs):,[DATE] (Blood Pressure), 66, (Pulse) 18 (Respiration), 97.4 (Temperature). The clinical record lacked evidence that skin assessments were consistently conducted twice a week in accordance with physician's order [REDACTED]. A review of the 24 hours nursing report from February 7, 2014 through February 10, 2014 lacked evidence that Resident #290 had any type of alteration in skin integrity. Consulted with Employee #41 telephonically on February 28, 2014 at approximately 4:20 PM regarding the necrotic toe. When queried regarding the necrotic toe on assessments; he/she stated, "The necrotic toe was discovered and I was informed. They stated that he/she had a vascular appointment. " A face-to-face interview was conducted with Employee #7 on February 28, 2014 at approximately 3:00 PM regarding the weekly skin assessments. After reviewing the skin sheets; he/she acknowledged the aforementioned findings. The clinical record was reviewed on February 28, 2014. Facility staff failed to consistently conduct skin assessments on Resident #290, who subsequently developed a " facility acquired dry gangrene " of the left 2nd toe. B. Facility staff failed to act with timeliness on an order to reschedule a nephrology appointment for Resident #290, who exhibited abnormal renal laboratory values. Greater than seven (7 months) lapsed before the order was acted upon. According to a re-admission history and physical dated [DATE] revealed, Resident #209 ' s [DIAGNOSES REDACTED]. Diabetes Type II and Bili (Biliary) Non obstructing Renal [MEDICATION NAME]. " According to an interim physician's order [REDACTED]. " A nurses note dated [DATE] at 14:02 (2:02PM) read: " Note Text: Resident was scheduled for nephrology appt with (nephrologists ' named) at (hospital named) at 10:30 AM. At 8:45 AM ... from (ambulance company) called and stated that they will come around 9:30 AM to pick the resident (up) for the appointment. At 9:45 AM, the writer called ambulance company), the operator stated that they are running behind schedule. That they will come around 10:10 AM and that they will call the doctor ' s office first to find out if they will still see the resident if they get him/her there late. Later the operator returned call and stated that they are cancelling the pick up because the doctor ' s office said they will not see the resident if he is late. Responsible party made aware. (Appointment) to be rescheduled " (SIC). An interim physician's order [REDACTED]. " (Normal Range- BUN-,[DATE], BUN/Creatinine- 3XXX,[DATE].0) A review of the doctor ' s progress notes revealed the following: " [DATE] at 1:30 PM- (chief complaint) - (follow-up) labs .... Resident labs came back and NP (nurse practitioner) for review: BUN/Creatinine- ,[DATE].90; Assessment/Plan: (Diagnosis) - [MEDICAL CONDITION], Diabetes 2, (status [REDACTED].. Increase GT flushes to 500 cc (times) 72 hours then (every) 6 hours (times) 24 hours. Repeat labs after flushes. Follow up with nephrology for [MEDICAL CONDITION] ... Signed Nurse Practitioner [DATE]- 1:40 PM- ... CC follow up labs ... BMP (Basic Metabolic Panel) with BUN/Creat ,[DATE].80 improving as compared to last labs- ,[DATE].90, Assessment/Plan: ... [MEDICAL CONDITION], DM 2, Follow-up Nephrology appointment. Repeat BMP (every) month .... Signed Nurse Practitioner [DATE]- Problem List (New) - Dehydration ..., BUN-75, Crt-1.8. Plan/Recommendations: (Increase) flushes, Repeat BMP. Signed: Attending Physician. [DATE] at 7:00 PM- CC- follow up labs .... BMP with BUN/Creat ,[DATE].60; Assessment/Plan: [MEDICAL CONDITION], Diabetes .... Signed by Nurse Practitioner. [DATE]- ... Lab Tests: BUN/Crt= ,[DATE].8; Plan/Recommendations: Push Fluids, Repeat BMP. Signed: Attending Physician. [DATE]- Lab work: ... BUN -72/ Crt- 1.7; Assessment: Dehydration; Plan: Start IV fluids- ? (normal saline) 50 ml/hour; Repeat BMP- Signed: Attending Physician [DATE]-.. Lab work- BUN-70, Crt- 1.4- Continue flushes and IV (Intravenous Fluid) fluids; Assessment: Dehydration, P- Continue IV fluid (increase) rate- Continue water flushes. Signed: Attending Physician. [DATE]- 3:00 PM- CC- follow up labs- ... BMP- BUN/Crt- 55- improved from 76, Creat 1.6, Assessment Plan: DX (Diagnosis) - [MEDICAL CONDITION]; Continue GT flushes, Completed IVF (IV Fluids). Signed- Nurse Practitioner. [DATE]- ...No lab values documented. Plan/Recommendations: Please resend Urology, Repeat Lab. Signed: Attending Physician. [DATE]- ...No lab values documented. Plan/Recommendations: Surgery Consult- Distended Gallbladder... Signed: Attending Physician. [DATE]- Problem List (New) - Dehydration, [MEDICAL CONDITION], and Plan/Recommendations: IV fluids- Continue (water) through PEG, Repeat Electrolytes. Signed: Attending Physician. [DATE]- ... BUN/CRt- ,[DATE].70, Plan/Recommendations: IV fluids. Signed: Attending Physician According to a request form for consults and/or appointments form dated February 26, 2014 revealed; " Type of Appointment: Nephrology; Reason for Appointment: for high BUN that has not been responding to treatments. Consults and /or Appointments Arranged: Date of Appointment: [DATE]; Time: 11:30 AM. There was no evidence in the clinical record that Resident #290 had an appointment scheduled prior to [DATE]. There was no evidence that the physician or the nurse practitioner included the resident ' s nephrology consultation in his/her total plan of care. A review of the medical record revealed that the attending physician made visits on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] and [DATE]. There was no evidence that the physician addressed the request for nephrology consultation. A face-to-face interview was conducted on February 26, 2014 at approximately 1:00 PM with Employee #7. When queried if the nephrology appointment had been rescheduled per physician's order [REDACTED]. A face-to-face interview was conducted on February 28, 2014 at approximately 1:30 PM with Employee #40. When he/she was queried; " What is the facility ' s process on scheduling appointments and arranging transportation for residents? " He/she stated; " I make transportation arrangements after the unit secretary schedules the appointment. The unit secretary schedules the appointment and the referral with the appointment date and time is faxed to me. Upon receiving the fax; transportation is arranged. I record the information in the referral/transportation log book. " Facility staff failed to act with timeliness on a physician's order [REDACTED]. The resident renal laboratory values were abnormal. Greater than seven (7 months) lapsed before the order was acted upon. C. Facility staff failed to turn and reposition Resident #290 in accordance to the comprehensive plan of care. During an isolated interview with Resident #290 ' s responsibility party on February 21, 2014 at approximately 12:45 PM. He/she expressed concerns regarding resident not being repositioned every two (2) hours. According to the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed that Resident #209 was coded in Section M (Skin Conditions) as having no venous and arterial ulcers and no foot problems; however, he/she was coded as being at risk of developing pressure ulcer(s). A review of the " Braden Scale for Predicting Pressure Ulcer Risk " dated [DATE]; the resident ' s score was 14 indicating he/she was at moderate risk for developing a pressure ulcer. A review of the comprehensive care plan most recently updated, [DATE] revealed , " Problem: The resident is potential for pressure ulcer development related to immobility ; Interventions: The resident needs assistance to turn/reposition at least every 2 (two) hours, more often as needed or requested. " Observations of the resident during the survey period revealed the following: February 25, 2014 at approximately 12:10 PM- Observed resident lying in bed on his/her back. February 25, 2014- at approximately 1:25 PM- Observed resident lying in bed on his/her back. February 25, 2014- 3:00 PM- Observed resident lying in bed on back. February 25, 2014 4:10 PM- Observed resident lying in bed on back. There was no evidence that facility staff turned and repositioned Resident #209 in accordance with the care plan as evidenced by observations and family interview. A face-to-face interview was conducted with Employee #7 on February 25, 2014 at approximately 3:00 PM regarding the aforementioned findings. After consulting with the assigned staff (CNA assigned to resident), Employee #7 stated, " The resident refuses to be turned and repositioned sometimes. " Employee #7 acknowledged the findings. The clinical record review and observations were conducted on February 25, 2014. 3. Facility staff failed to consistently assess, monitor and manage Resident #316's PICC (peripherally inserted central catheter) line. The nurse ' s Admission note dated [DATE] at 19:11 (7:11 PM), Resident #316 was readmitted to the facility on [DATE] with a Right Upper Arm PICC line. The facility ' s Central Line Catheter Protocol form initiated on [DATE] but signed by the physician on [DATE] revealed," Device Type: PICC, non-valved; Type of Infusion: unknown, this section of the form was blank; Number of Lumens: unknown, this area was blank; On Admission the PICC gauge , total catheter length and external catheter length sections were blank. Unused lumens/minimum flush interval: PICC non-valved q (every) 12 hours each lumen 5 ml (milliliters) ns (normal saline), 5 ml 10 units/ml [MEDICATION NAME] flush. " According to the Central Line Catheter Protocol/Fluid/Medication Orders dated and signed by the physician [DATE] at 10:00 AM, directed: Ertapenem 1 gm (gram) IV q 24 hours x (times) 10 days for UTI (Urinary Tract Infection). According to the resident ' s Infusion Medication Record and the MAR (Medication Administration Record), the resident received the antibiotic from [DATE] through [DATE] (seven days). There was no documented evidence in the clinical record that after the resident completed the antibiotics on [DATE] that facility staff maintained the resident ' s PICC line according to the Central Line Catheter Protocol. Further review of the Central-Line Catheter record revealed that the record lacked consistency in observing the site at least q 2 hours and PRN (as needed). The 8:00 PM and 10:00 PM observations for the month (month not legible but likely January since the resident ' s PICC line was in place from [DATE] through February 7, 2014) ) for dates of the 4th and 5th were left blank; 12M (midnight), 2:00 AM, 4:00 AM, 6:00 AM for the 5th, 6th and 7th and the 9th through the end of the month were left blank; 4:00PM, 6:00 PM 8:00 PM and 10:00 PM were left blank for the 11th, 12th; the 13th was not assessed at no time; 12M, 2:00 AM, 4:00 AM and 6:00 AM were left blank for the 14th and 15th; 12M to 4:00 PM was left blank for the 16th; 12M to 6:00 AM and 6:00 PM to 10:00 PM were left blank; 18th was not assessed at no time; 22nd, 23rd was not assessed at no time; 27th through the rest of the month (likely [DATE]st) was not assessed. The PICC line remained in place from [DATE] through February 7 2014 without evidence of nursing management/intervention (e.g. site assessment, dressing change and/or flushing to ensure patency).According to a nurse ' s note dated February 7, 2014 at 07:53, the Resident#316 was sent to the hospital due to an elevated temperature of 104.7 and three (3) loose stools. According to the Hospital Course February 7 through February 18, 2014, the resident was found to have positive blood cultures for " Coag (coagulation) Negative Staph (staphylococcus) " of(his/her) PICC line. A face-to-face interview was conducted with Employee #8 on February 25, 2014 at approximately 11:30 AM. He/she acknowledged the lack of consistent management of the resident ' s central catheter. Facility staff failed to consistently assess, monitor and manage Resident #316 ' s centrally inserted catheter (PICC line) and the resident consequentially sustained Central - Line Associated Bloodstream Infection (CLABSI). The record was reviewed [DATE]. 4. Facility staff failed to consistently assess the pre and post respiratory status of Resident #180 who received respiratory treatments. A review of the physician orders [REDACTED]. A review of the February 2014 Medication Administration Records (MAR) revealed that [MEDICATION NAME] was administered to the resident on the following dates and times: February 21, 2014 at 1300, and 2100 February 22, 2014 at 1300, 1700, 2100 February 23, 2014 at 1300, 1700, 2100 February 24, 2014 at 1300, 1700, 2100 February 25, 2014 at 1700, 2100 There was no evidence in the clinical record that facility staff assessed the resident for shortness of breath or wheezing, obtained the pulse, respirations, oxygen saturation, and/or lung sounds of the resident pre and post the administration of the [MEDICATION NAME] treatments. A face-to-face interview was conducted with Employee #11 on February 25, 2014 at approximately 4:06 PM. He/she stated respiratory therapists and licensed nurses both administer respiratory treatments and that assessments should be done prior to administering. He /she acknowledged aforementioned the findings. The clinical record was reviewed on February 25, 2014. 5. Facility staff failed to administer blood pressure medication according to physician's order [REDACTED]. According to a physician ' s history and physical dated [DATE], Resident #303 ' s [DIAGNOSES REDACTED]. According to a physician's order [REDACTED]. Hold for SBP (Systolic Blood Pressure) less than 110 and HR (Heart Rate) less than 55. " A review of the [DATE] MAR (Medication Administration Record) revealed on [DATE] at 2100 (9:00 PM), the resident received [MEDICATION NAME] 100mg and the resident ' s blood pressure was recorded as ,[DATE] (systolic blood pressure less than 110). Facility staff failed to ' hold ' the [MEDICATION NAME] medication as stipulated in the prescribed parameters, the resident ' s systolic blood pressure was assessed less than 110.The clinical record lacked evidence that Resident #303 received his/her medication in accordance to physician's order [REDACTED]. A face-to-face interview was conducted on [DATE] at approximately 10:30 AM with Employee #7 regarding the aforementioned findings. He/she acknowledged the findings. The clinical record was reviewed on [DATE]. 6. Facility staff failed to weigh Resident #399 in accordance to physician's order [REDACTED]. A review of the Resident #399 ' s clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Monthly weight to be done on (7AM-3PM) shift. " According to the electronic medical record " weight summary and dietary progress notes " the following was revealed: February 14, 2014- 218.8 p

Based on observation, record review and staff interview for three (3) of 51 sampled residents, it was determined that facility staff failed to provide necessary treatment and services to promote healing, and prevent new pressure ulcers from developing for two (2) residents who were initially assessed with [REDACTED]. Residents' #10, #150 and #347. The findings include: 1. Facility staff failed to comprehensively assess Resident #10 ' s skin with consistency and timeliness. The resident was subsequently identified with four (4) Pressure Ulcers that were initially assessed as unstageble. A review of Resident " 10 ' s clinical record revealed that the resident was readmitted to the facility after treatment at an area hospital on May 22, 2013. The resident ' s [DIAGNOSES REDACTED]. A review of the facility ' s Skin and Wound Management Policy revealed the following under Procedure: " Residents are evaluated on admission, quarterly, annually and with a significant change of status for their risk for the development of Pressure Ulcers using the Braden Scale. " (No date noted). Resident #10 was admitted to the facility with a [DIAGNOSES REDACTED]. In addition ther resident was also noted to be receiving [MEDICATION NAME] 325mg po daily, [MEDICATION NAME] 100mg daily and Folic Acid 1mg daily. A review of physician's order [REDACTED]. Review of dietary notes dated December 12, 2013 revealed that the resident often skipped breakfast due to a preference to sleep late according to caregiver. A review of preferences included a snack between breakfast and lunch. The resident receives " [MEDICATION NAME] with meals (high calorie nutritional supplement), and [MEDICATION NAME] 1 pkt (packet - protein supplement) po (by mouth) twice daily. " A dietary note dated January 14, 2014 read: " RDN (registered dietitian) to request orders for Prostat 30ml po three times a day and a health shake with meals. " Resident #10 was admitted to the facility with one (1) pressure ulcer. Resident was later observed with four (4) unstageble pressure ulcers. A review of a Skin Integrity Assessment form revealed that upon readmission the resident was noted with " Multiple old scars ... no open or current wound noted. " The unstageble ulcers are outlined below. A. Sacral ulcer identified as unstageble on October 28, 2013. Review of the Pressure Ulcer Evaluation sheet with an Effective Date of November 27, 2013 revealed the following: Under Site of Pressure Ulcer - Sacral Under Current Stage of Pressure Ulcer - Unstageble Under Documentation of measurement in centimeters Current length of Pressure Ulcer = 5.8cm Current Width of Pressure Ulcer = 7cm Current depth of Pressure Ulcer = 1.5cm Under date Pressure Ulcer first observed - October 28, 2013 Under Stage of Pressure Ulcer when first identified - Unstageble and Under exudates - Moderate amount, (Drainage on old dressing is the same size as the wound bed) serous: Clear or light yellow; thin watery drainage. Review of the same Pressure Ulcer Evaluation with an " Effective Date " of December 4, 2013 revealed the following: Origin of Wound - Facility acquired Site of Pressure Ulcer - Sacral Current Stage of Pressure Ulcer - Unstageble Documentation of measurement in centimeters Current length of Pressure Ulcer = 7 cm Current Width of Pressure Ulcer = 6cm Current depth of Pressure Ulcer = 0.9cm Date Pressure Ulcer first observed - October 28, 2013 Stage of Pressure Ulcer when first identified - Unstageble Exudates - Moderate amount, (Drainage on old dressing is the same size as the wound bed) serous: Clear or light yellow; thin watery drainage. B. R lateral leg ulcer identified as unstageble on January 1, 2014. Review of the Pressure Ulcer Evaluation sheet with an " Effective Date " of January 1, 2014 revealed the following: Under Origin of Wound - Facility acquired Site of Pressure Ulcer - Rt. (Right) lateral leg Current Stage of Pressure Ulcer - Unstageble Documentation of measurement in centimeters Current length of Pressure Ulcer = 7 cm Current Width of Pressure Ulcer = 2.5cm Current depth of Pressure Ulcer = 0cm Date Pressure Ulcer first observed - January 1, 2014 Stage of Pressure Ulcer when first identified - Unstageble and exudates - none. Review of the same Pressure Ulcer Evaluation sheet with an " Effective Date " of January 15, 2014 revealed the following: Origin of Wound - Facility acquired Site of Pressure Ulcer - Rt. (Right) lateral leg Current Stage of Pressure Ulcer - Unstageble Documentation of measurement in centimeters Current length of Pressure Ulcer = 14cm Current Width of Pressure Ulcer = 2.4cm Current depth of Pressure Ulcer = 0cm date Pressure Ulcer first observed - January 1, 2014 Stage of Pressure Ulcer when first identified - Unstageble and Exudates - none. No further evaluations were available for this ulcer. The resident was transferred to an area hospital on January 23, 2014. Review of the same Pressure Ulcer Evaluation sheet with an " Effective Date " of January 22, 2014 revealed the following: Origin of Wound - Facility acquired Site of Pressure Ulcer - Rt. (Right) lateral leg Current Stage of Pressure Ulcer - Unstageble Documentation of measurement in centimeters Current length of Pressure Ulcer = 14cm Current Width of Pressure Ulcer = 2.3cm Current depth of Pressure Ulcer = 0cm Date Pressure Ulcer first observed - January 1, 2014 Stage of Pressure Ulcer when first identified - Unstageble and Exudates - none. The resident was transferred to an area hospital on January 23, 2014. C. Rt. (Right) knee Pressure Ulcer identified as unstageble on January 8, 2014. Review of a Pressure Ulcer Evaluation sheet with an " Effective Date " of January 22, 2014 revealed the following: Origin of Wound - Facility acquired Site of Pressure Ulcer - Rt. (Right) knee Current Stage of Pressure Ulcer - Unstageble Documentation of measurement in centimeters Current length of Pressure Ulcer = 2.5cm Current Width of Pressure Ulcer = 2.5cm Current depth of Pressure Ulcer = 0 cm Date Pressure Ulcer first observed - January 8, 2014 Stage of Pressure Ulcer when first identified - Unstageble Exudates - none. No other documentation was available for this ulcer. D. According to the Pressure Ulcer Evaluation documentation with an Effective Date of January 9, 2014 the ulcer was described as: Origin of Wound - Facility acquired Site of Pressure Ulcer - Rt. (Right) hip Current Stage of Pressure Ulcer - Unstageble Documentation of measurement in centimeters Current length of Pressure Ulcer = 2.5cm Current Width of Pressure Ulcer = 2.5cm Current depth of Pressure Ulcer = 0.1cm Date Pressure Ulcer first observed - January 9, 2014 Stage of Pressure Ulcer when first identified - Stage 2 Exudates - none. However, the same wound was described as being unstageble when first observed on January 9 in Pressure Ulcer Evaluations with effective dates of January 15, 2014 and January 22, 2014. A face-to-face interview was conducted with Employee #39 at approximately 2:00PM on March 4, 2014. However, the employee was new to the facility and not able to explain the discrepancy in the documentation (regarding the staging of the right hip Pressure Ulcer.) He/she acknowledged that documentation in the clinical record reflects the pressure ulcers were initially identified as unstageble. A review of " Skin Sweep " sheets which were a part of Resident #10 ' s clinical record revealed that the resident ' s skin was being evaluated since June 2013. In reviewing the sheets for October, 2013; documentation was noted for October 3, 7, 10, 17, 21, 24, 28 and 31, 2014. The Skin Sweep Sheets were also reviewed for December and January, 2013. No new skin impairments were identified for December except on December 16, 2013. Per the Skin Sweep documentation for December, 2013 a new skin impairment was identified on the resident ' s right heel in the form of a blister. However, there was no documentation of any skin impairments for December on the Pressure Ulcer Evaluation Sheets for December. Documentation was done on the Skin Sweep Sheets for December 5, 12, 16, 19 and 26, 2013. A review of the Skin Sweep Sheets for the month of January 2014 revealed documentation of the resident ' s skin condition for January 16, 20, 22 and 23, 2013. Ruptured blister was written in on the document with a diagram of the resident ' s left leg for January 23, 2014. However, there was no check (>) to indicate whether there was an old ulcer, a new ulcer or no ulcer. The documentation for October 28, 2013 identified open blister on the sacrum and right buttock. This documentation conflicted with the Pressure Ulcer Evaluation for the same date (October 28, 2014) which identified the sacral impairment as an Unstageble Pressure Ulcer. Facility staff failed to consistently monitor the status of Resident #10 ' s skin and consistently provide preventive measures to prevent new sores from developing for Resident #10 who was subsequently identified with four (4) unstageble pressure ulcers on initial assessment. The record was reviewed on March 5, 2014. 2. Facility staff failed to assess Resident #150 ' s skin comprehensively and in a timely manner. The resident was subsequently identified with an unstageble Sacral Pressure Ulcer. According to the Admission documentation Resident #150 was admitted to the facility on [DATE] from an area hospital. Admitting [DIAGNOSES REDACTED]. The lower extremities were described as being weak with legs that could not bear weight and the right foot had " +1 (plus one) [MEDICAL CONDITION]). " The resident ' s skin was described as, " Skin between folds of buttocks and abdomen showing signs of skin breakdown. Healed ulcer on both elbows, multiple bruised areas on rt (right) and lt (left) arm from blood works. " A review of the facility ' s Skin and Wound Management Policy (No date noted) revealed the following under Procedure: " Residents are evaluated on admission, quarterly, annually and with a significant change of status for their risk for the development of Pressure Ulcers using the Braden Scale. " A review of the resident ' s Skin Assessment Sheets revealed documentation of what was classified as a " Non-Pressure Ulcer Skin Condition. " The type of skin condition was documented as a " Blister. " The site was documented as the " Left medial ankle. " The measurements were documented as " Length 6.0 centimeters, Width 4.0 centimeters and depth 0.0 centimeter. " The date of onset was listed as August 30, 2013. No other skin impairment was identified at that time. A review of additional skin sheets for the resident revealed documentation on " Pressure Ulcer Evaluation " form. On the first form (1) a Sacral Ulcer was described as Community acquired, first observed on September 14, 2013, Stage 2, measuring 0.8x0.6x0.1 centimeters with " Serous: clear or light yellow in color; thin watery; scant drainage, no odor and intact Peri-wound. " Another Pressure Ulcer Evaluation form (2) dated September 23, 2014 described a facility acquired Unstageble Pressure Ulcer which (according to the documentation) was initially assessed as " unstageble " on September 14, 2013. This ulcer measured 4x7x0 centimeters with " Serosanguinous: light red to pink; thin, watery; Minimal/small (amount): drainage smaller than size of the wound bed " and no odor. The resident was discharged to an area hospital on September on September 28, 2013 and no other documentation on the wounds was available. The facility has in place a weekly a policy that weekly skin assessments are to be conducted on the residents by the charge nurse. However, no skin assessment/evaluation sheets were available for Resident #150. A face-to-face interview was conducted with Employee #39 at approximately 2:30PM on March 5, 2014. However, the employee was new to the facility and therefore unable to respond to the query regarding the accuracy of the documentation of the pressure ulcer. The facility staff failed to consistently assess the condition of the Resident #150 ' s skin in order to identify impairment in the resident ' s skin integrity prior to an advanced and/or " unstageble " status. The record was reviewed on March 04, 2014. 3. Facility staff failed to consistently assess, monitor and provide preventive measures to promote healing and ensure that Resident #347 ' s pressure ulcers did not become worse and failed to implement measures to prevent new wounds from developing. A review of the clinical record revealed that the resident was admitted to the facility on [DATE]. According to the History and Physical dated September 13, 2013 the resident was admitted with the following Diagnoses: [REDACTED]. LE (lower Extremity) gangrene, Rt. BKA wound and according to the Central-Line Catheter Protocol dated September 12, 2013 the resident was admitted with a PICC Line (Peripheral Inserted Central Catheter) ... " There was no evidence that the physician included Left Ischium wound in the History and Physical. Further review of the clinical record Quality Assurance: Skin Integrity assessment dated [DATE] revealed that the resident was admitted with ... " left Ishium unstageble wound measured 3x2.5x0 50% red, 50% black, no exudates. Wound bed moist. No foul odor present, treatment [MEDICATION NAME] every 2 days and PRN (as needed). " According to the Pressure Wound Evaluation conducted by the wound team on September 13, 2013, the resident was admitted with a community acquired; Site: left ischium; Current Stage of Pressure Ulcer: Unstageble; measurements: 3x2.5x0; No exudates ... The following measurements were recorded on the Pressure Ulcer evaluation forms for the period of September 25, 2013 through November 1, 2013: September 20, 2013 Unstageble 3x2.5x0 Exudate: Sanguineous: bloody, red, thin, watery September 27, 2013 Unstageble [MEDICAL CONDITION] Exudate: Sero-sanguineous: light red to pink; thin, watery October 4, 2013 Unstageble [MEDICAL CONDITION] Exudate: Sero-sanguineous: light red to pink; thin, watery October 11, 2013 Unstageble [MEDICAL CONDITION] Exudate: Sero-sanguineous: light red to pink; thin, watery October 18, 2013 Unstageble 5.5x3x0 Exudate: Sero-sanguineous: light red to pink; thin, watery October 25, 2013 Unstageble 4x4x0 Exudate: Cloudy, yellow to tan; thin, watery ... November 4, 2013 Unstageble 4x4x0 Exudate: Purulent: yellow, tan or green, thick, opaque; foul smelling and /or [MEDICATION NAME], contain pus. Physicians Orders dated November 4, 2013 at 1:45 PM read: " (1) send resident out to (hospital name) ER (emergency room ) for eval (evaluation) secondary fever, [MEDICAL CONDITION], and sacral wound debridement ... " Review of the Nurses Notes revealed the following: November 1, 2013 at 23:21 (11:21 PM) " Writer noted a new skin impairment developed at the left upper buttocks area measuring approximately 4cm (centimeters) x 2cm. Both Supervisor and MD (medical doctor) notified. November 2, 2013 at 07:13 " ...sacral area done on shift, resident able to make needs known, denies any pain and discomfort at this time ... November 2, 2013 14:42 " Resident is alert and verbally responsive. IV Normal Saline in progress at 125mls/hr via PICC line, [MEDICATION NAME] 1 gm via picc line for wound infection no adverse reaction noted. Temp (temperature) to be monitored q (every) 2 hrs. (hours) At 9:30am, T 99.1. T101.7 at 3pm. Cold compress applied to cool (him/her) down. November 3, 2013 01:40 " Called unit to assess resident with a temp. of 104.9 and who was perspiring quite a bit and very warm to touch. It was determined between myself and charge nurse that the resident need to be sent out for evaluation. DON (Director of Nursing) was informed about sending the resident out due to (his/her) deteriorating condition but the resident flatly refused to go out and in this case the PMD (Private Medical Doctor) was not called at this time. Resident was bathed and dressing changed and made as comfortable as possible. V.S. (vital signs) 104.9 -122-22-78/50 O2 sats 97. " November 3, 2013 03:33 " ...Wound tx done, wound had moderate drainage brown in color, with slough covering the entire wound bed, and had foul odor. Vs=95/54, 112, 22, 99.1 with oxygen saturation 97% on room air. " There was no evidence in the clinical record that the physician was notified of the change in the residents ' condition on November 3, 2013. According to the Skin Integrity assessment dated [DATE], " (facility staff) reported that resident has an open blister on the left upper buttock. Upon assessment noted unstageble wound measured 8x5.3x0 cluster, 90% black, 10% skin, no exudates noted. Wound bed moist, peri-wound intact. Wound edges defined. Tx (treatment) Santyl and Xeroform TID (three times a day) Left sacrum wound was also noted. Measured 3x2x0 100% black, no exudates noted. Foul odor present. Treatment Santyl and Xeroform TID. According to the November 4, 2013 Pressure Ulcer Evaluation the resident developed a " facility acquired; site: left sacrum; Unstageble; measuring 3x2x0 ...wound bed 100% black ... " Review of the Skin Sweeps for November 1, 2013 through November 8, 2013 lacked evidence of any skin impairment noted for November 4, 2013. November 4, 2013 14:22 " ...Resident has persistence temperature, low blood pressure with an increase heart rate. At 0900 temp was 99.9 and administered 2 Tylenol and decreased to 98.6 at 0930 and spike again at 12:30pm to 101.5 administered 2 Tylenol again and evaluate at 1330pm (1:33) pm and was 99.5. Call was made at 1400 pm (2:00 PM) for (ambulance) transfer resident to (hospital name) and will pick up in 2 hrs .... " November 4, 2013 22:08 (10:08 AM) writer call (hospital name) resident admitted . According to the hospital discharge summary signed November 9, 2013 " this resident came in with severely infected sacral Decubitus ulcer with [MEDICAL CONDITIONS], who was resuscitated in step-down ICU (Intensive Care Unit). At the time of admission, (his/her) white blood count was 12.4 and as an outpatient it was 21. He had [MEDICAL CONDITION] and received units of blood transfusion prior to surgery. Surgery showed extensive sacral Decubitus ulcer that required extensive surgery... " According to the Nurses Notes dated November 8, 2013 the resident was readmitted to the facility ... " On assessment skin warm to touch lungs are clear on auscultation, abdomen is soft to touch and non-tender ... " The above nurse ' s note lacked description of the wound upon re-admission on November 8, 2013. The clinical record lacked evidence that the resident received care and services in a timely manner to ensure that the residents ' condition and wound did not become worse and prevent new wounds from developing. The resident was subsequently sent to the emergency room for evaluation secondary to fever, [MEDICAL CONDITION], and sacral wound debridement. A face-to-face interview was conducted with Employee #10. A query was made regarding the timeliness of the residents treatment to ensure that his/her condition did not worsen. Employee #10 acknowledged findings and that the care could have been delivered differently. Review of the Pressure Ulcer Evaluation dated February 5, 2014 revealed: " facility acquired rt (right) Ischium " current stage: Stage 2; measuring: 1x1.6x0.1; peri-wound intact, wound bed 100% granulation ...during wound rounds, resident was noted with new wound on the right ischium, 100% gran (granulation), no exudates, wound bed moist, peri-wound intact, wound edges defined. Tx (treatment) Aqcel ag daily and PRN (as needed). " Review of the Skin Sweep sheets for February 5, 2013 lacked evidence of a wound recognition for that day. A-face-face interview was conducted on January with Employee #21 on March 6, 2013 at approximately 11:00 AM. A query was made regarding the skin sweep assessment on February 5, 2013. He/she indicated that when he/she went into the room to check the skin there was already a bandage on it, so he/she did not look at it. A face-to-face interview was conducted with Employee #22 on March 6, 2013 at approximately 11:30 AM. A query was made regarding the condition of skin on February 5, 2014 and what is the process for notifying the nurse. Employee #22 stated " the wound team discovered the wound, I documented in the electronic notes, I do not remember who I told about it. " Review of the TAR (treatment administration record) revealed that the resident was to have an " air loss mattress to prevent skin breakdown " order date February 19, 2014 one (1) after developing two (2) unstageble wounds. The clinical record lacked evidence that the facility staff ensured that the residents ' condition and wound did not become worse and failed to prevent new wounds from developing. The resident was subsequently sent to the emergency room for evaluation secondary to fever, [MEDICAL CONDITION], and sacral wound debridement, returned and developed another facility acquired wound one (1) month later.

Based on observation, staff interviews and record review, it was determined that facility staff failed to maintain the keypad lock on the lobby stairwell door on 1 North which resulted in harm to one (Resident #1) of five record reviews. Resident #1 entered the 1 North stairwell, fell and subsequently sustained a fractured right tibia and fibula. The findings include: Review of an incident report, which was received from the facility, revealed that Resident #1 fell in the 1 North lobby stairwell and subsequent fractured the right tibia and fibula. The incident occurred on February 11, 2014 at 4:30 AM. The resident, who resided on 3 North, took the elevator to the lobby level at approximately 4:20 AM and sustained an unwitnessed fall in the stairwell of the 1 North lobby. During a face-to-face interview with Employee #3 on February 12, 2014 at 3:00 PM. He/she stated, "The stairwells all have locks on the doors. The stairs are for staff only. We don't encourage residents or visitors to use the stairs. That's why there are locks on the doors." Between 2:30 PM and 2:45 PM on February 12, 2014, the key pad locks were tested and found to be functional on the stairwell doors for 5 North, 5 South, 4 North, 4 South, 3 North, 3 South, 2 North, 2 South and 1 South. The lock on the door to the stairwell on 1 North, lobby level was not functional. This was the stairwell where Resident #1 had fallen. The door lock did not engage when the door was closed. Residents, who were leaving the elevator, had to pass by the 1 North lobby door to the stairwell to go to the dining room for meals and activities. On February 12, 2014 at 2:45 PM, approximately 40 residents were in the dining room attending a musical activity. The facility did not initiate any interventions to prevent residents from entering the stairwell through the 1 North lobby door. Face-to-face interviews were conducted on February 12, 2014 at 3:00 PM. Employee #4 stated, "On February 3 (2014) my employee, told me that the lock was broken on the stairwell on 1 North lobby door and the door wasn't locked." When asked if he told anyone, Employee #4 stated, "I forgot to tell anyone." Employees #1, 3 and 5 were present at this time and acknowledged that they were unaware that the 1 North stairwell door lock was not functioning properly until Resident #1's fall was reported on February 11, 2014. At 4:30 PM on February 12, 2014, Employee #4 stated, "I was wrong about the date. It was February 10, 2014. I was told the same day I ordered the parts. I fixed the lock and told Employee #3 at 8:30 PM last night (February 11, 2014). The fire alarm company came out today to test our new sprinklers and it could have caused a surge and fried the keypad." An e-mail was presented by Employee #4 that was dated February 10, 2014, requesting two (2) (company) keypads. When asked how the lock could have been fixed without the necessary parts, Employee #4 stated, "I don't know but it was working when I left last night." Through interview with Employee #5 conducted on February 12, 2014 at 4:45 PM, there were 31 residents who were competent and ambulatory and 31 residents who were confused and ambulatory currently residing in the facility and had access to the 1 North lobby stairwell door. A repairman from (Repair Company) was called by Employee #4 at 3:00 PM. He/she arrived at approximately 4:15 PM. At 6:10 PM on February 12, 2014, the door lock was tested and was observed functional. A face-to-face interview was conducted with the repairman from the (Repair Company), at 6:15 PM on February 12, 2014. The repairman was asked what was wrong with the lock and stated, "The keypad was defective. I don't know why that happened. I have left extra keypads so that the engineering staff can replace them immediately in the future." Employee #4 was asked on February 12, 2014 at 4:30 PM if there was a preventive maintenance schedule for the keypad and the shelf life of the key pad. Upon review of the package insert of the keypad, conducted in the presence of Employee #4, it was determined that there was no manufacturer's suggested schedule of preventive maintenance or indication of the shelf life of the product. Employee #4 stated, "During a fire drill the locks disengage. When the fire drill is done, I walk from the 5th floor down and check all the keypads to make sure they are working properly." Employee #4 was asked if he/she had checked the locks today after the sprinkler system was tested . He/she stated, "No." The facility staff failed to maintain a safe environment by ensuring that the keypad lock to the 1 North lobby stairwell was properly functioning. Resident #1 entered the stairwell on February 11, 2014 at 4:30 AM, fell and subsequently sustained a right tibia and fibula fracture.

Based on staff interview and record review for facility staffing, it was determined that the facility failed to provide sufficient staff to provide nursing services to one (Resident #1) of five residents resulting in harm to Resident #1. The findings include: Review of Resident #1's Minimum Data Set (MDS) assessment with an assessment reference date of January 26, 2014, he/she achieved a score of 11/15 on the Brief Interview for Mental Status in Section C (Cognitive Status). According to the "MDS 3.0 User's Manual" page C-14, a score of "8-12" suggests that the resident has "moderately impaired" cognitive skills for daily decision making. Resident #1 resided on 3 North and was blind. He/she was observed by facility staff on February 11, 2014 at 4:20 AM sitting in the day room listening to the television. The CNA assigned to Resident #1 answered the call light of another resident. When the CNA finished with the resident, Resident #1 was no longer in the day room. The CNA checked with the LPN, who stated that he/she had not seen the resident. The CNA checked the resident's room and bathroom and did not locate the resident. The resident was found in the stairwell of 1 North lobby and subsequently sustained a fractured right tibia and fibula. A telephone interview was conducted on February 14, 2014 at 11:40 AM with Employee #2. Employee #2 was asked about events that occurred during the evening and stated, "About 4:15 AM the CNA was in room (number) changing the resident and I went to (room) to flush a [DEVICE]; the machine was alarming. Resident #1 was sitting in the dining room listening to TV. Neither of us could see the dining room from the rooms we were in. A few minutes later the CNA came to the door and asked me if I had seen Resident #1. I told the CNA to check his/her room, finished up quickly with the [DEVICE] dressing, I was almost done anyway. I took the cart back to the nurse's station and someone from the second floor called on the phone and told me that Resident #1 was on the floor in the stairwell. I ran down the stairs to him/her and my CNA also ran down stairs. There were two other CNAs there from the second floor. Resident #1 would not stand so I rushed back upstairs to get a wheelchair. Everyone helped to get him/her quickly back in the wheelchair. We put him/her into bed and I did an assessment. He/she was complaining of pain in his/her right foot. There was no bruising or swelling. Then the supervisor came and did an assessment. We called the doctor and the RP and I ordered the x-ray. Then I left at seven (7:00 AM) at the end of my shift." Employee #2 was asked if it was usual for Resident #1 to be awake and walking around the unit during his/her shift (11:00 PM to 7:30 AM). Employee #2 stated, "Resident #1 is very unpredictable. Some nights he/she slept all night and other nights Resident #1 was awake and walking around all night. Many times Resident #1 wanted to go downstairs to smoke at three or four in the morning. Even though he/she is blind, Resident #1 was able to walk to the elevator and get to the first floor. Staff was supposed to go with him/her when he/she went downstairs." Employee #2 was asked about staffing on 3 North (where the resident resides) that night and stated, "There was me and the CNA that covered part of 3 North. There was another CNA who covered part of 3 North and part of 3 South. Then there was another CNA and LPN on the South side. The CNA who worked both the North and South side was on the South side when Resident #1 fell ." Employee #2 was asked if both the CNA and he/she went to assist Resident #1, who was available to assist the residents left on 3 North. Employee #2 stated, "I didn't really think of that. I was responding to the emergency. We brought Resident #1 back as quickly as we could. We weren't gone very long. Nothing else happened to the other residents while we were helping Resident #1." The facility failed to provide sufficient nursing staff as evidenced by the staff being aware of Resident #1's behaviors at night and that insufficient staff was available to respond to a resident's emergency and continue to meet the needs of other residents on the unit. The record was reviewed February 12, 2014.

Based on observation, staff interview and record review, it was determined that the facility staff failed to supervise one of five residents (Resident #1), who subsequently fell and sustained a broken right tibia and fibula and failed to maintain staff on the unit to supervise the other residents when Resident #1 fell . The findings include: A [AGE] year old resident was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of January 26, 2014, he/she achieved a score of 11/15 on the Brief Interview for Mental Status in Section C (Cognitive Status). According to the "MDS 3.0 User's Manual" page C-14, a score of "8-12" suggests that the resident has "moderately impaired" cognitive skills for daily decision making. He/she was assessed as requiring supervision with eating, limited assistance with walking in the room and corridor, and extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to the nurses' notes reviewed from October 18, 2013 through February 11, 2014, Resident #1, facility staff documented six (6) episodes of agitated behaviors that occurred during the night shift (11:00 PM to 7:30 AM). According to the resident's care plan, updated on January 21, 2014, the following was noted: "Resident #1 went out the back door on the first floor (on October 17, 2013 at 11:40 AM) and when the alarm sounded, the safety officer went to check on him/her and he/she had fallen down a slight embankment outside the door. No injuries were noted. "The intervention for this fall was to accompany Resident #1 downstairs should he/she insist on going downstairs to smoke at night." According to a nurse's note dated February 11, 2014 at 4:52 AM, "At 4:20 AM Resident #1 was sitting in the Day room. This writer was passing medication on the unit. At 4:30 AM, I was called that Resident #1 was down stairs and had fallen. I went to assess him/her. He/she could not get up by him/herself. I called for help and assisted him/her in the wheelchair. We brought him/her on the unit. Took Vital signs: 98.6, 86, 20, 142/76. X-ray of the Rt (Right) Tibia was ordered with claim (number). Supervisor was called to make assessment at 4:58 AM ..." According to the resident's care plan updated on January 21, 2014, Resident #1 was to be accompanied by facility staff when he/she left the unit at night. Resident #1 resided on the 3rd floor of the facility. Although he/she was blind, the resident was able to take the elevator by him/herself down to the lobby of the facility. This is a common behavior for this resident. There were no residents residing on the lobby level. The lobby houses the admission's office, which was closed; the front desk, which was unmanned; and the dining room, which was empty. A security guard is located at the front of the lobby entrance in a booth, between the outside glass doors and the inside glass doors. On February 12, 2014 at 5:00 PM, it was observed that when positioned between the inside and outside glass front doors, the elevator bell cannot be heard in the booth. A telephone interview was conducted on February 14, 2014 at 11:40 AM with Employee #2. Employee #2 was asked about events that occurred during the evening and stated, "About 4:15 AM the CNA was in room (number) changing the resident and I went to (room) to flush a [DEVICE]. The machine was alarming. Resident #1 was sitting in the dining room listening to TV. Neither of us could see the dining room from the rooms we were in. A few minutes later the CNA came to the door and asked me if I had seen Resident #1. I told the CNA to check his/her room, finished up quickly with the [DEVICE] dressing, I was almost done anyway. I took the cart back to the nurse's station and someone from the second floor called on the phone and told me that Resident #1 was on the floor in the stairwell." The resident was found in the stairwell of 1 North lobby. The Employee continued, "I ran down the stairs to him/her and my CNA also ran down stairs. There were two other CNAs there from the second floor. Resident #1 would not stand so I rushed back upstairs to get a wheelchair. Everyone helped to get him/her quickly back in the wheelchair. We put him/her into bed and I did an assessment. He/she was complaining of pain in his/her right foot. There was no bruising or swelling. Then the supervisor came and did an assessment. We called the doctor and the RP and I ordered the x-ray. Then I left at seven (7:00 AM) at the end of my shift." There was no assessment completed while the resident was in the stairwell. The resident was transported to his/her room and placed in his/her bed before the assessment was done. Employee #2 was asked if it was usual for Resident #1 to be awake and walking around the unit during his/her shift (11:00 PM to 7:30 AM). Employee #2 stated, "Resident #1 is very unpredictable. Some nights he/she slept all night and other nights Resident #1 was awake and walking around all night. Many times Resident #1 wanted to go downstairs to smoke at three or four in the morning. Even though he/she is blind, Resident #1 was able to walk to the elevator and get to the first floor. Staff was supposed to go with him/her when he/she went downstairs." Employee #2 was asked about staffing on 3 North (where the resident resides) that night and stated, "There was me and the CNA that covered part of 3 North. There was another CNA, who covered part of 3 North and part of 3 South. Then there was another CNA and LPN on the South side. The CNA who worked both the North and South side was on the South side when Resident #1 fell ." Employee #2 was asked if both the CNA and he/she went to assist Resident #1, who was available to assist the residents left on 3 North. Employee #2 stated, "I didn't really think of that. I was responding to the emergency. We brought Resident #1 back as quickly as we could. We weren't gone very long. Nothing else happened to the other residents while we were helping Resident #1." This was an unwitnessed fall. The record was reviewed February 12, 2014.

Based on observations, record review and staff interview for six (6) of 47 sampled residents, it was determined that facility staff failed to ensure that each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: consistently assess and monitor the status of one (1) resident who exhibited an acute change in status as manifested by low blood pressure and persistent [MEDICAL CONDITION] turn and reposition the resident every two (2) hours while in bed, transfer the resident out of bed as per the plan of care, change the PICC (Peripheral Intravenous Central Catheter) line dressing in accordance with physician's orders [REDACTED]. Additionally facility staff failed to: obtain a psychiatric consult per physician orders [REDACTED]. Residents #281, 10, 38, 120, 143, 282. The findings include: 1. Facility staff failed to consistently assess and monitor the status of Resident #281, who exhibited an acute change in status as evidenced by the presence of low blood pressure and persistent [MEDICAL CONDITION] Subsequently, the resident was transferred to the emergency room (ER) via Emergency Medical Systems (EMS - 911). Additionally, facility staff failed to turn and reposition Resident #281 every two (2) hours while in bed; failed to transfer the resident out of bed as per plan of care; failed to change the resident ' s PICC line dressing according to physician's orders [REDACTED]. A. Facility staff failed to consistently assess and monitor Resident #281when the resident sustained [REDACTED]. Subsequently, the resident was transferred to the ER via 911and hospitalized for [REDACTED]. According to the hospital discharge summary dated March 13, 2013, the resident was admitted on [DATE] and returned to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. The resident returned with a peripherally inserted central catheter (PICC) of the right upper arm and an indwelling urinary catheter. The resident ' s medication regimen included intravenous antibiotic therapy administered daily for a positive wound and throat culture for MDR (Multi Drug Resistance) Pseudomonas. Interdisciplinary progress notes documented by the medical team included, but was not limited to the following: March 4, 2013 at 13:38- " Dietary note: Seen resident today during lunch round as staff feeding at time of visit and 75% meal tolerated. Last labs dated 12/4/2013 (12/4/2012) with abnormal protein levels. New labs ordered Complete Metabolic Panel (CMP) and hydration and protein status will be evaluated when available. " March 5, 2012 at 12:50- Skin/Wound Note: " Resident was seen by wound nurse for wound dressing change, noted resident seems to (lose) weight. Unit manager was made aware, dietitian was called to assess resident and review supplement. Dietitian requested CMP, lab (draw). Speech therapist was called to assess resident. Awaiting speech therapist recommendation." March 5, 2013 at 1:00 PM - Nurse Practitioner Progress Notes: " CC - (Chief Complaint) - (Follow-Up) Labs; Resident labs came back and NP (Nurse Practitioner) for review. CBC (Complete Blood Count) with differential, (Hemoglobin and Hematocrit) 36/11, (Complete Metabolic Panel). Fairly good limits. PT, INR- 42/3.62. Hold [MEDICATION NAME] (times) 2 (two); resume 3-7-13. A/P (Assessment/Plan) Dx (Diagnosis): [MEDICAL CONDITIONS], History of [MEDICAL CONDITION] Embolism, Generalized Debility. Repeat PT, ([MEDICATION NAME] Time) INR 3-11-13 AM. Will f/u prn." March 5, 2013 16:12- Nurses Note- " Resident is alert and is being monitored closely; supplement has been increased to enhance weight gain and also promote wound healing. Resident has speech working with her for appetite enhancement. Resident ate 75% breakfast, and lunch 50%. " March 6, 2013 at 16:12 (4:12 PM) - Nurses Note- " Resident was observed to be slightly lethargic. Ate breakfast about 50%. Resident ate lunch 80%. Resident ' s (Vital Signs) - B/P (Blood Pressure) - 88/60 (normal b/p 90/60 - 120/90 per American Heart Association), Pulse- 122 (normal pulse 60-80 beats per minute per American Heart Association) , (Temperature) - 98.6, Pulse Ox (Oximetry) 97%. Resident ' s (treatment) was done and the activity was tolerated. CRNP (Certified Registered Nurse Practitioner) was informed of slight change of condition. P.O. fluid (fluids by mouth) was encouraged and mouth care was done. Resident was continuously monitored throughout the day. " March 6, 2013 at 4:35 PM - Nurse Practitioner Progress Notes- " CC- Resident blood pressure is low. Nurse Practitioner was called to assess resident stating that B/P (blood pressure) was low and HR (heart rate) was high. Resident in bed. Denies any (shortness of breath), chest pain, dizziness, headaches, n/v (nausea and vomiting) and other symptoms. Stated " I ' m OK. " Not on any blood pressure medications. Vital Signs- B/P- 88/60, HR -122, Temp- 97.6, RR (Respiratory Rate) 20. Pulse Ox- 97% on RA (Room Air). Nurses stated that B/P earlier was 71/48 and HR was 126. Resident is a feeder and does not drink or take oral fluids by herself. Temperature earlier today was 99.6. Lungs - Fairly CTAB (Clear to auscultation bilateral). Extremities- negative [MEDICAL CONDITION]. CVS (Cardiovascular System) - S1, S2 (heart sounds) ( " + "- present; not abnormal ) but [MEDICAL CONDITION](rapid heart rate) 116. A/P (assessment/plan) - Diagnosis: [REDACTED]. Will start IVF (Intravenous Fluid) D5 ? ( [MEDICATION NAME] Water- one half ) since resident is fairly stable and f/u ( follow-up) in AM. Also, EKG (electrocardiogram). " There was no evidence that resident ' s blood pressure reading (referenced in the Nurse Practitioner ' s note above) " 71/48 " was documented in the clinical record. March 6, 2013 19:51 (7:51 PM) - Nurses Note- " Resident remains in bed alert and verbally responsive. Ate 50% of (his/her) dinner and encouraged po fluids. Nurse Practitioner gave order for D5 ? NS (Normal Saline) at 75 cc/hr (per hour) times 3 liters. EKG to (evaluate) [MEDICAL CONDITION] BMP (Basic Metabolic Panel) on 3-11-13 AM. (Nursing) supervisor (inserted) IV (intravenous) peripheral line on (right) arm, IV NS (Intravenous Normal Saline) at 75 cc/hr infused; no reaction noted. PM care done with one person assist, TARP (turn and repositioned). Vital Signs- 120/80, 99.2, 126, 18. " March 7, 2013 at 06:50- Nurses Note; "Resident removed (his/her) IV peripheral. Night supervisor was informed. Kept on observation during the shift. Due ADL (Activities of Daily Living) cares provided. Zero discomfort or distress noted. Alert and responsive. Call light within reach." March 7, 2013 at 06:53- Nurses Note: "Resident removed her IV peripheral line. Night supervisor was informed. Kept on observation during the shift. Due ADL cares provided. Zero discomfort or distress noted. Alert and responsive. Call light within reach." March 7, 2013 at 9:40 AM Nurse Practitioner ' s Note: "CC- Resident is not looking good. Nurse Practitioner was called by staff to evaluate resident stating that she was not looking good. Resident was seen by NP yesterday due to [MEDICAL CONDITION] and [MEDICAL CONDITION] Started on IVF- B/P improved but HR was still 136. Resident mental status changed and had labored breathing. IV line infiltrated. A/P- Stopped IVF, Send resident out via 911 to nearest ER (acute care hospital named) for evaluation secondary to change in mental status, [MEDICAL CONDITION] and respiratory distress. PCP (Primary Care Physician) notified. Will f/u (follow up)." March 7, 2013 at 14:53 (2:53 PM) - Nurses Note: " Resident was observed to have change of condition during the AM care hours. Resident ' s V/S- T- 99.9, B/P- 139/75, Pulse- 123, (RR) 20. Resident was observed to be lethargic and semi-non-responsive to stimulus. (PCP ' s named) was called and awaiting return call at about 9:00 AM. At about 9:10 AM, CRNP was notified and did assessment and gave order to send (resident) to the hospital. 911 was called and came and transported resident to (hospital named). Family member (responsible party named) was called but could not leave message. Social worker notified to help contact family member. " Nursing assessments of the resident ' s status were inconsistent. There was no documented evidence of a correlating note and/or assessment of vital signs inclusive of pulse oximetry from March 6, 2013 at 19:51(7:51 PM) to March 7, 2013 at 14:53(1:53 PM); which is indicative of approximately 19 hours. March 7, 2013 15:22 (3:22 PM) - Nurses Note: " Mobile x-ray for EKG could not be done because resident was moving around too much. " A written statement by Employee #36 (assigned licensed nurse on night shift) (no date or time) presented to the SA (State Agency) from Employee #2 revealed the following: " On March 7th, 2013 during my rounds in the early hours of the morning, I observed resident had removed (his/her) peripheral IV line. It was lying on (his/her) bed. I checked there was no bleeding noted. Asked resident if (he/she) was having any pain or discomfort and (he/she) said ' No ' . I reinforced the site with 4 X 4 and taped. Called the night supervisor and informed (him/her) concerning this development. Told (him/her) the steps that I took. (He/she) asked me to keep an eye on (him/her) during the shift and inform the morning shift when they arrive in the morning. Resident denied any pain or discomfort during subsequent rounds. Signed (Licensed Nurse Named). " A review of Laboratory results included, but was not limited to the following: March 4, 2013: " Hemoglobin- 11.3 Low - (normal range 12.0 -16.0); Hematocrit 36.5 Low (normal range 37.0- 47.0); BUN/Creatinine (Blood Urea Nitrogen) - 28.6 (normal range 3.6 - 50.0); Potassium 3.8 (normal range 3.8 - 5.0). " A review of physician's order [REDACTED]. March 6, 2013 at 4:45 PM - " D5 ? NS at 75 cc/hr x 3 liters; Nurse to insert Peripheral Line; EKG to eval (evaluate) [MEDICAL CONDITION] BMP on 3-11-13 AM. " March 7, 2013 at 9:45 AM: Send resident out via 911 to (hospital named) ER or nearest ER for evaluation secondary to Respiratory Distress, [MEDICAL CONDITION] Change in Mental Status (for evaluation). " A review of the Treatment Administration Record for March 2013 included, but was not limited to the following: March 6, 2013 (no time indicated)- " D5 ? NS ([MEDICATION NAME] Water- one-half normal saline) at 75 cc/hr x 3 liters. " March 6, 2013 (no time indicated)- " Nurse to insert peripheral line. " March 6, 2013 (no time indicated) - " EKG to evaluate [MEDICAL CONDITION]" March 6, 2013 (no time indicated) - " BMP (Basic Metabolic Panel) on 3-11-13 AM " March 7, 2013 (no time indicated) - " Send pt (patient) out via 911 to (hospital named) ER or nearest ER for evaluation secondary to Respiratory distress, [MEDICAL CONDITION] change in mental status. " The space allotted for documenting the administration of D5 ? NS revealed initials that were circled for the hours of 7 AM to 3 PM on March 7, 2013, indicating that D5? NS was not given. Additionally, there was no documented evidence to indicate the quantity of IV fluids that was administered to the resident. A face-to-face interview was conducted with Employee #7 on March 17, 2013 at approximately 1:00 PM regarding the lack of consistent monitoring prior to transfer to the ER. In response to a query regarding the inconsistent monitoring, and how much fluid did the resident received; he/she stated, "We can calculate how much fluid the resident received." State Surveyor informed Employee #7 the need to see the written documentation. After reviewing the clinical notes; Employee # 7 acknowledged that the resident should have been monitored more consistently and vital signs should have been taken. A face-to-face interview was conducted with Employee #2 on March 18, 2013 at approximately 3:30 PM. After a discussion regarding the lack of evidence that facility staff consistently monitored the resident prior to his/her transfer to the ER, he/she presented an "Acute Change in Condition - Timeline " for the episode. He/she stated, " I know the nurse did the vital signs; he/she just did not write it in his/her progress notes. The staff has been taught to use SBAR (Situation, Background, Assessment, and Recommendation) to document clinical assessment. " The clinical record lacked evidence that facility staff consistently assessed and monitored Resident #281 when the resident sustained [REDACTED]. Nursing assessments were inconsistently documented and failed to depict an ongoing account of the status of the resident ' s condition. Several hours lapsed between the assessment of vital signs. Orders for the administration of intravenous fluids were not followed through reportedly secondary to infiltration. There was no evidence of the amount of IV fluids administered to the resident. The resident ' s condition declined as evidenced by a change in mental status, labored breathing and persistent [MEDICAL CONDITION] depicted in the Nurse Practitioner ' s note on the morning of March 7, 2013. The resident was subsequently transferred to the ER via 911and hospitalized for [REDACTED]. The clinical record was reviewed March 18, 2013. B. Facility staff failed to turn and reposition Resident #281 every two (2) hours while in bed according to physician's order [REDACTED]. According to the quarterly Minimum Data Set (MDS) dated [DATE], the resident was coded with a stage 3 pressure sore of the sacrum/buttocks. A physician's order [REDACTED]. " Observations of the resident during the survey period revealed the following: March 18, 2013 at approximately 10:00 AM- Resident positioned on right side; facing window. March 18, 2013 at approximately 11:00 AM- After wound treatment; resident was re-positioned back on right side with wedge behind back. March 18, 2013 at approximately 1:10 PM - Resident positioned on right side with wedge behind back. March 18, 2013 at approximately 3:10 PM- Observed resident on right side with wedge behind back. There was no evidence that facility staff turned and repositioned Resident #281 (away from the right side) in accordance with the physician ' s order as evidenced by observations on March 18, 2013. A face-to-face interview was conducted with Employee #7 on March 18, 2013 at approximately 3:30 PM. When queried, " Why resident was not being turned and re-positioned every two (2) hours? " Employee #7 responded, " He/she should have been repositioned every two (2) hours." Employee #7 asked the CNA (Certified Nursing Assistant) assigned to Resident #281 on evening shift, to reposition resident. The observations and record review was made on March 18, 2013. C. Facility staff failed to transfer Resident #281 out of bed in accordance with physician's order [REDACTED]. Resident #281 was observed lying in bed on March 14, 15, and 18, 2013 during the hours of 10:00 AM to 4:30 PM. An interim physician's order [REDACTED]. " The Treatment Administration Record for March 2013 revealed that staff transcribed the " out of bed " schedule for Resident #281 on March 14, 16 and 18th. Circled initials were noted in the allotted spaces for March 14, 16, and 18, which indicated that the directive was omitted and the resident was not out of bed on those days. Through observation of Resident #281 (on March 14, 15, and 18, 2013 during the hours of 10:00 AM to 4:30 PM); there was no evidence that the resident was out of bed in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted with Employee #7 on March 18, 2013 at approximately 3:30 PM regarding the aforementioned findings. After review of the clinical record and consulting with staff, Employee #7 stated, " The resident refused to get of the bed one day and the evening shift was going to follow-up. Also, staff was supposed to get (him/her) out of bed on Sunday; but it did not occur." Employee #7 acknowledged the findings. The clinical record review and observation was made on March 18, 2013. D. Facility staff failed to change Resident #281 ' s PICC line dressing site in accordance with physician's order [REDACTED]. On March 18, 2013 at approximately 2:30 PM, Resident #281's PICC line dressing site was observed on the right upper arm, brachial area. There was no date, time or initials to indicate when the dressing was last applied/changed. A " physician's order [REDACTED]. " According to a (hospital name) progress note dated March 12, 2013 at 0925 revealed, " Radiology, Procedure: 4F single lumen PICC ...length= ___ (left blank) ...Status: PICC ready for use. " The "Central-Line Catheter Protocol " dated March 12, 2013 and signed by the physician on March 13, 2013 directed, Device Type: PICC, Non-valved; On Admission- PICC gauge 18, Total catheter length-_ (left blank) " Treatment Protocols: Change Dressing: (box checked for): Transparent dressing Q (every) week and PRN (as needed). " The "Central-Line Catheter " administration record for March 2013 Change Dressing: (box was checked for) " Gauze dressing Q (every) 48 hours. " After review of the Central-Line Catheter protocol and the Central Line catheter administration record, there was no evidence that the order was transcribed in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted with Employee #7 on March 18, 2013 at approximately 3:30 PM regarding the aforementioned findings. Observation was made in the presence of Employees #7 and #35. He/she acknowledged the resident ' s dressing had not been changed since transfer from the hospital. The assigned charge nurse proceeded to change the resident ' s PICC line dressing site. The observation and record was made on March 18, 2013. E. Facility staff failed to clarify physician's order [REDACTED]. According to a " Re-Admission Progress Note " dated and signed March 13, 2013 directed: " Recent hospitalization : Fall Precautions secondary to MS ([MEDICAL CONDITION]) with debility, Foley care, Rt (Right) upper arm PICC line- Flush Per Protocol. " The "Central-Line Catheter Protocol " dated March 12, 2013 and signed by the physician on March 13, 2013 directed, " Device Type: PICC, Non-valved; On Admission- PICC gauge 18, Total catheter length-_ (left blank); Flushing Protocol- box for Intermittent Meds- no box was checked to indicate the method of flushing protocol. According to the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. When Employees #7 and #35 were queried regarding the flush protocol and technique. Both stated, " We flush the PICC line with normal saline before and after the administration of the antibiotic. We do not flush with [MEDICATION NAME] because the (resident named) is on [MEDICATION NAME]. " The record lacked evidence that the physician's order [REDACTED]. A face-to-face interview was conducted on March 18, 2013 at approximately 10:30 AM with Employees #7 and #35. Both acknowledged the lack of clarity in the physician's order [REDACTED]. The employees contacted the physician via telephone subsequent to the face-to-face interview and clarified the order as follows: " No [MEDICATION NAME] flushes due to resident on [MEDICATION NAME] 5mg q (every) pm. Clarification order. " The clinical record was reviewed on March 18, 2013. 2. Facility staff failed to follow the physician's orders [REDACTED]. A review of the resident ' s clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's order [REDACTED]. The resident is currently being treated with a total of 150mg of Quetiapine daily, (25mg PO q am/every am; 50mg at 5:00PM and 75mg at 9PM daily.) Review of the Medication Administration Records (MARs) revealed that the medication (Quetiapine) is being administered as ordered. However, the review of the " Consultation Reports failed to reveal a report to indicate that the requested consultation was obtained. A face-to-face interview was conducted with Employee #4 at approximately 3:30 PM on March 15, 2013. The employee was queried whether the resident has been seen by the psychiatrist as requested by the primary physician's order [REDACTED]. I will find out and let you know. " At approximately 4:30PM on March 15, 2013 Employee #4 informed this surveyor that the resident is on a list to be seen by the psychiatrist when (he/she) visits the facility. The employee added, " I will call the psychiatrist and make sure that the physician's order [REDACTED]. Facility's staff failed to follow the physician's orders [REDACTED]. 3. Facility staff failed to follow physician's orders [REDACTED].#38 who received nutrition/hydration via [DEVICE] (Gastrostomy tube). The physician's orders [REDACTED]. every 24 hours." A review of the February 2013 TAR (Treatment Administration Record), for the period of February 4 through February 28, 2013 revealed a line drawn through the spaces allotted for nurses to record the changing of the " feeding (spike cap set/bag). " The February, 2013 TAR lacked evidence that the facility staff followed the physician's orders [REDACTED]. A face-to-face interview was conducted on March 19, 2013 at approximately 8:50 AM with Employee #20. After review of the above, he/she acknowledged the findings. The record was reviewed on March 19, 2013. 4. Facility staff failed to clarify physician's orders [REDACTED].#120 with a pacemaker and failed to obtain information related to the pacemaker type and maintain a record of such on the active clinical record. A review of the physician's order [REDACTED]. Policy Title: " Pacemaker, Care of Resident with " (no date of origination or update indicated) " Policy: A designated staff member will perform periodic evaluation of residents with pacemakers per physician's order [REDACTED]. Purpose: Monitoring the resident ' s cardiac status after pacemaker implantation anticipates and avoids complications. Procedure RN/LPN ...3. Record in medical record the model, date of insertion, location of pacer, and pacer rate. Teach the resident the following about self-care related to pacemaker. To report to nurse any signs of dizziness or weakness, to count his or her pulse daily, avoid microwave diathermy, encourage female residents to wear a bra to support muscles ...6. Conduct phone checks as indicated by physician ' s, observe vital signs, count pulse for 1 minute. 7. Notify physician (if) any of the following signs occur: change of more (than) 5 impulses, missed beats, pacemaker fails to sense rate drop, complaints of dizziness, shortness of breath or chest pain. " A review of clinical record revealed a care plan entitled, " The resident has, a pacemaker/implanted cardiac device r/t (related to) [MEDICAL CONDITION] " . The interventions revealed, " Monitor vital signs as ordered/per facility protocol and record. Notify MD of significant abnormalities. Pacemaker checks as ordered and document: heart rate, rhythm, battery check per protocol. " After reviewing the clinical record, the care plan and the facility policy it was revealed that the facility policy deferred to the physician's order [REDACTED]. There was no evidence the order was clarified to indicate when to evaluate the resident ' s pacemaker. A face-to-face interview was conducted with Employee # 4 on March 19, 2013 at 3:15 PM. He/she acknowledged that the physician's orders [REDACTED]. The record was reviewed on March 19, 2013. 5. Facility staff failed to obtain diagnostic test results and follow through on an order for [REDACTED]. A. Facility staff failed to obtain the results of Resident #143 ' s diagnostic test, [MEDICATION NAME] ([MEDICATION NAME]) level, with timeliness. A review of the March 2013 physician's order [REDACTED]. A physician ' s interim order dated March 1, 2013 directed " [MEDICATION NAME] level on 3/4/12 in AM then q (every) month. " The results of the [MEDICATION NAME] level of March 4, 2013 was sub-therapeutic at 1 mcg/ml (normal range: 10-20 micrograms per milliliter). On March 4, 2013, the physician prescribed a modification to the [MEDICATION NAME] order as follows: " Give extra [MEDICATION NAME] 500mg tonight and 500mg in AM po for [MEDICAL CONDITION]. " An interim order dated March 5, 2013 directed " repeat [MEDICATION NAME] on 3/6/13 AM then weekly. " A review of the March 2013 MAR indicated [REDACTED]. A review of the clinical record on March 19, 2013 lacked evidence of the results of the March 11th [MEDICATION NAME] level. A face-to-face interview was conducted with Employee #22 on March 19, 2013 at 2:30 PM. In response to a query regarding the results of the March 11, 2013 [MEDICATION NAME] level, he/she was unable to locate the results having been received. He/she contacted the laboratory and obtained the [MEDICATION NAME] level which remained sub-therapeutic at 7 mcg/ml. The employee proceeded to contact the medical team regarding the results. Facility staff failed to obtain the results of a [MEDICATION NAME] level, until brought to their attention during the survey process. A period of eight (8) days lapsed before the results were obtained. There was no evidence that the resident exhibited any [MEDICAL CONDITION] activity secondary to the sub-therapeutic [MEDICATION NAME] level. The record was reviewed March 19, 2013. B. Facility staff failed to follow through with timeliness on a physician's order [REDACTED]. A review of physician's order [REDACTED]. Psych (psychiatric) consult follow up due to change in medication. " A review of the clinical record lacked evidence of a psychiatric consultation subsequent to the aforementioned order. A face-to-face interview was conducted with Employee #5 on March 19, 2013 at 3:00 PM. He/she acknowledged that the psychiatrist had not seen the resident since the physician prescribed a consultation on February 22, 2013. He/she stated that there was a psychiatrist that comes to the facility regularly and that the consultation schedule is determined by the psychiatrist. It is usual for a consult to be followed through within a week or two. The employee was unable to determine when and/or if Resident #143 was on the psychiatrists list to be seen, however stated that he/she would follow up. Facility staff failed to follow through with timeliness on a physician's order [REDACTED]. The record was reviewed March 19, 2013. 6. Facility staff failed to consistently conduct pain assessments and consistently include the intensity of the pain for Resident #282 who received [MEDICATION NAME] for pain. A review of the physician's order [REDACTED]. A review of the March 2013 MAR indicated [REDACTED]. A review of the reverse side of the March 2013 MAR indicated [REDACTED]. There were four (4) instances where the resident complained of pain and [MEDICATION NAME] was administered without an assessment of the intensity of the pain prior to administration of the medication. There were 14 instances where facility staff assessed the effectiveness of the medication, but failed to include the intensity of the pain after the medication was administered to the resident. There was no evidence that facility staff consistently conducted pain assessments that included the intensity of the pain (e.g. numeric scale) before administration of [MEDICATION NAME] and; there was no evidence that an assessment was completed after the administration of [MEDICATION NAME] to determine the level of intensity. A face-to-face interview was conducted with Employee # 4 on March 18, 2013 at 1:30 PM. He/she acknowledged that the facility staff failed to consistently conduct pain assessments and to consistently include the intensity of the pain for Resident #282 who received [MEDICATION NAME] for pain. The record was reviewed on March 19, 2013.

Based on observations, record review and staff interview for five (5) of 27 sampled residents, it was determined that facility staff failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by: failure to follow a physician ' s recommended parameters for the administration of two (2) antihypertensive medications; follow a physician's orders [REDACTED]. Residents #10, #185, #417, #TF1 and #TF2. The findings include: 1.Facility staff failed to follow the physician ' s recommendations for the administration of two antihypertensive medications, [MEDICATION NAME] and [MEDICATION NAME]. Resident #10. A review of the physician ' s orders revealed an order for [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s signature in the appropriate box indicated that the [MEDICATION NAME] was administered. Further review of the physician's order [REDACTED]. A review of the MAR for May 2013 revealed that on May 21, 2013 the resident ' s B/P (blood pressure) was recorded as 162/58 and that the nurse ' s signature in the appropriate box indicated that the medication was administered. In both instances the resident's diastolic blood pressure was recorded as 58 which was lower than 65 (110/65) that was recommended by the physician for administration of [MEDICATION NAME] and [MEDICATION NAME]. A face-to-face interview was conducted with Employee #11 at approximately 1:00PM on May 21, 2013. The employee acknowledged that [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident outside of the parameters (110/65) recommended by the physician. The record was reviewed on May 21, 2013. 2. Facility staff failed to follow a physician's orders [REDACTED]. The Physician's re-admission order sheet and plan of care dated May 17, 2013 directed, "Weight on admission, 2nd (second) day weight on (7 AM- 3 PM). " According to a re-admission progress note dated May 17, 2013 [DIAGNOSES REDACTED]. According to weight records retrieved from the electronic medical record, the resident's weight history was as follows: May 17, 2013 - 127.4 pounds (admission weight) May 20, 2013 - 122.4 pounds The electronic " Nutrition Assessment " dated May 20, 2013 revealed; " Resident with a history of significant weight loss (times) 90 days, however resident had [DEVICE] placed while admitted to outside hospital and has gained 24% or 23.7 (pounds) (times) 30 days. " There was no evidence that facility staff obtained a weight on May 18, 2013 for Resident #185 in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted with Employees # 5and #13 on May 21, 2013 at approximately 4:00 PM. After reviewing the clinical record, both acknowledged that the second day weight was not obtained as ordered. The clinical record was reviewed on May 21, 2013. 3.Facility staff failed to consistently conduct pain assessments and include the intensity of the pain for Resident #417 who received [MEDICATION NAME] for pain. The physician's order [REDACTED]. " A review of the May 2013 MAR indicated [REDACTED]. There were seven (7) instances where the resident received [MEDICATION NAME] 2mg. In four (4) of seven (7) instances, the resident was not assessed for pain before and after administration of the pain medication. In three (3) of seven (7) instances, there was an assessment of the resident ' s pain prior to the administration of the medication, however there was no reassessment post administration of the medication to determine the effectiveness of the medication. There was no evidence that facility staff consistently conducted pain assessments that included the intensity of the pain (e.g. numeric scale) before and after the administration of [MEDICATION NAME]. A face-to-face interview was conducted with Employee #5 on May 21, 2013 at 11:46 AM. He/she acknowledged that the facility staff failed to consistently conduct pain assessments and to consistently include the intensity of the pain for Resident #417 who received [MEDICATION NAME] for pain. The record was reviewed on May 21, 2013. 4.Facility staff failed to consistently conduct pain assessments and consistently include the intensity of the pain for Resident #TF2 who received [MEDICATION NAME] for pain. A review of the physician's order [REDACTED]...1 tab po (by mouth) Q (every) 6 hours PRN for pain." A review of the May 2013 MAR indicated [REDACTED]. A review of the May 2013 MARs revealed, that [MEDICATION NAME] was administered on six (6) occasions for pain. There were no consistent assessments related to the intensity of the pain prior to and post administration of [MEDICATION NAME] for Resident #TF2. There was no evidence that facility staff consistently conducted pain assessments that included the intensity of the pain (e.g. numeric scale) before and after the administration of [MEDICATION NAME]. A face-to-face interview was conducted with Employee #6 on May 20, 2013 at 3:50 PM. He/she acknowledged that the facility staff failed to consistently conduct pain assessments for Resident #TF2 who received [MEDICATION NAME] for pain. The record was reviewed on May 21, 2013. 5.Facility staff failed to administered the right medication to the right resident who complained of pain. Resident #TF1. A review of the Nurses ' Progress Notes revealed the following: May 14, 2013 at 21:56, Resident #TF1 " Was a new admit ...[DIAGNOSES REDACTED]. " According to the physician's order [REDACTED]. "[MEDICATION NAME] HCL ([MEDICATION NAME]) 5 MG Oral (by mouth) - PRN (as needed), PO (By mouth) Q (every) 12 HRS (Hours) for pain, order date 5/17/13" A review of the May 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication cart was inspected on May 20, 2013 at approximately 3:25 PM. There was no evidence that the cart contained [MEDICATION NAME] 5 mg designated for Resident #TF1. Employee # 18 who was present at the time of the inspection stated, "I took the [MEDICATION NAME] from the interim box, because it ([MEDICATION NAME]) had not been delivered from the pharmacy. " A review of the " Controlled Drug Administration Record " designated for interim medication use was conducted on May 20, 2013 at approximately 3: 40 PM. There was no evidence that [MEDICATION NAME] IR 5mg (the available medication on hand) was administer to Resident #TF1 on May 20, 2013. A follow up interview was conducted on May 20, 2013 at 3:55 PM with Employee #18 to clarify the source from which he/she obtained the [MEDICATION NAME], as there was no [MEDICATION NAME] 5mg removed for the interim box on today May 20, 2013. Employee #18 stated, " I will tell you the truth. I took the medication from another resident (Resident #TF2). I didn ' t want my resident to suffer. I was doing my best. " A review of the " Controlled Drug Administration Record " designated for Resident #TF2, revealed that on May 20, 2013 at 9:00 AM [MEDICATION NAME] 1 tablet was administered; and the documented amount of tablets remaining was 27. A review of the blister package which contained the [MEDICATION NAME] for Resident #TF2 revealed that 27 [MEDICATION NAME]-APAP 5-325 mg tablets remained. The May 2013 MAR for Resident #TF2 revealed that [MEDICATION NAME] 1 tablet was not administered to Resident #TF2 on May 20, 2013 at 9:00 AM. Facility staff failed to obtain and administer the prescribed medication ([MEDICATION NAME]) to the right resident when he or she complained of pain. Instead Employee # 18 administered [MEDICATION NAME] 1 tablet from another resident, which was not the medication prescribed. A face-to-face interview was conducted on May 20, 2013 with Employee #6. He/she acknowledged the findings at the time of the observations.

Based on record review and staff interview of two (2) of 62 sampled residents, it was determined that facility staff failed ensure that one (1) who entered the facility without a pressure ulcer did not develop pressure ulcers and failed to ensure that one (1) resident with skin impairment sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Residents #165 and #117. The findings include: According to the facility's policy, "Clinical Programs Manual: Skin Care and Wound Management", original date: October 2002, revised date: August 2007 Procedure number 2 stipulated, "2. Initiate the Weekly Skin Sweep (FSE 3-10-1) on admission and weekly thereafter, identify areas of skin impairment and any pre-existing signs ..." 1.Facility staff failed to accurately assess and implement interventions with timeliness to care for Resident #165 who entered the facility without a pressure ulcer however, develop a pressure ulcer to his/her left heel. The "Nursing Admission Evaluation" form revealed that Resident #165 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The Skin/Wounds Evaluation identified the skin intact, no open wounds. The " Nurses Progress Note " dated August 12, 2011 6:30 PM indicated that the resident was admitted with skin intact, no open wounds. The " Braden Scale " - for Predicting Pressure sore risk dated August 12, 2011 was scored " 16 " a level which indicated " Mild Risk " The "History and Physical" dated August 12, 2011 revealed skin: good texture and turgor ... According to the "Admissions MDS (Minimum Data Set)" with an ARD (Assessment Reference Date) dated August 19, 2011 indicated that the resident was coded in Section M: Skin conditions as "0" indicative that the resident was admitting without pressure ulcers. Pressure Ulcer-Heel: A review of the "Quality Assurance " : Skin Integrity assessment dated [DATE] revealed, "upon assessment, noted lt (left) heel black fluid blister measured 4x5x0 peripheral intact, Non-surgical ...treatment skin prep. Lt (left) medial heel light brown fluid blister Stage II measured 5x5x0 peripheral intact no s/s (signs or symptoms) of infection noted. Treatment skin: bilateral heel to be floated on pillows while in bed. " The "Weekly Skin Sweep" form signed and dated November 29, 2011 revealed, "no new skin impairment" between November 22, 2011 and November 29, 2011. Further review of the skin sweep forms for the period of November 1, 2011 through January 17, 2012 revealed documentation that the resident did not have any new or pre- existing skin impairments. A face-to-face interview was conducted with Employee #18 on March 22, 2012 at approximately 1:15 PM. A query was made as to what would be the cause of a wound of this type. Employee #18 indicated it is due to pressure. A face-to-face interview was conducted with Employee #8 and Employee #18 on March 22, 2012 at approximately 1:20 PM. A query was made if there were any skin sweep forms/assessments from previous weeks/months leading up to the discovery of the wound on November 25, 2011, Employee #8 acknowledged that the current skin impairments were not identified on the skin forms. A Review of the "Wound Assessment Form" dated November 14, 2011: revealed Stage II blister to the Left medial heel measured 4x4x0, and a Stage II 4x5x0 blister to the left heel, both identified as acquired in the facility: Left Medial Heel "Wound Assessment Form" dated November 21, 2011, 4cm length, 4cm width, no depth, Stage II (blister): Lt (left) medical heel light brown, fluid filled blister intact, skin prep to blister Q (every) shift. Left Medial Heel "Wound Assessment Form" dated November 25, 2011, 5cm length, 5cm width, 0 cm depth, stage: vascular, fluid filled...Left medial heel noted with slightly brown fluid filled blister. Intact, no s/s of infection noted. Peripheral intact. Treatment skin prep. Left Medial Heel: "Wound Assessment Form" dated November 21, 2011 (November 28, 2011) no measurements, Stage II (blister): Lt (left) medical heel blister intact, skin prep to blister Q (every) shift. Left Medial Heel: "Wound Assessment Form" dated December 6, 2011, stage: NS (Non-Stageable) 5cm length, 4.5cm width, .1 depth... Left medial heel wound bed 100% necrotic black tissue. Light amount of serous exudates noted, no foul odor present. Left Medial Heel: " Wound Assessment Form " dated December 13, 2011, stage: NS, 2 cm length, 3cm width, .1 depth ...Wound bed 50% red and 50% black, light amount of serous exudates noted. No foul odor present treatment calcium alginate. Left Medial Heel: " Wound Assessment Form " dated December 19, 2011 stage: NS, 2.5cm length, 2.5cm width, 0cm depth ...Skin prep to Lt medial heel, necrotic tissue, no exudates noted, no foul odor present surrounding skin intact. Left Medial Heel: " Wound Assessment Form " dated December 26, 2011, stage: NS, 2.5cm length, 2.5cm width, 0cm depth ...Lt medial heel eschar stable, no exudates noted, peripheral intact. Treatment skin prep Left Medial Heel: " Wound Assessment Form " dated January 3, 2012 stage: NS, 2cm length, 2cm width, 0cm depth ...Wound bed 100% necrotic tissue, no exudates noted, peripheral intact, treatment skin prep. Left Medial Heel: " Wound Assessment Form " dated January 9, 2012, stage: NS, 2cm length, 1.5cm width, no depth identified ...Wound has 100% yellow, no exudates noted, no foul odor present, surrounding skin intact. Left Medial Heel: " wound Assessment form " dated January 16, 2012, stage: NS, 4cm length, 3cm width, .5 depth ...Wound bed 100% black, light amount of purulent exudates noted, no foul odor present, surrounding skin intact. Left Medial Heel: " wound Assessment Form " dated January 23, 2012, stage: NS, 2cm length, 2cm width, .3cm depth ...Wound bed 100% slough, light amount of purulent exudates noted, no foul odor present, surrounding skin intact. Left Heel: "Wound Assessment Form" dated November 21, 2011, no measurements, Stage II (blister): Lt heel blister intact, skin prep to blister Q (every) shift. Left Heel: "Wound Assessment Form" dated November 25, 2011, stage: vascular, measuring 4cm length, 5cm width and depth 0cm, Type identified as " black Stage III " Lt heel black, non fluid filled blister intact, no s/s (signs/symptoms) of infection noted. Peripheral intact, treatment skin prep. Left Heel: "Wound Assessment Form" dated November 28, 2011 no measurements. Left Heel: " Wound Assessment Form " dated December 6, 2011 stage: stage II, 4.5cm length, 3.5 width, 0cm depth, black tissue ...Left heel black fluid, intact, no exudates noted, peripheral intact, treatment skin prep and float heels. Left Heel: " Wound Assessment Form " dated December 13, 2011, stage: II, 5cm length, 3.5 width, 0cm depth ...Lt heel remains black fluid, but intact peripheral intact. No s/s of infection noted, treatment skin prep. Left Heel: " Wound Assessment Form " dated December 19, 2011, stage II, 3cm length, 3.5cm width, 0cm depth ...Wound has 100% necrotic (stable) no exudates noted, no foul odor noted, Tx (treatment) skin prep. Left Heel: " Wound Assessment Form: dated December 20, 2011, stage: II, 3cm length, 2.5cm width, 0cm depth ...Lt heel DTI (Deep Tissue Injury) black fluid noted (?) fluid black DTI. Peripheral intact, Treatment skin prep. Left Heel " Wound Assessment Form " dated January 3, 2012, stage: NS, 3cm length, 2.5 width, 0cm depth ...Wound bed 100% necrotic tissue, no exudates noted. Wound dry, peripheral intact. Treatment skin prep. Left Heel " Wound Assessment Form " dated January 9, 2012, stage: NS, 3cm length, 2.5 width, no depth identified ...Wound bed 100% necrotic tissue, no exudates noted, foul odor present, surrounding skin intact. Treatment skin intact. Left Heel " Wound Assessment Form " dated January 16, 2012, stage: NS, 3cm length, 2. width, .5cm depth ...Wound bed 100% black, no exudates noted, no foul odor present, surrounding skin intact. Left Heel " Wound Assessment Form " dated January 23, 2012, stage: NS, 3.5cm length, 2.5 width, .2cm depth ...Wound bed 100% slough, no exudates noted, no foul odor present, surrounding skin intact. A wound observation was made on March 23, 2012 at 10:20 AM: Left heel: described by Employee #18 as pinpoint, intact skin surrounding the wound. Left medial heel: healing stage IV, observed at a Stage II, clean, no odor, skin normal flesh surrounding the wound area. Pressure Ulcers-Buttocks: A review of the clinical record for Resident #165 revealed a " Quality Assurance " : Skin Integrity assessment dated [DATE] revealed the Charge Nurse reported that the resident has an open area on the buttocks, upon wound team assessment resident noted with right buttock wound measuring [MEDICAL CONDITION], 30% skin, 70% yellow, no exudates - NS (Non-surgical), and a left buttock wound measuring [MEDICAL CONDITION], 70% red and 30 % yellow, exudates noted, surrounding skin intact. " The Weekly Skin Sweep form signed and dated October 18, 2011 identified the resident had " No New Skin Impairment " between October 18, 2011 and November 22, 2011. A face-to-face interview was conducted with Employee #18 on March 22, 2012 at approximately 1:17 PM. A query was made as to what would be the cause of a wound of this type. Employee #18 indicated it is due to pressure. A face-to-face interview was conducted with the Employee #8 and Employee #18 on March 22, 2012 at approximately 1:20 PM. A query was made if there were any skin sweep forms/assessments from previous weeks/months leading up to the discovery of the wound on October 18, 2011. Employee #8 indicated that there were no forms identified from the previous weeks. Employee #8 also acknowledged that the forms lacked identification of current and pre-existing skin impairments. Review of the " Wound Assessment Form " dated October 18, 2011 identified the resident with a pressure ulcer Stage III wound to the right buttock with yellow color measuring [MEDICAL CONDITION] and a pressure ulcer to the left buttock, Stage III, yellow in color, measuring [MEDICAL CONDITION], both identified as acquired in the facility. According to the " Physician ' s Interim Order Form " dated and signed October 18, 2011 directed: 1. Cleanse rt (right) buttock wound with wound cleanser, pat dry, apply Santyl/Xeroform, cover with 4x4 (gauze) and ABD pad and secure with tape (everyday) and PRN (as needed); 2. Cleanse lt (left) buttock wound with wound cleanser, pat dry, apply Santyl/Xeroform, cover with 4x4 (gauze) and ABD pad and secure with tape (everyday) and PRN (as needed). Review of the "Nurses Progress Notes" from October 19, 2011 to October 26, 2011 lacked documentation in the progress of the alterations in skin integrity for Resident #165. According to the "Nutrition Review/Pressure Ulcer " form review date October 28, 2011 indicated the resident would benefit from Vit (Vitamin) C, ZnSO4 (Zinc Sulfate) for wound healing. According to the PT (Physical Therapy) Discharge summary dated September 23, 2011, " Short term and long term goals: resident discharged [DATE]. Pt is mod (moderate) with bed mobility, dependent for transfers, poor sitting balance, unable to ambulate and on 02 (oxygen) via nasal canula and complains of severe BLE (Bilateral Lower Extremity) pain with movement ...recommends pain management consult. " According to the OT (Occupation Therapy) Discharge Summary dated September 23, 2012 the patient (resident) is dependent for ADL (Activity of Daily Living) transfers with hoyer lift due to severe pain in BLE ' s (Bilateral Lower Extremities). According to the SPT (Speech Therapy) Discharge Summary dated November 10, 2011 patient (resident) tolerating pureed diet with thick liquid and is demonstrating safe PO(by mouth) intake at this level of positioning. During a wound observation on March 23, 2012 at approximately 10:20 AM with the Wound Nurse (Employee # 18) and Employee # 47. There was an open pin point area to the left heel and the skin on the left and right buttocks was intact. The Wound Nurse indicated that the right buttock wound was resolved on January 16, 2012, and the left buttock wound was resolved on November 14, 2011. There was no evidence that facility staff accurately assessed and implemented interventions with timeliness to care for Resident #165 who entered the facility without a pressure ulcer however, develop a pressure ulcer to his/her left heel. The record was reviewed on March 22, 2012. 2. Facility staff failed to accurately assess and implement interventions with timeliness to care for Resident #117 with skin impairment and failed to ensure that the resident received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The "Nursing Admission Evaluation" form revealed that Resident #117 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The Skin/Wounds illustrations indicated to mark and number the location of skin condition/wounds on illustration ... revealed R&L amputations: amputation suture line dry on Rt. (right) side, small drainage (L) stump, no sutures. The "History and Physical" dated October 2, 2011 revealed skin: poor texture and turgor ...(L) hip ST (stage) II Ulcer. According to Section M, Skin Condition of the "Admission MDS (Minimum Data Set)" with an ARD (Assessment Reference Date) of October 7, 2011, the resident was coded with a Stage 3 pressure ulcer. Skin conditions: M0100 Determination of Pressure Ulcer Risk: coded A. Resident has a stage 1 greater, a scar over bony prominence, or a non-removable dressing/device; B. Formal assessment instrument/tool (e.g., Braden ...); Clinical assessment; M0150 Risk of Pressure Ulcers: Is the resident at risk for developing pressure ulcers was coded one (1) yes. M0210 Unhealed Pressure Ulcers(s): Does this resident have one or more unhealed pressure ulcer(s) at stage 1 or higher was coded 1 (one) yes. According to the "Nutrition Review/Pressure Ulcer " form review date September 30, 2011 indicated the resident [MEDICATION NAME] 1.5 @ 60ml/hr for 18 hours. According to the " Physician ' s Interim Order Form " dated and signed December 9, 2011 to 1. D/C (discontinue) hydrogel to Santyl, 2. Clarification of wound location - cleanse R right buttock wound with wound cleanser, pat dry apply Santyl ointment Xeroform cover with 4x4 (four by four gauze). A review of the clinical record for Resident #117 revealed a " Quality Assurance " : Skin Integrity assessment dated [DATE] revealed the Charge Nurse reported resident noted with sacral wound upon assessment, resident noted with ? buttock wound. NS (Non-Surgical) measurement [MEDICAL CONDITION] 100% (percent) black tissue peripheral bruise. No exudates noted, wound moist. Treatment change from (unable to read) to Santyl ointment and Xenoform qd (every day) and prn (as needed). A face-to-face interview was conducted with Employee #18 on March 22, 2012 at approximately 1:17 PM. A query was made as to what would be the cause of a wound of this type. Employee #18 indicated it is due to pressure. A face-to-face interview was conducted with Employees #18 and #26 on March 27, 2012 at approximately 3:20 PM. Review of the medical record lacked evidence of the " Weekly Skin Sweep " forms. A query was made if skin sweep forms were available for the weeks prior to the discovery of the wound on December 9, 2011. The Employee # 26 indicated that there were no Weekly skin forms identified. Review of the " Wound Assessment Form " dated December 9, 2011 identified the resident with a NS (Non-Stageable) pressure wound to the right buttock, 100% black tissue peripheral bruises. No exudates noted, but wound moist. Treatment Santyl oint (ointment) and Xeroform, measuring [MEDICAL CONDITION] acquired in the facility. Review of the " Wound Assessment Form " dated December 13, 2011 identified the resident with a NS (Non-Stageable) pressure wound to the right buttock, 100% black tissue, no exudates noted, but wound moist, treatment hydrogel, [MEDICAL CONDITION]. Review of the " Wound Assessment Form " dated December 19, 2011 identified the resident with a NS (Non-Stageable) pressure wound to the right buttock, 100% black, no exudates noted, no foul odor present surrounding skin intact, measuring [MEDICAL CONDITION]. Review of the " Wound Assessment Form " dated December 26, 2011 identified the resident with a NS (Non-Stageable) pressure wound to the right buttock, 100% black tissue peripheral bruises. No exudates noted, no foul odor presents surrounding skin intact, measuring [MEDICAL CONDITION]. According to the PT (Physical Therapy) Discharge summary dated 11/4/11, resident discharged : MAX A (maximum assist) with bed mobs (mobility), poor sitting bal (balance), dependent for transfers and non ambulatory. PT continues to educate staff to position pt (patient) with wedge and turn every 2 hours to prevent skin breakdown and PT wrote order to have pt out of bed in geri chair x (times) 5 hours per day x 7 days per week. According to the OT (Occupation Therapy) Discharge Summary dated November 5, 2011, patient able to tolerate positioning in a reclining geri-chair up to 4 hours with occasional repositioning. There was no evidence that facility staff accurately assessed and implemented interventions with timeliness to care for Resident #117 with skin impairment and failed to ensure that the resident received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident was discharged to an acute care facility on December 27, 2011. The closed record review conducted March 27, 2012.

Based on observation, staff interviews and record review for one (1) of five (5) residents, it was determined that facility staff failed to utilize positioning strategies with pillows or a positioning device to prevent continuous pressure for the current left posterior ear wound. Resident #1 The findings include; Resident #1 was born on December 25, 1923 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment dated [DATE], Resident #1 scored 12/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the " MDS 3.0 User ' s Manual, " page C-14, a score of " 8-12 " describes the resident as " moderately impaired. " Resident #1 was assessed as requiring extensive assistance with eating and totally dependent for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated December 6, 2011 at 10:30 AM: " Resident was found with an abrasion, round shape behind the left ear. Area was cleansed with NS (normal saline) and covered with gauze. Wound nurse to reassess. Daughter, Ms. (NAME REDACTED), notified. NP (nurse practitioner) made aware. 126/68, 70, 96.7 and 18. " Resident #1 was observed on January 12, 2012 at 9:50 AM. Resident #1 was on his/her left side. A pillow was positioned between his/her knees. There was no evidence that facility staff utilized positioning strategies with pillows or a positioning device to prevent continuous pressure on the left posterior ear wound. In the company of the Employee #1, Resident #1 was turned slightly towards his/her right side and the dressing removed on the wound located behind his/her left ear. The wound was approximately quarter size, with a deeper core approximately dime size. There was serosanguinous drainage on the dressing. There was no odor. Resident #1 moaned loudly. The observation was terminated. Employee #1stated at the time of the above observations, " (Resident #1) shouldn ' t be lying so far over. He/she is lying right on the ear wound. " Through record review, it was determined that Resident #1 had two (2) additional pressure sores one (1) on his/her right shoulder and one (1) on the sacrum. A telephone interview was conducted with Physician #1 on January 17, 2012 at 9:30 AM. Physician #1 was asked about Resident #1 ' s wounds. Physician #1 stated, " (Resident #1) is very frail and has very low [MEDICATION NAME] and Hemoglobin. He/she doesn ' t eat well. He/she has very little protein stores for healing and a very low blood count for delivering those proteins. The breakdown of his/her ear happened very fast. It ' s amazing that we had any success with the wounds, with the patient being so compromised. The shoulder and the sacrum were originally from pressure. The ear, I think, was from shearing. The wound doesn ' t look good at all. " According to the resident ' s record, the sacral wound was identified on August 15, 2011 approximately 2 cm x 1.5 cm x 1 cm. On January 1, 2012 the sacral wound was described as 2.5 cm x 0.5 cm 100% necrotic tissue. The right shoulder wound was identified on December 6, 2011 and described as 1cm x 1 cm x 0.1 cm. On January 1, 2012 the wound was described as 2 cm x 2 cm x 0.1 cm with 100% necrotic tissue. Facility staff failed to utilize positioning strategies with pillows or a positioning device to prevent continuous pressure for the current left posterior ear wound. The record was reviewed January 12, 2012.

Based on observations during a tour of the laundry on April 19, 2011 at 12:30 PM, a review of water temperature logs and through staff interview, it was determined that facility staff were unable to determine the washing machine water temperatures for linens and clothing washed in the laundry. An Immediate Jeopardy was called at 5:21 PM on April 19, 2011. The findings include: During a tour of the laundry on April 19, 2011 at 12:30 PM, in the presence of Employees #1, 6 and 7, it was determined that facility staff were unable to determine the washing machine water temperatures for linens and clothing washed in the laundry. Three (3) of four washing machines were observed operational. In response to this surveyor ' s request for staff to demonstrate the method used for assessing hot water temperatures for washing linens and clothing, Employee #6 stated that the thermometer was broken and that water temperatures had not been assessed since April 1, 2011 when the thermometer initially broke. A review of the temperature log book maintained by laundry personnel lacked evidence of hot water temperature assessments subsequent to April 1, 2011. Employee #7 stated that He/she attempted to order a replacement thermometer, but the supplier stated that the thermometer was on " backorder. " Employee #7 stated that the hot water temperature could be assessed by an alternate method and proceeded to redirect the water entering the washing machine so that it entered into a bucket The temperature of the water flowing into the bucket was 123?F. Employee #1 requested that the survey team revisit the laundry because the situation had been rectified. A secondary visit to the laundry was conducted at 3:45 PM on April 19, 2011. A thermometer was observed attached proximal to the rear of one of the three washing machines. Employee #7 stated that a replacement thermometer was installed and that the thermometer was formerly used for the " chiller. " The maximum temperature threshold of the " replaced " thermometer was 120?F. After agreeing that the temperature range of the replacement thermometer was inadequate, Employee #7 proceeded to reassess the water temperature using the bucket method described above. That assessment rendered a hot water temperature of 117?F at 3:50 PM on April 19, 2011. Employee #1 established a conference call at 3:55 PM on April 19, 2011 with the Regional Director from the facility ' s laundry product distribution company. The individual stated that the chloride content of the washing products utilized by the facility were for the purpose of stain removal and not for sanitizing purposes. S/he also stated that the chlorine component was for laundering whites only and not utilized for colored clothing/fabrics. He/she was queried regarding the parts-per-million (ppm) property of the chlorine product used by the facility, and He/she stated that an " educated guess " would be somewhere around 50-100 ppm, however; deferred the specifics of that query to the service technician. It is an industry standard that the entire washing process (wash/rinse/softener) acts in unison for the removal of bacteria. In addition there was no evidence that the facility implemented alternate measures to ensure resident safety in preventing the spread of infections. It was noted that the facility had four (4) residents with clostridium difficile and two residents with methicillin resistant staphylococcus aureus (MRSA) community acquired and were on transmission based precautions. According to the CDC (Center for Disease Control and Prevention) Laundry: Washing Infected Material - HAI: " Commercial laundry facilities often use water temperatures of at least 160 degrees Fahrenheit and 50-150 ppm (parts per million) of chlorine bleach to remove significant quantities of microorganisms from grossly contaminated linen. Studies have shown that a satisfactory reduction of microbial contamination can be achieved at water temperatures lower than 160 degrees Fahrenheit if laundry chemicals suitable for low-temperature washing are used at proper concentrations. " (http://www.cdc.gov/HAI/prevent/laundry.html) The facility staff demonstrated an inability to accurately determine the hot water washing temperatures for linens and clothing washed in the laundry. There was no evidence that the facility implemented a methodology to ensure an effective way to destroy microorganisms in laundry items. The above observations were made on April 19, 2011.