Every finding on record at Forest Hills of DC

Based on record review and interview, the facility staff failed to inform residents when changes are made to Medicare covered items and services as soon as reasonably possible as evidenced by the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was not given by the facility at least two days before the end of Medicare covered services for two (2) Medicare beneficiary residents in 33 sampled residents. (Resident #61, #68)The findings include:On 03/24/2026 approximately at 4:35 PM, review of the beneficiary notices revealed that Notices of Medicare Non-Coverage (NOMNC) were not sent at least two days before end of the covered services.A review of NOMNC sent to Resident #61's representative revealed the following: - Skilled Services Episode Start Date: 09/04/2025 - Last covered day of Part A Service: 09/25/2025 - NOMNC - Employee #5 (Social Worker) wrote on the Signature of Patient or Representative, [Resident Representative's name] acknowledged NOMNC via email on 09/24/2025 at 12:52 pm. The clinical record showed an email exchange dated 09/24/2025 at 10:14 AM between Employee #5 (Social Worker) and Resident #61's Representative (family) that read in part .Attached is a notice letting you know that [Resident's first name's] rehab services are ending tomorrow under this version of Medicare . This review revealed the NOMC was not sent to Resident #61 at least two days before the end of covered services.2. Review of the NOMNC sent to Resident #68 revealed the following: - Skilled Services Episode Start Date: 08/29/2025 - Last covered day of Part A Service: 09/22/2025 - NOMNC - on the signature line, Resident #68 printed full name and dated 09/22/2025. The NOMC was not sent to Resident #68 at least two days before the end of covered services.On 3/24/2026 approximately at 4:35PM, during a face-to-face interview, Employee #5 (Social Worker), affirmed that the Notices of Medicare Non-Coverage (NOMNC) were not sent to the two residents (Resident #61 and #68) 48 hours in advance the covered services end dates. Employee #5 added that the facility staff already understood not sending NOMNCs at least 48 in advance before covered services were ending was not a compliant practice and corrected it. Employee #5 said, we have been sending NOMNCs at proper notification time to residents since then.

Based on observation, record reviews, and staff interviews, for two (2) of 33 sampled residents, the facility staff failed to ensure the licensed pharmacist conducted a monthly drug regimen review for one resident and the attending physician, or designee failed to respond to pharmacists' recommendations for one resident. Residents #6 and #26 The findings included: 1. A review of a facility policy titled 'Medication Review' with a review date of 02/11/2026 documented, in part: 6. The Consultant Pharmacist shall review each resident's medication regimen monthly. Resident #6 was admitted to the facility on [DATE] with a history of multiple diagnoses that included: Diabetes Mellitus, Dementia, Hypertension and Chronic Kidney Disease. A physician's order dated 08/25/25 documented, oxycodone HCl Oral Tablet 5 MG (milligram) (Hydrochloride - opioid analgesic controlled drug) Give 1 tablet by mouth every 6 hours as needed for pain control. severe pain 7-10. An admission Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '03,' that indicated the resident was severely impaired. During a review of Resident #6's medical record from September 2025 through February 2026, showed no documented evidence that a monthly medication review of the resident's medication regimen had been conducted for October 2025. During a telephone interview conducted on 03/26/26 at approximated 2:55 PM with Employee #4 (Consultant Pharmacist) she acknowledged the findings and stated that, I review the medical record and write either a note that no irregularity was found, or there's a note if there is a finding, but I should have made a note for every resident for every month. I don't see my note in [electronic health record name] for that month [October] either. I may have made a mistake and left it off; it could be an error on my part. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease, Dementia, Unspecified Severity, with Mood Disturbance, Type 2 Diabetes Mellitus, Depression, and Generalized Muscle Weakness. A review of Resident #26's medical record showed the following physician 's orders updated and e-signed (electronically signed) by the physician on 12/08/25 at 1:23 PM that directed: Donepezil 10 mg (milligram) tab (tablet), 1 (one) tablet at bedtime for Dementia with intermittent psychotic features. Trazodone HCl Oral Tablet 100 mg (Trazodone HCl). Give 1(one) tablet by mouth at bedtime for insomnia. Diazepam Oral Tablet 5 mg (Diazepam) Controlled Drug. Give 1 tablet by mouth in the evening for anxiety. Fetzima Oral Capsule Extended Release 24-Hour ,120 mg (Levo milnacipran HCl). Give 1 capsule by mouth one time a day for depression. Valium Oral Tablet 2 MG (Diazepam) Controlled Drug. Give 2 mg by mouth in the morning for anxiety. Give a Valium 2 mg tablet by mouth every morning for anxiety. Abilify Oral Tablet 5 MG (Aripiprazole) Give 1 tablet by mouth one time a day for depression / psychosis. Remeron Oral Tablet 30 mg (Mirtazapine). Give 1 tablet by mouth at bedtime for depression. A Medication Regimen Review dated 12/08/25 that documented: Due to polypharmacy of psychopharmacological medications, recommend a regular psych consult to monitor therapy efficacy and side effects, as well as consider gradual dosage reductions. Trazodone 100 mg, Diazepam 2 mg, and 5 mg. Remeron 30 mg, Fetzima 120 mg, Abilify 5 mg, Donepezil 10 mg. The clinical record lacked documented evidence of a Physician/Prescriber's response to this recommendation. During a face-to-face interview on 03/26/26 1: 36 PM, Employee #3 (Registered Nurse/Clinical Nurse Manager), when asked what the process was for ensuring that the pharmacist's medication review recommendations are seen by the physician/prescriber and so the physician/ prescriber can respond, she stated, The pharmacist reviews the resident's medications from the resident's electronic health record monthly. If the consultant pharmacist has any medication recommendations, she writes a pharmacy review progress note and sends the residents' MRRs to me by email. I then print a hard copy of each resident's MRR from my email and flag it in each Resident's paper chart for the physician/prescriber to respond. Once the physician responds, I place the resident's MRR in a binder in my office. When asked where the physician/prescriber's response to the pharmacist's recommendations on 12/08/25 was, the Employee stated that she could not find the physician's response to the 12/08/25 MRR. When asked how she ensures that no residents' MRRs are missed, the Employee made no comment and acknowledged the finding.

Based on observations, record reviews and staff interviews, facility staff failed to prepare and distribute food under sanitary conditions as evidenced by the following observations. The findings include:During an initial kitchen survey in the kitchen on 03/24/2026 approximately at 10:15 AM, the following observations were made: Undated shredded cheese in opened plastic bag inside refrigeratorMultiple half gallons milk in the reach-in refrigerator passed their sell-by dates 3/23/2026), content looked settledCondensation water leaking onto packaged food (potato fries in plastic bags) in the walk-in freezer.Employee # 9 (kitchen manager) checked food (tuna salad) temperature before washing handsSignificant food residue built-up on cooking equipment and floor at the cooking and dish washing areasExcessive limescale accumulation on interior surfaces of the automatic dish washing machineA dish washing employee used towel to dry-up food contact surfaces of the washed-sanitized kitchenware.Mold on wall surfaces and caulk lines at the automatic dish washing area.Employee #7 (Corporate chef) and Employee #6 (Kitchen manager) were immediately made aware of these findings and proceeded to implement measures to address the issue.Record review of the pest control report from [company named] dated 2.19.2026 in part .Kitchen - Inspected. Some general cleaning is needed under equipment on cooking line. Clean floor along wall an floor drain under 3 compartment sink in dish room. Clean corner area of floor under juice counter. Everything else was ok.Record review of the pest control report from [company named] dated 7.18.2025 in part .Kitchen - Inspected. Floor area along wall under counters and behind cooking equipment need to be cleaned. There are a lot of food debris in areas. Small center drain on cooking line needs to be cleaned. Everything else was ok.During a face-to-face interview on 03/24/2026, approximately at 10:15 AM, the above observations were acknowledged by Employee #7 (Corporate Chef) and Employee #6(Kitchen Manager).During follow-up kitchen survey on 03/27/2026 approximately at 11:00 AM, the following observation was made: Employee belongings jacket and backpack stored on racks in dry storage room, not properly stored in a locker room, to prevent cross contamination of the food and food contact surfaces stored in the dry storage room.During a face-to-face interview on 3/27/2026, approximately at 11:10 AM, the above observation was acknowledged by Employee #6 (Kitchen Manager)

Based on record reviews and staff interviews for two (2) of 33 sampled residents, it was determined that facility staff failed to show documented evidence that they provided nursing care and treatment for a resident on aspiration precautions; and for a resident on fall precautions and at risk for pressure injury. Residents' #10, #1.The findings included: A facility policy titled 'Charting and Documentation' and 'Electronic Medical Records' with review dates of 02/11/2026 documented, in part: Documentation in the medical record will be objective, complete and accurate. Electronic records are an acceptable form of medical record management.1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Parkinson's Disease and Severe Protein-Calorie Malnutrition.A physician's order dated 01/23/26 documented, ASPIRATION PRECAUTIONS EVERY SHIFT.A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '03,' that indicated the resident was severely impaired.During a review of the resident's Treatment Administration Record dated March 1, 2026, to March 31, 2026, it revealed there was no documented evidence that facility staff ensured aspiration precautions were being conducted on the following dates and times: 03/07/26 night shift and 03/18/26 evening shift.2. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Respiratory Failure, Pneumonia, Asthma and Chronic Back Pain.A physician's order dated 02/06/26 documented the following orders: NON SKID SOCKS ON 3-11 SHIFT, OFF 7-3 SHIFT-FALL RISK every day and evening shift and ELEVATE/FLOAT HEELS ON PILLOWS FOR PRESSURE RELIEF EVERY SHIFT WHILE IN BED every shift.An admission Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' that indicated the resident was cognitively intact and required supervision with Activities of Daily Living.During a review of the resident's Treatment Administration Record dated February 1, 2026, to February 28, 2026, it revealed no documented evidence that facility staff ensured non-skid socks were placed on the resident during the evening shift for the following dates: 02/07/26, 02/13/26, 02/21/26 and 02/22/26.During a review of the resident's Treatment Administration Record dated February 1, 2026, to February 28, 2026, it revealed no documented evidence that facility staff ensured the resident's heels were elevated/floated on pillows for pressure relief during the evening shift for the following dates: 02/07/26, 02/13/26, 02/21/26 and 02/22/26.During a face-to-face interview conducted on 03/26/26 at approximately 11:40 AM with Employee #3 (Clinical Nurse Manager) she acknowledged the findings and stated, Normally the night shift do [does] 24-hr chart check for new orders, but I'm not sure if they check the documentation to see if those orders were documented as being done.Cross Reference: DCMR S 3231.2

Based on observations and staff interviews, facility staff failed to maintain essential kitchen equipment (walk-in freezer) in good order.The findings include:During the initial tour in the kitchen on 03/24/2026 approximately at 10:15 AM, the following observation was made: The condensation pipe conveying condensate wastewater from air condenser in the walk-in freezer has been leaking. During a face-to-face interview on 03/24/2026, approximately at 10:30 AM, the above observation was acknowledged by Employee #6 (Kitchen Manager) and Employee #7 (Corporate Chef).

Based on observations, record reviews and staff interviews, facility staff failed to maintain an effective pest control program so that the facility is free of pests (flies).The findings included:During the initial kitchen tour on 03/24/ 2026 approximately at 10:15 AM, it was observed multiple live flies at the juice counter and dish washing areas.Record review of the pest control report from Bay City pest management Co. Inc dated 2.19.2026 in part .Kitchen - Inspected. Some general cleaning is needed under equipment on cooking line. Clean floor along wall an floor drain under 3 compartment sink in dish room. Clean corner area of floor under juice counter. Everything else was ok.Record review of the pest control report from Bay City pest management Co. Inc dated 7.18.2025 in part .Kitchen - Inspected. Floor area along wall under counters and behind cooking equipment need to be cleaned. There area a lot of food debris in areas. Small center drain on cooking line needs to be cleaned. Everything else was ok.During a face-to-face interview on 03/24/2026, approximately at 10:15 AM, Employee #7 (Corporate Chef) and Employee #6 (Kitchen manager) acknowledged the above observation.

Based on record review and staff interview, for one (1) of three (3) sampled residents, the facility's staff failed to ensure a resident's assessment reflected the type of facility where she was previously admitted . (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with a history of Acute Pulmonary Embolism and Hypertension. According to the admission intake form dated 12/13/24, Resident #1 was being discharged from an out-of-state nursing home. An Entry Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was discharged from short-term general hospital. During a telephone interview on 12/27/24 at 1:34 PM, Employee #8 (MDS Coordinator) stated that she coded the resident as being discharged from a hospital based on the hospital discharge summary provided by the nursing staff. She said that she was informed by Employee #2 (Director of Nursing) that the resident had been discharged from a nursing home.

Based on record review and staff interviews, for one (1) of three (3) sampled residents, the facility failed to: administer Eliquis(anticoagulant)at the currently prescribed dose [5mg by mouth two-times a day]. And, Metoprolol (beta blocker) in the currently prescribed formulary [Succinate Extended Release].(Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with a history of Acute Pulmonary Embolism and Hypertension. A review of Resident #1's admission packet from the facility's Admission Office revealed the following pre-admission documents: -An out-of-state hospital discharge summary dated 12/10/24 documented that the resident was hospitalized between 12/05/24 and 12/10/ 24 with Acute Pulmonary Embolism. The discharge summary also revealed that the following medications were prescribed: Apixaban (Eliquis) 5 mg 2 tablets (10 mg) by mouth daily 2 times a day for 6 days. Then take [Eliquis 5 mg] 1 tablet (5mg) by mouth two (2) times daily . Metoprolol Succinate ER (exten release) 50 mg one (1) tablet by mouth nightly . -A facility's (Forest Hills) admission intake form dated 12/13/24 indicating that the resident was being discharged from an out-of-state skilled nursing facility. -A discharge summary from an out-of-state skilled nursing facility revealed that the resident was admitted between 12/10/24 and 12/19/24. In addition, the summary showed the resident was prescribed the following medications: (Eliquis)5mg 2 tablets (10 mg) by mouth twice a day for 6 days starting on 12/10/24 and ending on 12/17/24 . Eliquis 5mg one (1) tablet by mouth every 12 hours . Metoprolol Succinate Extended Release (Generic name -Toprol XL) 50 mg one (1) tablet by mouth at bedtime . -A Complete Blood Count with Differential lab result dated 12/11/24 documented in part, Hemoglobin 11.7 g/dL range 11. 2 - 15.7 g/dL (grams per deciliters) . Please note: The documents listed above, except for the facility's admission intake form, were included in the resident's hard medical record on the unit the resident resided. A nursing progress note dated 12/19/24 at 5:32 PM, documented in part, Resident .admitted today at the facility at 1:00 PM with history of Acute PE (pulmonary embolism) . Alert, oriented X3 . speech is clear .Heart rate and rhythm are normal. Vital signs stable .oriented to call light and bed control. Resident is adjusting well to .surroundings. A physician order dated 12/19/24 instructed: Apixaban (Brand name- Eliquis) 5mg give 2 tablets by mouth two (2) times a day for a clot in lung for 6 days. Give 10 mg (milligrams) . Metoprolol Tartrate (Generic name -Lopressor) 50 mg give one (1) tablet by mouth at bedtime . A care plan dated 12/19/24 documented in part, Focus - [Resident's name] is on anticoagulant therapy (Apixaban/Eliquis) related to clot in lung .Interventions- Administer anticoagulant medication as ordered by physician. Monitor for side effects and effectiveness every shift A physician order dated 12/22/24 instructed, Monitor resident for bleeding and report any abnormal. Phone findings to the attending physician every shift for 7 days. A Director of Nursing progress note dated 12/23/24 at 6:30 PM, documented in part, During the medication administration on 12/22/24, it was noted that Eliquis 10 mg BID was inadvertently given instead of prescribed Eliquis 5 mg BID. Upon discovery, the attending physician was promptly notified , and the medication order was corrected to reflect the proper dosage of Eliquis 5mg BID .A head-to-toe assessment was completed and revealed no evidence of active bleeding or bruising .Laboratory results .a hemoglobin [test dated12/23/24] showed a level 10.5 g/dL, a decrease from 11.7 g/dL compared to lab work from the previous facility (12/11/24) .[NP's name] was on-site around 6:00 PM to assess the resident, an no abnormal findings were noted during the assessment. According to the Medication Administration Record (MAR) for December 2024, the resident received Apixaban (Eliquis) 10 mg two (2) times a day between 12/20/24 and 12/21/24 (four occasions). The MAR also revealed that the resident received Metoprolol Tartrate (Generic name-Lopressor) 50 mg at bedtime between 12/19/24 and 12/22/23 (four occasion). A Complete Blood Count with Differential lab result dated 12/23/24 documented in part, Hemoglobin 11.7 g/dL range 11.1 - 15.9 g/dL (grams per deciliter) . A review of the resident's blood pressure levels between 12/19/24 to 12/23/24 revealed the resident's systolic blood pressure ranged from 113 to 128 mmHg (millimeter of mercury) and diastolic blood pressure ranged from 58 to 80 mmHg (millimeter of mercury). During a telephone interview on 12/26/24 at 11:32 AM, Resident #1's daughter/POA stated that when she brought her mother to the facility, she gave the nurse on duty copies of her mother's medications and physical medication from her previous nursing home. The daughter also said that she coordinated a call between the facility's nurse and the nurse from the previous nursing home. While visiting her mother on the evening on 12/22/24, she noticed the nurse attempting to administer Eliquis 10mg. When she asked the nurse why her mother was receiving 10 mg instead of 5mg, the nurse informed her that her mother had a physician order for Eliquis 10 mg twice a day for six days. The daughter stated that she informed the nurse that was a onetime order that was completed at the previous nursing home. The supervisor was called, and the medication was held. The Director of Nursing came in the next morning and apologize for the mistake. As a result of the medication error, she decided to discharge her mother home. Additionally, as she reviewed her mother's mediation list during discharge, she discovered that her mother was receiving Metoprolol Tartrate (Lopressor) 50 mg instead of Metoprolol Succinate Extended Release (Toprol XL) that she received while in the previous nursing home. During a telephone interview on 12/26/24 at 1:19 PM, Employee # 3 (assigned RN) stated that she and Employee #5 (LPN) admitted Resident #1 on 12/19/24. She said that although she received report via phone from the unit manager of the discharge facility, it did not include the resident's medications. The resident's daughter did provide her with a discharge summary that included a medication list from the discharging nursing home. After receiving the medication list, she reviewed it and handed it to Employee #5 (LPN) to transcribe. When asked if the summary was from a nursing home or hospital? She said that the medication list was from the nursing home. During a telephone interview on 12/27/24 at 8: 20 AM, Employee #4 (primary care physician) stated that she gave medication orders based on the hospital discharge summary. According to the documents, Eliquis 10 mg by mouth two times a day was prescribed, along with Metoprolol Succinate Extended Release 50 mg one (1) tab at bedtime every evening was ordered. According to the employee, she said she didn't recall seeing a discharge summary from the nursing home. Additionally, the employee stated that staff informed of the error with Resident #1receiving10 mg twice a day instead of Eliquis 5 mg twice a day. She also stated that staff did not inform her that that the resident was receiving Metoprolol Tartrate 50 mg a day instead of Metoprolol Succinate 50 mg a day. In addition, the employee stated that the resident should have been given Eliquis and Metoprolol as documented on her discharge summary from the nursing home. During a telephone interview on 12/27/24 starting at 8:42 AM, Employee #5 (LPN) stated that she helped Employee #3 (RN) admit Resident #1. She reviewed the hospital discharge summary given to her by Employee #3. She was not given a discharge summary from a nursing home. She reviewed the medications and took a picture of the medication list and sent it to the physician. After the physician approved the medications, she entered the orders into Resident #1's electronic medication record and sent the ordered the medications from pharmacy. During a face-to-face interview on 12/27/24 at approximately 2 PM, Employee #2 (DON) stated that the staff transcribed hospital orders for Eliquis 10 mg twice daily by mouth for six (6) days instead of Eliquis 5 mg twice daily as indicated on the nursing home discharge summary. Additionally, she said that unaware that the resident was receiving Metoprolol [Tartrate] instead of Metoprolol [Succinate] as ordered by the physician. Please note: The surveyor and Employee #2 (DON) reviewed Resident #1's electronic pharmacy record on 12/27/24 at approximately 2 PM, the review revealed that Employee # 5 entered Metoprolol Tartrate 50 mg by mouth at bedtime [daily] instead of Metoprolol Succinate 50 mg by mouth at bedtime [daily] as indicated on the both the hospital and nursing home discharge medication orders. During a face-to-face interview on 12/27/24 at 9:01 AM, Employee #6 (Director of Admissions/Marketing) stated that she received several documents from the nursing home on 12/17/24 via email, including a discharge summary from the nursing home [dated 12/17/24] and a discharge summary from the hospital [dated 12/10/24]. A copy of the documents was sent to the Administrator/RN for approval. After the Administrator approved Resident #1 for admission, the documents were given to a nurse on the resident's assigned unit for review. This was prior to her admission on 12/19/24. Employee #6 could not recall the date or the nurse's name who was provided the documents for review.

Based on record review and staff interview, the facility failed to ensure Resident #1 was not administered unnecessary medications. This was evident for one (1) of three (3) sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE] with a history of Acute Pulmonary Embolism and Hypertension. A review of Resident #1's medical record showed that the resident was discharged from an out-of-state nursing home prior to her admission on 12/19/24. Continued review of the resident's medical record revealed multiple documents from the discharging nursing home including: -A hospital discharge summary dated 12/10/24 documenting the resident was hospitalized between 12/05/24 and 12/10/ 24 with Acute Pulmonary Embolism. The discharge summary also revealed that the following medications were prescribed: Apixaban (Eliquis) 5 mg 2 tablets (10 mg) by mouth daily 2 times a day for 6 days. Then take [Eliquis 5 mg] 1 tablet (5mg) by mouth two (2) times daily . -A discharge summary from an out-of-state skilled nursing facility indicating the resident was admitted between 12/10/24 and 12/19/24. The summary also showed the Apixaban (Eliquis) 5 mg 2 tablets (10 mg) by mouth daily 2 times a day for 6 days was completed on 12/17/24. In addition, the resident was prescribed .Eliquis 5mg one (1) tablet by mouth every 12 hours . A physician order dated 12/19/24 instructed the following: Apixaban (Brand name- Eliquis) 5mg give 2 tablets by mouth two (2) times a day for a clot in lung for 6 days. Give 10 mg (milligrams). A Director of Nursing progress note dated 12/23/24 at 6:30 PM, documented in part, During the medication administration on 12/22/24, it was noted that Eliquis 10 mg BID was inadvertently given instead of prescribed Eliquis 5 mg BID. Upon discovery, the attending physician was promptly notified, and the medication order was corrected to reflect the proper dosage of Eliquis 5mg BID . According to the Medication Administration Record (MAR) for December 2024, the resident received Apixaban (Eliquis) 10 mg two (2) times a day between 12/20/24 and 12/21/24 (four occasions). During a face-to-face interview on 12/26/24 at approximately 10 AM, Employee #2 stated that there was an error with Resident #1's medication (Eliquis). The employee said that staff transcribed the order for Eliquis 10 mg by mouth twice-a-day from a hospital discharge summary [dated 12/10/24]. The staff should have transcribed medications from the discharging nursing home discharge summary [dated 12/19/24] which instructed Eliquis 5 mg by mouth two times a day. The employee stated the when the resident's daughter brought it to staff attention on 12/22/24. They quickly notified the physician (Employee #4) and corrected the order. The resident was assessed, monitored, and labs were drawn. The resident did not have any bleeding or other apparent side effects from the error with Eliquis. During a telephone interview on 12/26/24 at 11:32 AM, Resident #1's daughter/POA stated that while visiting her mother on the evening on 12/22/24, she noticed the nurse attempting to administer Eliquis 10mg. When she asked the nurse why her mother was receiving 10 mg instead of 5mg, the nurse informed her that her mother had a physician order for Eliquis 10 mg twice a day for six days. The daughter stated that she informed the nurse that was a onetime order that was completed at the previous nursing home. The supervisor was called, and the medication was held. The Director of Nursing came in the next morning and apologize for the mistake. As a result of the medication error, she decided to discharge her mother home. During a telephone interview on 12/27/24 at 8: 20 AM, Employee #4 (primary care physician) stated that when the resident was admitted on [DATE] she gave an order for Eliquis 10 mg by mouth for six (6) days based on a hospital discharge summary [dated 12/10/24]. According to the documents, Eliquis 10 mg by mouth two times a day was prescribed. According to the employee, she said she didn't remember seeing the discharge summary from the discharging nursing home in the resident's record. When staff informed her of the error, she gave orders to change Eliquis to 5 mg by mouth twice a day, monitor resident for bleeding, and have labs drawn [complete blood count with differential]. In addition, she instructed the nurse practitioner to go to the facility and assess the resident. The assessment found no negative outcome. Cross reference: 483.25 Quality of Care (F689)

Based on observation, record review, and staff interview, the facility staff failed to ensure a medication cart was locked and secure from residents, visitor, and other personnel for one (1) of two medications observed on Unit 2. The findings included: A policy titled, Security of Medication Cart, instructed staff to secure medications carts during medication passing to prevent unauthorized use when parking carts in hallways place cart against the wall with drawers facing the wall .carts must be securely lacked at all times when out of the nurse's view . On 12/27/24 at approximately 9:24 AM, an unlocked medication cart was observed parked in a common with drawers facing forward, visible and accessible to anyone passing by. There were no staff members in view of the medication cart. Additionally, residents and staff were gathered in a dining area nearby. During a face-to-face interview on 12/27/24 at 9:25 AM, Employee #8 (RN) stated that the cart should be locked, and he would go get Employee #9 (LPN) who was passing medication in the dining area. During a face-to-face interview on 12/27/24 at 9:26 AM, Employee #9 (LPN) stated she should have locked the cart before leaving. The employee then said, I prefer not to give any further comments.

Based on record review and staff interview, the facility failed to ensure a resident's Medication Administration Record included the correct formulary for a medication used to treat elevated blood pressure for one (1) of three (3) sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with a history of Acute Pulmonary Embolism and Hypertension. A review of Resident #1's medical record revealed that the resident was discharged from an out-of-town nursing home on 12/19/24. The discharge summary documented that the resident was prescribed . Metoprolol Succinate [Toprol XL] Extended Release 50 mg one (1) tablet by mouth at bedtime. A physician order dated 12/19/24 instructed, Metoprolol Tartrate [Lopressor] 50 mg one (1) tablet by mouth at bedtime for elevated blood pressure. The December 2024 Medication Administration Record (MAR) showed an order for Metoprolol Tartrate [Lopressor] 50 mg one (1) tablet by mouth at bedtime for elevated blood pressure. According to the MAR, the staff administered Metoprolol Tartrate [Lopressor] on five different occasions between 12/19/24 and 12/23/24. During a telephone interview on 12/26/24 at 11:32 AM, Resident #1's daughter/POA stated that when her mother was discharged from the facility on 12/23/24 she discovered that her mother had been receiving Metoprolol Tartrate [Lopressor] fast-acting, instead of Metoprolol Succinate [Toprol XL] slow-acting, as she had previously been prescribed. During a telephone interview on 12/27/24 at 8:20 AM, Employee #4 (physician) stated that staff that she ordered Metoprolol Succinate [Toprol XL] extended release 50 mg a day when the resident was admitted on [DATE]. She said that staff did not inform her that Metoprolol Tartrate [Lopressor] was being administered. Furthermore, the employee explained that Metoprolol Succinate [Toprol XL] should have been administered rather than Metoprolol Tartrate [Lopressor]. During a face-to-face interview on 12/27/24 at approximately 3 PM, Employee #2 (Director of Nursing) after reviewing Resident #1's electronic pharmacy record she stated that when Employee #5 (LPN) ordered Resident #1's medications from pharmacy she selected Metoprolol Tartrate [Lopressor] instead of Metoprolol Succinate [Toprol XL].

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions. These findings have the potential to affect all residents. The findings included: 1. An open pack of provolone cheese and a pan with chunks of grapefruit were stored in a refrigerator undated, in the kitchen on unit Healthcare 1. 2. Two (2) of 14 white cutting boards, and two (2) of 14 green cutting boards in the main kitchen were soiled and discolored. 3. Food temperature logs from the main kitchen, and the kitchen on healthcare 1 and 2, were missing several entries throughout the month of October 2024. 4. One (1) of two (2) convection ovens in the main kitchen (bottom), was soiled. 5. Two (2) of eight (8) fire suppression nozzles, located above the grease fryer and the gas stove were soiled with grease deposits, and one (1) of eight (8) was corroded. 6. One (1) of two (2) fire sprinkler heads in the walk-in refrigerator was soiled and rusty. Employee #5 (Director of Dietary Services) acknowledged the findings during a face-to-face interview on 12/5/2024, at approximately 11:00 AM.

2. Resident #57 was admitted to the facility on [DATE] with diagnoses that included: Memory, T12 Vertebral Fracture, Fracture of Femoral Neck, Dementia, Osteopenia, and Glaucoma. A review of Resident #57 s medical record revealed an admission Minimum Data Set (MDS) assessment dated [DATE] showing that facility staff coded a BIMS summary Score of 6, indicating the resident's cognition was severely impaired, no behavioral symptoms, partial assistance for mobility, and the resident had a fall prior to admission. An Incident Note dated 10/26/24 at 11:59 PM documented: .At 10:30 pm, [the] resident turned the call light on. When answered, [the Resident] stated that [pronoun]was on the floor in [pronoun] room. [The] Resident stated that [pronoun] did not know how [pronoun] got on the floor .[The] Writer immediately went to the room and Resident was observed on the floor beside [pronoun] bed laying on [pronoun] back. Head-to-toe assessment completed. [The] Resident was alert and oriented x 3. [The] Resident is [was] able to move all extremities . No apparent injury noted . A Health Status Note dated 10/27/24 at 2:30 PM, documented: Resident found on the floor bedside [ponroun] bed. When asked what happen(ed). [The] resident said, I'm looking for my son, does he know that I'm in this place, I'm trying to go home, my son is waiting for me. Upon assessment, [the] resident denies hitting [pronoun] head on the floor, denies pain, no bleeding or redness noted on the skin, ROM (range-of-motion) within [the] limit on bilateral lower extremities and upper extremities. No discomfort or pain noted. A Post-Fall Evaluation Note dated 11/01/24 documented: Date / Time of Fall: 11/01/2024 6:45 PM Fall was not witnessed. [A] Fall occurred in the Resident's room. Activity at the time of fall: Resident crawled out of bed. [The] bed was in the lowest position. The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did [the] fall result in an ER (Emergency Room)visit/hospitalization: No. A review of a Psychosocial Note dated 11/11/24 at 1:47 PM documented: Resident was discharged at her family's request over the weekend - on 11/09/24 . A Discharge MDS assessment dated [DATE] showed facility staff coded: in response to questions in Section J regarding falls: Has the resident had any falls since admission/entry or reentry or the prior assessment), whichever is more recent? No. Number of falls since admission or Prior assessment - (with No Injury). [The] Response was left blank. Of note, there was no documented evidence that facility staff noted the resident's unwitnessed falls with no injury on the resident's discharge assessment. During a face-to-face interview on 12/05/24 at 10:00 AM, Employee #4 acknowledged the deficient practice and stated that the Resident #57's falls on 10/26/24, 10/27/24 and 11/01/24 should have been captured on the resident's Discharge MDS assessment. Cross Reference 22B DCMR § Sec. 3231.11 Based on record reviews and staff interviews, for two (2) out of 19 sampled residents, facility staff failed to accurately code their Minimum Data Set (MDS) assessments. (Residents #11 and #57) The findings included: 1. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus and Hypothyroidism. Review of the resident's medical record revealed the following: A physician's order dated 01/04/23 that directed, Aripiprazole 5 mg (milligrams) by mouth every night for Depression. A physician's order dated 03/23/23 that directed, Remeron Oral Tablet 15 MG, give 1 tablet by mouth at bedtime for Depression. A physician's order dated 10/02/23 that directed, Fetzima Oral Capsule Extended Release 24 Hour 120 MG, give 1 capsule by mouth one time a day for Depression. Physician's order dated 03/12/24 that directed, Abilify Oral Tablet 5 MG (Aripiprazole), give 1 tablet by mouth one time a day for Depression. In addition, the medical record contained a Geriatric Psychiatry Note dated 07/12/24 which documented under diagnosis: Dementia with Behavioral Disturbance, Depression; other - psychosis. A Social Services Psychosocial Note for 10/11/24 at 1:33 PM documented: - Social worker met with the resident 1:1 for MDS assessment. - Resident admitted to feeling depressed usually each day (this is not new for her). - Resident is diagnosed with Dementia and Depression and her presentation was consistent with her diagnoses. - Resident is followed regularly by a psychologist for Depression. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: clear speech; usually makes self-understood; usually understands others; a BIMS summary score of 11, indicating moderately impaired cognitive response; feeling down, depressed or hopeless occurred 12-14 days; Feeling bad about yourself - or that you are a failure or have let yourself or your family down occurred 12-14 days; Resident Mood Interview (PHQ-2 to 9) total severity score of 06, indicating mild depression; for the area active diagnoses, facility staff coded No for Depression. The evidence showed that facility staff failed to accurately code Resident #11's Quarterly MDS to reflect Diagnoses of Depression. During a face-to-face interview on 12/03/24 at 3:14 PM, Employee #4 (MDS Coordinator) stated, Somehow the Depression diagnoses was accidentally deleted from the resident's diagnoses page. But it should have been captured based off the progress notes.

Based on record review and staff interview, for one (1) out of 19 sampled residents, facility staff failed to develop a care plan with goals and interventions to address Resident #11's use of antibiotics. The findings included: Review of the facility's Care plans, Comprehensive Person-Centered policy (not dated) documented: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus and Hypothyroidism. Review of the resident's medical record revealed a physician's order dated 03/14/24 that directed, Trimethoprim (type of antibiotic) oral tablet 100 MG (milligrams), give 1 tablet by mouth at bedtime for UTI (urinary tract infection) prophylaxis. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 11, indicating moderately impaired cognitive response and received Antibiotic medications. Review of the resident's comprehensive resident care plan on 12/04/24 showed no documented evidence that a care plan was developed with goals and interventions to address the resident's use of an antibiotic for UTI prophylaxis. During a face-to-face interview on 12/04/24 at 10:36 AM, Employee #2 (Director of Nursing/DON) reviewed the residents medical record and acknowledged the findings. Cross Reference 22B DCMR § Sec. 3210.4

Based on record reviews and staff interviews, for one (1) of 19 sampled residents, the facility staff failed to update and revise the care plan with resident-centered goals for Resident #55 following a fall that occurred on 07/13/24. The findings included: A review of the facility's policy titled Managing Falls and Falls Risks with a revision date of 08/21/21, documented the following: If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. Resident #55 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Difficulty Walking, Unspecified Lack of Coordination, Cognitive Communication Deficit, and Repeated Falls. A review of Resident #55's medical record revealed a progress note dated dated 07/12/24 at 8:24 AM, documenting, During the shift report, staff heared (sp) noise from room [ROOM NUMBER]. Immediately responded to noise and all of us went to room [ROOM NUMBER]. Upon arrival rsident (sp) observed lying on floor on her left side by the bathroom. On assessment there is injury noted to bilateral elbows. Resident was alert and verbally responsive. C/O (complains of) intense pain to the right arm. Denies hitting her head. ROM (range of motion) performed and WNL (within normal limits) except right arm. MD (medical doctor) notified and gave order to send resident to the nearest ER (emergency room). A progress note dated 07/12/24 at 7:03 PM, documented, The resident returned from (Hospital Name) at approximately 4:00 PM. in a wheelchair with her friend with no distress. Alert and able to make needs known. (Resident #55's) new diagnosis is a closed fracture of the olecranon process to the right Ulna initial encounter. Continues on neuro check post fall and denies pain at this time. Resident back from (Hospital Name) with soft cast /sling to Rt (right) arm. A review of the Care Plan Focus area with an initiation dated of 07/12/24 revealed, had an actual fall with c/o (complain of) pain to right hand, Dx (diagnosis) from hospital fx (fracture) to the right elbow. The documented interventions with a revision date of 07/12/24 included, Rehab (rehabilitation) to evaluate and treat, Safety hourly rounding for staff to anticipate and meet the residents needs at all times, ling and soft cast to right lower arm, Toilet resident upon arising, before meals at bedtime and prn (as needed). An Incident Progress Note dated 07/13/24 at 10:51 PM, documented At 10:30 pm I was called to the room by the nurse who was making rounds and found the resident was sitting up in the floor in front of her wheelchair. A two-person lift was conducted to place her back in wheelchair. She has a hx (history) of falls with the last one being 3 days ago. She stated she went to the bathroom and came out and slipped and fell on her buttock then stabilized herself with her right elbow so she did not fall backwards. She was not wearing socks or shoes (barefoot) at the time of incident. She admitted that she forgot to use call bell and that was reoriented to both bed and bathroom. A review of a [Care Plan] focus area revised on 08/05/24 documented, 7/13/2024 had a fall without c/o (complaints of) pain to the right elbow or buttock. It is noted that there was no documented evidence in the medical record of any updated or revised care plan interventions after Resident #55's fall that occurred on 07/13/24. During a face-to-face interview conducted on 12/05/24 at approximately 11:35 AM, Employee #3 (Clinical Manager) stated, Whenever there is a fall, we update the care plan. Employee #3 then stated she did not know why the care plan was not updated after the residents fall on 07/13/24 and acknowledged the findings.

Based on record review and staff interview, for one (1) out of 19 sampled residents, facility staff failed to implement their antibiotic stewardship system for monitoring antibiotic use and adverse reactions for one (1) resident since 03/14/24, approximately nine (9) months. (Resident #1) The findings included: Review of the facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy (not dated) documented: - Antibiotic usage and outcome data will be collected and documented using facility-approved antibiotic surveillance tracking form. - The IP (Infection Preventionist) or designee, will review antibiotic utilization as part of the antibiotic stewardship program. - All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus and Hypothyroidism. Review of the resident's medical record revealed a physician's order dated 03/14/24 that directed, Trimethoprim (type of antibiotic) oral tablet 100 MG (milligrams), give 1 tablet by mouth at bedtime for UTI (urinary tract infection) prophylaxis. 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 moderately impaired cognitive response and received Antibiotic medications. During a face-to-face interview on 12/04/24 at 10:36 AM, Employee #2 (Director of Nursing/DON) presented the surveyor with the facility's antibiotic stewardship binder that documented a line listing of all the residents who were previously and currently taking antibiotic medications since January 2024. Upon review of the antibiotic surveillance tracking forms, it revealed that Resident #11's name was not listed on any of the forms since she was started on antibiotics as of 03/14/24 through today, and was still taking them as of 12/04/24. When asked to provide documented evidence that the facility was tracking the resident's use of an antibiotic and monitoring for adverse reactions, the employee was not able to provide it and stated, It's an oversight on my part. The findings show that facility staff failed to implement their antibiotic stewardship system for monitoring antibiotic use and adverse reactions for Resident #11, who has been on an antibiotic medication since 03/14/24, approximately nine (9) months.

Based on record review and staff interviews, for one (1) of 32 sampled residents (#7), the facility staff failed to implement adequate supervision and assistance to prevent falls with injury for a cognitively impaired resident identified as a high risk for falls. These failures resulted in actual harm to Resident #7 on 1/2/23. The findings included: Resident #7 was admitted on [DATE] with multiple diagnoses including Generalized Muscle Weakness, Dementia, and Alzheimer's Disease. A review of Resident #7's medical record revealed a physician's order dated 06/25/22 that directed, Maintain fall risk precaution at all times every shift. A Facility Reported Incident (DC~11166) received by the State Agency on 11/04/22 documented, 11/04/22 Resident taken to the bathroom at approximately 9:30 PM by a nursing assistant and placed on the toilet. The nursing assistant stepped out to get the resident a fresh gown and the resident was found lying on the floor on the staff's return. The resident had a laceration to the back of head left side .transfer to the hospital . for further evaluation. A care plan focus area dated 11/04/22 documented, [Resident #7] had a fall with injury with interventions that included, Resident should not be left in the wheelchair in the bathroom unattended. A Transfer to Hospital Summary dated 11/04/22 at 10:20 PM documented, Supervisor notified by the Charge Nurse that at approximately 9:30 PM the resident was found lying on the bathroom floor . The nursing assistant placed the resident on the toilet and stepped away to get a fresh gown. The assistant returned to the resident lying on the bathroom floor . She had a laceration to the back left of her skull . [Doctor's name] who was in the building came and evaluated the resident. The physician wrote a transfer order . Resident taken to [hospital name]. A Health Status Note dated 11/05/22 at 2:14 PM revealed Resident #7 returned from the hospital after a fall with a laceration to the left occipital (back of the head). The documentation indicated the resident was alert and oriented to name but confused about place and time. As a result of the fall the resident obtained three staples to the laceration. Resident #7's left elbow was bruised, but all extremities were movable, and neuro checks were ordered, fall precautions were in place with close monitoring and hourly rounding. A progress note dated 12/20/22 at 7:59 PM noted an unwitnessed fall at 6:30 PM. The note documented, Fall occurred in resident's room . Stated she was arranging her belongings whilst in the wheel chair, slid off unto the floor in a sitting position with back leaning on her wheel chair. Denied hitting her head. no apparent injury. New order for x-ray of the left post fall. A Health Status Note dated 12/21/22 at 3:35 AM showed, x-ray of the left hip to R/O (rule out) fracture due to s/p fall done result pending. A Health Status note dated 12/21/22 at 7:03 PM: Left hip x-ray result received and reviewed by [Doctor's name], NNO [no new order] obtained . Resident #7's care plan was updated on 12/20/22 to reflect, Resident on close monitoring every shift for fall risk. An Incident Note dated 01/02/23 at 8:01 AM documented, At about 5:55 AM assigned CNA [certified nurse aid] reported to the floor charge nurse, observed resident on the floor by the bedside in a supine position. Resident assessed and sustained two puncture wounds to the posterior left ear with minimal bright red blood. Neuro checks initiated. The resident was unable to state how it happens due to Dementia. [Doctor's name] and POA [power of attorney] were notified. Resident transferred to ER [emergency room ] via 911 for evaluation. A care plan focus area dated 1/2/23, documented, at approx. 5:55 AM Resident falls and sustained puncture wounds to the posterior left ear and pelvic fracture which do not require surgery. The updated care plan intervention indicated, ER Transfer for further evaluation secondary to fall, and Fall EZZ mat on right side of resident bed floor every shift for fall risk precaution. Clean and fold when a resident is out of bed. Every shift while the resident is in bed. A Progress Note dated 01/02/23 at 7:01 PM showed, One of the doctors at [hospital name] called to update us on resident status .The cut she sustained on the back of her left ear is superficial. The patient sustained a pelvic fracture which does not require surgery. Patient to follow up with orthopedic at the clinic in few weeks . A Facility Reported Incident (DC~11439) received on 01/03/23 documented, 01/02/23 10:42 AM . at about 5:55 AM assign CNA (Certified Nurse Aide) reported to the charge nurse that resident was noted on the [floor]. upon assessment, the resident was observed lying on the floor in a supine position on the right side of her bed .Two punctured wound measuring 0.1cm x 0.1cm was noted on the posterior left ear with minimal bleeding .MD[medical doctor] notified with order to send the resident to the nearest ER[emergency room ] for further evaluation, 911 called and the resident was transferred to [hospital name] . A Health Status Note dated 04/21/23 at 10:17 PM showed, Assigned CNA called the writer and notified [resident name] fall and resident observed on the floor. The writer assessed the resident for injury or pain. No apparent injury or sign of pain was noted. Two people assist the resident put back into her wheelchair safely. A review of resident #7's care plan revealed a focus area revised on 4/21/23 which documented, [Resident #7] deliberately placed herself on the day room floor expressed a preference to do so. No injury noted at the time. Care plan interventions were updated to indicate, Close observation on the resident by nursing staff every shift for fall risk. A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: severely impaired cognitive skills for decision making, totally dependent on the physical assistance of one person for bed mobility, transfer, toilet use, and personal hygiene and sustained a fall with no injury since the prior assessment. During a face-to-face interview conducted on 08/08/23 at 1:50 PM, Employee #2 (Director of Nursing) acknowledged the findings and stated that the facility staff is aware of the need to frequently check on the resident with fall risk/fall precautions to ensure safety and prevent falls. [Cross Reference 22B DCMR Sec. 3211.1]

Based on record review and staff interview, for four (4) of 32 sampled residents, facility staff failed to provide written notice of the bed hold policy to include the number of bed hold days to the resident or their responsible party upon transfer to the emergency room . Residents' #197, #253, #27 and #98. The findings included: The facility policy Bed Hold documented, . At the time of transfer or leave of absence, the social worker will notify the resident/responsible party of the transfer and the number of bed-hold days remaining . 1. Resident #197 was admitted to the facility on [DATE] with multiple diagnoses that included: Repeated Falls, Muscle Weakness, Unsteadiness on Feet and Abnormalities of Gait and Mobility. Review of Resident #197's medical record revealed: An Admission Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition. A Health Status Note dated 11/03/22 at 8:20 AM documented: On 11/3/22 around 7:30 AM during rounds resident reported to charge nurse that resident fell . MD (medical doctor) notified and order to transfer resident to the nearest ER (emergency room ). POA (power of attorney) made aware . A physician's order dated 11/03/22 directed, Transfer resident to the nearest ER via 911 for further evaluation post fall. A Facility Reported Incident (FRI), DC~11151, received by the State Agency on 11/03/22 documented, On 11/3/22 around 7:30AM during rounds resident reported to Charge Nurse that She fell .On assessment swelling with bruise noted to the right hip .MD[ medical doctor] notified and ordered to transfer resident to the nearest ER [emergency room ] . Resident's emergency contact person notified .Resident transferred as ordered. Further review of Resident #197's medical record showed no documented evidence that facility staff provided the resident or their POA written notice of the bed hold policy to include the number bed hold days upon transfer to the emergency roiagnom on [DATE]. During a face-to-face interview conducted on 08/04/23 at 9:25 AM, Employee #3 (Director of Social Services) acknowledged the findings and stated, We have identified holes in our process of informing residents and their family or responsible party of bed hold policy and days. It's been brought up to quality improvement and we are working on ways to make improvements. 45104 2. Resident #253 was admitted to the facility on [DATE] with the following diagnoses: Left Hip Arthroplasty, Thrombosis Distal Left Cephalic Vein, Bilateral Leg Swelling, Rheumatoid Arthritis, and Osteoporosis. Resident #253's medical record revealed the following: A Face Sheet that documented that the resident had a representative. A Five (5)-Day Scheduled Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff did not complete Section C (cognitive patterns). A Change in Condition Note dated 11/07/21 at 4:08 PM documented: Situation: Resident reported that her left calf is hurting. Background: Resident .admitted with a diagnosis of left hip replacement . A quick assessment was done; she was noted with a swollen left leg calf filled with fluid, but skin remains intact. Recommendations: Md (Medical Director) notified, and new order given to send resident to the nearest ER (emergency room ) for evaluation. Contact person notified. A Health Status Progress Note dated 11/07/21 at 11:42 PM documented: Resident was transferred to [Local Hospital] . by .[Local Medical Emergency Response Team] at 5:30 PM. Writer called . E.R.(emergency room ) the E.R. Nurse confirmed that [Resident #253] is being admitted for leg pain . Further review of Resident #253's medical record lacked documented evidence that facility staff provided written notice of the bed hold policy to include the number bed hold days upon transfer to the emergency roiagnom on [DATE]. During a face-to-face interview conducted on 08/04/23 at 9:25 AM, Employee #3 (Director of Social Services) acknowledged the findings and stated, We have identified holes in our process of informing residents and their family or responsible party of bed hold policy and days. It's been brought up to quality improvement and we are working on ways to make improvements. 47555 3. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included: Alzheimer's Disease, Vascular Dementia, Muscle Weakness, Difficulty Walking and Heart Failure. Review of Resident #27's medical record revealed: An Annual Minimum Data Set (MDS) dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 4, indicating the resident had severely impaired cognition. A Change in Condition Note dated 01/01/23 at 11:32 AM documented: At 10:35 AM resident called for help in the day room, upon arrival resident observed on the floor on his left side . [doctor's name] notified and order given to send resident to ER (emergency room ) for evaluation. [Daughter's name] made aware . A Facility Reported Incident (FRI), DC~11435, received by the State Agency on 01/03/23 documented, .At about 10:35 AM, staff heard resident called for help. Upon arrival, resident was observed on the floor on his left side . Further review of Resident #27's medical record showed no documented evidence that the facility staff provided the resident, or resident daughter written notice of the bed hold policy to include the number of bed hold days upon transfer to the emergency roiagnom on [DATE]. During a face-to-face interview conducted on 08/04/23 at 9:25AM, Employee #3 (Director of Social [NAME]) acknowledged the findings and stated, We have identified holes in our process of informing residents and their family or responsible party of bed hold policy and days. It's been brought up to quality improvement and we are working on ways to make improvements. 27513 4. Resident #98 was admitted to the facility on [DATE] with multiple diagnoses that included: Diabetes Mellitus, Hypertension, Dementia, Deep Vein Thrombosis (DVT) and Open Reduction and Internal Fixation (ORIF) and Left hip Pain. Review of Resident #98's medical record revealed: A 5-day scheduled assessment Minimum Data Set (MDS) dated [DATE] showed facility staff coded: not able to do Brief Interview for Mental Status Interview, cognitive skills for daily decision making as modified independence- some difficulty in new situations only. A Health Status Note dated 10/11/22 at 3:15 PM documented: Resident was doing great , walking with a walker but today complaining of pain at the surgical site unable to walk .X-ray of the LT [left] surgical leg with Doppler to rule out fracture related to pain and DVT was ordered by [doctor's name] via telephone. Family members notified [daughter] Pls [please] monitor site. A physician's order dated 10/13/22 directed, Resident transfer to ER for evaluation. A progress note dated 10/13/22 at 12:00 PM . Resident had a decrease in mobility due to increased c/o [complaints of] pain to left surgical leg which[ doctor name] was made aware of and ordered x-ray and Doppler study done. Resident's daughter was made aware . Resident's son-in-law who was visiting this morning made charge nurse aware that [doctor name] who is a surgeon at [hospital name] for resident had requested resident to be transferred to [Hospital name] for further evaluation of the surgical leg .the attending physician was made aware of the surgeon's request and agreed. The resident was transferred to [Hospital name] at 10:30 AM via facility's transportation accompanied by daughter and son-in-law . Further review of Resident #98's medical record showed no documented evidence that facility staff provided the resident or their responsible party written notice of the bed hold policy to include the number bed hold days upon transfer to the emergency roiagnom on [DATE]. A Facility Reported Incident (FRI), DC~11034, received by the State Agency on 10/14/22 documented, .The surgeon requested resident be transferred to the hospital and the attending physician [doctor name] agreed with the transfer. Resident was transferred to [hospital name] on 10/13/22 at 10:30 AM via the facilities transportation system accompanied by daughter and son-in-law. During a face-to-face interview conducted on 08/08/23 at 10:50 AM, Employee #3 (Director of Social Services) acknowledged the findings and stated, I do not have the bed hold policy and days information for Resident #98. [Cross Reference - 22 B DCMR Sec. 3270.1]

Based on record review and staff interviews, the facility staff failed to revise and update person-centered care plans for 4 (four) of 32 sampled residents. Residents #12, #41, #17, and #23 The findings included: The facility policy Care Plans, Comprehensive Person-Centered documented, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . The Interdisciplinary Team (IDT) must review and update care plan . when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay . 1. Facility staff failed to update Resident #12's care plan to show that the resident had sustained a fall with injuries. Resident #12 was admitted to the facility on [DATE] with the following diagnoses: Unspecified Fall, Multiple Fractures of Pelvis without Disruption of Pelvic Ring, Displaced Intertrochanter Fracture of Right Femur, Osteoporosis, Unsteadiness on Feet, and Generalized Muscle Weakness. Review of Resident #12's medical record revealed: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: moderately impaired cognitive skills for decision making; exhibited wandering behaviors 1-3 days; required extensive assistance with 2 persons for bed mobility, transfer limited assistance with 2 persons for transfers; had unsteady gait and only able to stabilize with staff assistance; and had one (1) fall with no injury. An Incident Note dated 03/11/23 at 6:16 AM documented: Around 4:30 AM during nursing rounds, resident noted sitting on left side of bed Resident unable to explain. On assessment resident alert and verbally responsive, skin remain intact, no(t) any visible injuries noted .no c/o (complaint of) pain verbalized . A Health Status Note dated 03/11/23 at 7:59 PM documented, Upon change of shift, Resident noted laying on .bed with verbal report of moderate pain to right hip .was unable to rate pain, kept saying it hurts. Writer assessed right hip, noted swollen, pain on touch and warm to touch. Resident is SP (status post) fall on 3/11/23@ 4:30am ROM (range of motion) to left leg adequately tolerated, not able to lift right leg . MD (Medical Director) notified, new order for STAT x-ray to rt (right) hip to r/o (rule out) fx (fracture). Order called in to radiation physics and awaiting x-ray . A Radiology Results Report on 03/12/23 at 11:24 AM documented: .Findings: There is an old fracture of the right pelvic ring. There is a right hip fixation .Impression: Right hip fixation 2. No evidence of acute fracture . A physician's order dated 03/14/23 at 1:45 PM directed, Transfer Resident to [Local Hospital] for further evaluation due to excruciating pain to right hip post fall day .Stat x-ray to right hip to r/o (rule-out) fx (fracture) due to pain and swelling on rt (right) hip s/p (status-post) fall one time only until 03/12/23. A Review of the Discharge Summary from [Local Hospital] on 03/14/23 documented: . Imaging /results: CT (computed tomography scan) Pelvis without Contrast.-Impression: 1. Acute right superior and inferior pubic rami fractures 2. Acute right sacral alar fracture .XR (Xray) Hips Bilateral with Pelvis 3-4 Views (Final Result) - Impression: Right superior pubic ramus mildly displaced fracture .Findings: Mildly displaced fracture of the right superior ramus noted .Patient is status post ORIF (open reduction and internal fixation) of the right hip with intramedullary rod and head and neck screw . A Facility Reported Incident (FRI), DC~11758) received by the State Agency on 03/15/23 at 6:18 AM documented: Resident had a(n) unwitnessed fall on 3/11/23 around 4:30 AM with no apparent injury noted. X-ray of right hip .done due complaint of pain. Result .No evidence of acute fracture. On 3/14/23 Resident's right hip/leg noted swollen, and painful to touch. MD (Medical Director) notified and ordered to transfer Resident to the nearest ER (emergency room ) for further evaluation of x-ray and Ultrasound .Resident returned on 3/15/23 around 2:10 AM with new diagnosis of open fracture of multiple pubic rami (bones), right . A Significant Change MDS dated [DATE] showed facility staff coded: one (1) fall with a major injury since the prior assessment. A care plan revised on 04/18/23 documented: Focus: . 3/11/23: [Resident #12] has had an actual fall without any apparent injury . Further review of Resident #12's comprehensive person-centered care plan lacked documented evidence that facility staff updated the aforementioned care plan to reflect that the fall on 03/11/23 resulted in injuries (open fractures of multiple pubic bones). During a face-to-face interview on 08/04/23 at 10:56 AM, Employee #2 (Director of Nursing) acknowledged the findings and made no comments. [Cross Reference 22B DCMR Sec. 3210.4] 43776 2. Facility staff failed to revise Resident #41's nutritional care plan to reflect her new diet order. Resident #41 was admitted to the facility on [DATE] with multiple diagnoses that included: Dysphagia and Protein Calorie Malnutrition. Review of Resident #41's medical record showed the following: A care plan focus area: [Resident #41] is at potential nutritional risk . initiated on 07/11/23 had interventions that included, .Provide regular diet/regular texture/thin liquids. An Admission Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; required limited assistance for eating; and received a mechanically altered diet. A Speech Language Therapy Evaluation and Plan of Treatment Summary dated 07/20/23 recommended, .Solids - mechanical soft textures . An active physician's order dated 07/27/23 directed, Other diet, mechanical soft/chopped meats texture. Further review showed no documented evidence that facility staff revised Resident #41's nutritional care plan with the new diet order of mechanical soft. During a face-to-face interview on 07/30/23 at 8:40 AM, Resident #41 stated, I have Dysphagia and I get a puree diet. I've been seeing the Speech Therapist and I was supposed to get upgraded to a mechanical soft diet. During a face-to-face interview conducted on 08/03/23 at 1:58 PM, Employee #8 (Registered Dietician) acknowledged the findings, and stated that she would take care of it now. [Cross Reference 22B DCMR Sec. 3210.4] 27513 3. Facility staff failed to update Resident #17's Fall care plan to reflect she fell . Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included: Diabetes Mellitus, Major Depressive Disorder, and Anxiety. A review of the care plan showed the focus area: [Resident #17 name] had a fall without injury . initiated on 10/03/19 had interventions that included, . Anticipate and meet [resident name] . A quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: Unable to complete Interview for Mental Status (BIMS) summary score, Cognitive skills for daily decisions making 3 indicating severely impaired (never rarely made decisions) Bed mobility, Transfer, toileting use, and personal hygiene need extensive assistant with two person's physical assist. The history of the fall box was left blank indicating No fall. A review of the Incident Note dated. 07/04/23 at 7:24 AM documented, Private duty aide reported that the resident was shaking and shifting in her wheelchair and slid off the wheelchair. She was unable to stop her from sliding. Resident was observed on the floor in a sitting position in front of her wheelchair . no apparent injury was noted. A change in Condition Note dated 7/04/23 at 6:04 PM documented, .Resident was observed on the floor in front of her wheelchair.Head to toe assessment was done and no apparent injury was noted. Able to move all her extremities within her normal baseline.recommended close monitoring. MD and RP made aware. Further review showed no documented evidence that facility staff updated Resident #17's fall care plan to reflect that the resident had a fall. During a face-to-face interview conducted on 08/03/23 at 1:58 PM, Employee #2 (DON) acknowledged the findings and stated we will update Careplan. 4. Facility staff failed to update Resident #23's pressure ulcer care plan to reflect her sacrum ulcer. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses that included: Parkinson's Disease, Seizure, General Muscle Weakness, Protein Calorie Malnutrition, and unstageable sacrum ulcer. A review of the care plan initiated on 7/21/22 showed the focus area: [Resident #23] has potential risk for developing pressure ulcer r/t . bony prominence to pressure point areas. 12/15/22 [resident name] has actual pressure injury r/t open wound to left inner forearm, 4/19/23 [resident name] noted with open areas to the left wrist. A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: unable to complete a Brief Interview for Mental Status (BIMS), Daily decision-making skill coded for severely impaired (never /rarely made decision). Skin condition coded for 1 unstageable pressure ulcer. A review of a Change in Condition Note dated 7/03/2023 at 3:09 PM documented, . 11 AM during AM care, resident noted with redness to coccyx area, New orders obtained for zinc oxide to coccyx area. A Wound care observation on 8/02/2023 at 9:50am with Employee#16 [wound nurse] showed a sacrum wound that was measured 1x 0.5 x 0cm without slough, drainage, and odor . There was no evidence that facility staff updated Resident #23's pressure ulcer care plan to reflect the resident had a sacrum ulcer. During a face-to-face interview conducted on 08/03/23 at 1:58 PM, Employee #2 (DON) acknowledged the findings and stated we will update Careplan.

Based on record review and staff interviews, the facility staff failed to ensure that three (3 ) of 32 sampled residents had hospice care plans that included: a description of the care, services, and frequency of visits to be provided by the contracted hospice provider. Residents' #252, #4, #23 The findings included: Review of the facility's Hospice contract documented, .Hospice plan of care means a written plan which is established, maintained, reviewed and modified if necessary . which includes . details concerning the scope of frequency of such hospice services . Nursing Home shall develop a nursing home plan of care in coordination with the hospice plan of care . Nursing home will periodically review and modify the nursing home plan of care in coordination with hospice .The Nursing Home shall prepare and maintain complete and detailed clinical records for each residential hospice patient receiving nursing home and hospice services . each medical record shall completely, promptly and accurately documents all services provided . Resident #252 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Atherosclerosis, Encounter for Palliative Care, Cerebral Infarction, Dementia, Depression, Congestive Heart Failure, and Anemia. A review of Resident #252's medical record revealed: A Face Sheet documented that Resident #252 had a representative. A Physician's Order dated [DATE] that documented: Admit (ted) to [Name of Hospice]. Dx (Diagnosis): Cerebral Atherosclerosis Please call [Name of Hospice] at .for any change in condition. An Informed Consent Form documented that Resident #252 was to receive hospice services from [Name of Hospice], signed by Resident #252's Representative on [DATE] at 8:38 AM. A Medicare Hospice Benefit Election Form that documented that the Resident was to receive hospice benefits and signed by Resident #252's Representative on [DATE] at 8:38 AM. A care plan initiated on [DATE] that documented: Focus: [Name of Resident] has a terminal prognosis r/t (related to) cerebral atherosclerosis *[DATE] - admitted into [Name of Hospice] A Significant Change in Status Minimum Data Set Assessment on [DATE] documented that the Resident was on hospice and had received hospice services in the last 14 days. A hospice visit frequency grid that documented visits for [DATE] and [DATE]. A Plan of Care Review Form from [Name of Hospice] dated [DATE] documented the Hospice Agency's Plan of Care for Resident #252 in the following manner: Response to Care and Updates to Comprehensive Assessment: Neurosensory - Manage agitation /confusion. Pt (patient) has indiscriminate words. Redirect patient. Give Ativan as needed; Respiratory - Manage SOB (shortness of breath). Elevate HOB (headed bed). Continuous O2 (oxygen) via NC (nasal cannula). Morphine on board; Gastrointestinal - Decrease oral intake. Pureed diet with thickened liquids; Genitourinary - Patient incontinent, wears brief; Musculoskeletal - .ADLs. Bed confined. Contracted in four (4) extr (extremities); .Integumentary - Stage II on sacrum, cleanse, bacitracin; .Physical Pain - Tylenol scheduled. Morphine as needed . A review of Hospice Aide/Homemaker /Volunteer Plan of Care Notes Files documented that between [DATE] to [DATE], the Resident received 26 hospice visits on the following days: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE], [DATE]. A review of the Quarterly Minimum Data Set Assessment on [DATE] documented that the Resident had received hospice services within the last 14 days of the assessment. Further review of Resident #252's medical record lacked documented evidence that the Resident received hospice visits from the Hospice Aide after [DATE]. In addition, there was no documented evidence that the facility staff updated the Resident's comprehensive person-centered care plan to include the hospice agency's care plan for the Resident. A review of a Health Status Note on [DATE] at 07:06 AM documented: Writer called to Resident's room around 4 AM. Upon arrival Resident observed unresponsive to stimuli. On assessment no B/P, no pulse, no respiration, and no temperature. Resident pupils fixed, skin warm to touch. Resident pronounced dead at 4:08 AM and Verified by 2 RN (Registered Nurses), MD (Medical Director) notified and ordered to release Resident's body [Name of Funeral Home]. Postmortem care done. Writer notified [Name of Hospice] . During a face-to-face on [DATE] at 12:39 PM, Employees #2 (Director of Nursing) and #3 (Director of Social Services), stated that Resident # 252 started receiving hospice services from [DATE] until the Resident expired in the facility. Employee #2 said that the facility could not provide documented evidence of the frequency or number of hospice aide visits for Resident #252. In addition, the Employee acknowledged that the facility staff did not update the Resident's comprehensive care plan to include the hospice agency's most recent hospice care plan. 43776 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Multiple Sclerosis, Malignant Neoplasm of the Left Kidney and Anemia. Review of Resident #4's medical record revealed the following: A physician's order dated [DATE] that directed, admitted to [Hospice provider name] for diagnoses of Intraparenchymal Hemorrhage A Hospice Plan of Care document dated [DATE]. A care plan focus area [Resident #4] has a terminal prognosis and admitted to [Hospice provider] diagnoses of Intraparenchymal Hemorrhage last revised on [DATE] had interventions of: Adjust provision of ADLs (activities of daily living) to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate .Observe resident closely for signs of pain, administer pain medications as ordered .Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Work with nursing staff to provide maximum comfort for the resident. A Modification Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded severely impaired cognitive skills for daily decision making and that hospice care was being received while a resident. During a telephone interview conducted on [DATE] at 11:25 AM, Employee #9 (Hospice Clinical Manager) stated, [Resident #4's] Hospice Plan of Care (POC) was last reviewed and updated on [DATE]. It includes the services being provided and the frequency of visits for the hospice nurses and social services. The most recent POC should've been in the chart. I can email the most recent one to you. An email correspondence from Employee #9 was received on [DATE] at 11:55 AM that documented, [Resident #4] Hospice Plan of Care . [DATE] . frequencies Hospice RN (Registered Nurse) 2 x month for 1 month starting [DATE] . Hospice Social Worker 1 x month for 1 month starting [DATE] . The evidence showed that facility staff failed to have a person centered hospice care plan for Resident #4 that included a description of the care, services and the frequency of visits to be provided by the contracted hospice provider and failed to have the most recent hospice plan of care in Resident #4's medical record. During a face-to-face interview conducted on [DATE] at approximately 12:00 PM, Employees #2 (Director of Nursing/DON) and Employee #3 (Director of Social Services) acknowledged the findings with Employee #2 stating, We will make sure that the hospice care plan is more detailed and that the most recent hospice plan care is in the chart and that aligns with our plan of care. 27513 3.Resident #23 was admitted to the facility on [DATE] with multiple diagnoses that included: Parkinson's Disease, Seizure, General Muscle Weakness, and Protein Calorie Malnutrition. Physician Order dated [DATE] that directed, Resident resides in-house under Hospice care for Parkinson's Disease. A review of the two Hospice Plans of Care found in Resident#23 manual chart showed that one plan of care started on [DATE] and the other plan of care started on [DATE], the frequency of hospice treatment and care was no longer in existence indicating plan of care were not updated. A review of the care plan initiated [DATE] focus area documented, [Resident #23] has a terminal prognosis r/t Parkinson's Disease and severe malnutrition w/new admission to Hospice [DATE]. Last revised on [DATE], had interventions of: Encourage support system of family and friends, keep the environment quiet and calm, keep linens clean, dry and wrinkles free, keeps lightening low and familiar objects near, Observe resident closely for signs of pain, administer pain medications as ordered .Work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Work with nursing staff to provide maximum comfort for the resident. A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: unable to complete a Brief Interview for Mental Status (BIMS), Daily decision-making skill coded for severely impaired (never /rarely made decision). Hospice care is being received while a resident. During a telephone interview conducted on [DATE] at 11:25 AM, Employee #9 (Hospice Clinical Manager) stated, [Resident #23's] Hospice Plan of Care (POC) was last reviewed and updated on [DATE]. It includes the services being provided and the frequency of visits for the hospice aide, nurses, and social services. The most recent POC should've been in the chart. I can email the most recent one to you. An email correspondence from Employee #9 was received on [DATE] at 11:55 AM that documented, [Resident #23] Hospice Plan of Care . [DATE] . frequencies Hospice aide (CNA) 3x week for 4 weeks starting [DATE] ., Hospice RN (Registered Nurse) 2 x month for 1 month starting [DATE] . Hospice Social Worker 1 x month for 1 month starting [DATE] . The evidence showed that facility staff failed to have a person-centered hospice care plan for Resident #23 that included a description of the care, services, and the frequency of visits to be provided by the contracted hospice provider and failed to have the most recent hospice plan of care in Resident #23's medical record. During a face-to-face interview conducted on [DATE] at approximately 12:00 PM, Employees #2 (Director of Nursing/DON) and Employee #3 (Director of Social Services) acknowledged the findings with Employee #2 stating, We will make sure that the hospice care plan is more detailed, and that the most recent hospice plan of care is in the chart and that it collaborates with our plan of care.

Based on policy review, record review and staff interview for three (3) of 16 sampled residents, the facility failed address Resident #37's systolic blood pressure which remained over 160 millimeters of Mercury for three (3) consecutive days, failed to assess for physiological and behavioral signs and symptoms of distress to facilitate prompt interventions to address changes in condition such as cough and an unwitnessed fall preceding a death in the facility; and failed to show evidence of collaboration with hospice services to provide resident-directed care for two (2) residents to minimize the risk harm. (Residents #37, 11, 187) Findings included . A. The facility failed address Resident #37's systolic blood pressure which remained over 160 millimeters of Mercury for three (3) consecutive days and failed to assess for physiological and behavioral signs and symptoms of distress, to facilitate prompt interventions to address changes in condition, to minimize the risk for harm. Facility's policy titled Neurological Assessments, not dated, states it is the policy of the facility to conduct neurological assessments on any resident who sustains an unwitnessed fall. As a part of the resident assessment after a fall and as otherwise indicated, the licensed nurse completes and documents a neurological assessment. Facility's Documentation policy dated (MONTH) 26, (YEAR), states daily clinical notes are written by a licensed nurse for residents receiving Medicare benefits. These guidelines are also applicable for other required clinical notes. Clinical notes for respiratory conditions . lungs sounds, nature of respirations, cough, temperature, hydration, medication to include any new medication prescribed, changed, or discontinued, response to medications started, changed or discontinued, and changes in resident's condition. Resident #37 was admitted on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. On (MONTH) 9, (YEAR), at approximately 4:30 PM, Resident #37 experienced an unwitnessed fall with injury of unknown source and subsequently expired at 4:46 PM. Review of medical record on (MONTH) 13, (YEAR), at 11:00 AM showed a 30- Day Minimum Data Set (MDS) dated (MONTH) 11, (YEAR). Resident #37 was documented as requiring extensive assistance of one (1) staff for bed mobility, transfer, locomotion on and off the unit, and personal hygiene, in Section G0110. Nursing Admission Screening/History dated (MONTH) 15, (YEAR) at 11:58 PM showed limited range of motion of left upper extremity due to left wrist fracture; left mid hip surgical site has 8 staples, and left upper hip surgical site has 6 staples. Resident #37 wears a hard cast on her left wrist. Also, limited range of motion on left lower extremity due to fracture on left hip, cannot bear weight at this time. Admission Physician order [REDACTED]. and/or diastolic blood pressure is greater than 100 and less than 60 for three (3) consecutive readings, weight bearing on left leg as tolerated, left hip precautionary measures every shift, and On (MONTH) 16, (YEAR), the telephone orders for Occupational Therapy evaluate and treat five (5) times per week for four (4) weeks and Physical Therapy evaluate and treat for five (5) times per week for four (4) weeks. Occupational Therapy and Physical Therapy evaluations. Review of the Medication Administration Record [REDACTED]. The medical record lacked documented evidence of notification of the physician or interventions when the resident's systolic blood pressure was over 160 millimeters of Mercury for three (3) consecutive days. On (MONTH) 28, (YEAR), Resident #37 was seen in follow-up with orthopedic with recommendation for full WB (weight bearing) in cast (left) wrist, full WB (weight bearing) L (left) hip, and follow-up in 3 weeks. In addition, the medical record contained a handwritten prescription from the Orthopedist dated (MONTH) 28, (YEAR) with instructions as follows: left wrist full WBAT (weight bearing as tolerated), Please add platform to walker left side. The medical record lacked documented evidence the facility staff notified the physician of the prescription for the addition of the platform to the walker. In addition, the physician progress notes [REDACTED]. Review of the physical therapy and occupational therapy notes from (MONTH) 28, (YEAR) to (MONTH) 2, (YEAR), failed to show the therapist acknowledged the recommendations for change in weight bearing status and addition of platform to left side of walker from the orthopedic consult or adjust the treatment plan to reflect the platform walker. Further review of the physical therapy notes from (MONTH) 3, (YEAR) through (MONTH) 9, (YEAR) (date of expiration) showed precautions/ Contraindications: L UE (left upper extremity) 50%/PWB (partial weight bearing) and L LE (left lower extremity) WBAT (weight bearing as tolerated). Review of care plans showed the facility staff initiated care plans for pressure ulcers, dental care, falls, ADL (Activities of Daily Living) function, [MEDICAL CONDITION] drug use, short-term rehab, and fracture to arm. However, the care plans lacked documented evidence of person-centered goals and approaches to address use of assistive device (walker and wheelchair), interventions to manage left wrist cast, [MEDICATION NAME] 0.25 milligrams as needed for anxiety, staples to left hip area, hip precautions, and weight bearing status. The nursing note dated (MONTH) 8, (YEAR), at 4:30 PM, Resident #37 complained of intermittent non-productive cough. The physician was called and new order obtained for [MEDICATION NAME] (use to treat cough) 5 milliliters by mouth three (3) times a day for five (5) days, [MEDICATION NAME] 3 milligrams for [MEDICAL CONDITION]. Nursing note dated (MONTH) 9, (YEAR) at 1:39 PM, showed the resident's representative came into the facility to report Resident #37 complained of generalized weakness and did not have enough strength to pick up the phone in the morning when the resident representative called. The resident was assessed and noted to be alert and arousable, and reported not feeling tired. The lungs were auscultated, and noted to be congested bilaterally (mild crackles) on upper lobes, lower lobes clear bilaterally, cough present, non-productive . The physician was notified and new telephone order obtained for chest x-ray to rule out an upper respiratory infection. Review of The Respiratory Therapy/ Impaired Respiratory Status instructs the staff to describe accurately breaths sounds overall lung aspects, the respiratory rate, rhythm and quality, the effectiveness of any respiratory treatments given such as oxygen, resident's comfort level as it relates to respiratory status, any changes in level of consciousness, anxiety or other mental status changes, and the resident's overall condition as related to respiratory status and any skilled nursing interventions used to aid in comfort and improve overall status. The medical record lacked documentation of a respiratory assessment performed by the direct care nurse, in accordance with the facility's impaired respiratory status assessment standards. On (MONTH) 9, (YEAR), at 11:41 PM, the nursing staff documented that Resident #37 was found lying on the floor by the therapy staff at approximately 4:32 PM. On assessment, the resident skin was cold and clammy to touch, rapid respirations, cyanosis in color, non-verbal, and unresponsive but breathing. The vital signs were blood pressure ,[DATE], heart rate- 53, respiratory rate- 28, temperature- 95.6, blood sugar- 260 and oxygen saturation- 72% on room air. Physician notified at 4:32 PM and updated on the resident's condition. New orders were given and noted. Oxygen therapy initiated, oxygen was given at 5 liters per minutes via face mask for oxygen saturation less than 80%. Paramedics were called 4:33 PM. The son was notified at 4:35 PM and requested that his mother be transferred to (local) Hospital because it is much closer to his home. Paramedics arrived on unit at 4:37 PM and took over. The resident was pronounced at 4:46 PM by paramedics. Physician orders [REDACTED].<80% (less than 80 percent), (2) change oxygen tubing and humidifier bottle every week on Tuesday's on ,[DATE] pm shift, when in use, transfer resident to nearest emergency room for further evaluation, monitor discoloration on forehead qshift til resolved. During a face to face interview with Employee #7, Clinical Resource Nurse on (MONTH) 13, (YEAR), at 5:22 pm, the employee stated that he was called early in the morning by the Employee #4, Licensed Practical Nurse, because the resident's representative was in the building with a lot of questions. The son reported receiving a call from his mother saying she was very weak and could not up the phone. After speaking with the son, Employee #7 went to assess the resident. Resident #37 lungs were pretty much clear with a little congestion. The employee placed a call to the physician and obtained an order for [REDACTED].>When the employee returned to the unit, Employee #10, Certified Occupational Therapy Assistant, was running out of the room yelling for help. Employee #7 stated that he grabbed the crash cart and went to the resident's room. Resident #37 was on the floor. Employee #7 performed an assessed of Resident #37. She was unresponsive but breathing. When queried about the performance of assessments by the primary nurse related to the change of condition experienced on (MONTH) 8, (YEAR) and (MONTH) 9, (YEAR), Employee #7 was unable to give further insight. The medical record lacked documented evidence of the observation and assessment to include the recording of physiological and behavioral signs and symptoms of distress when the resident's condition declined before arrival of the paramedics and the resident's subsequent death. The facility staff's failure to assess, evaluate interventions and promptly intervene placed Resident #37 at risk for harm. During a face to face interview on (MONTH) 13, (YEAR), at 5:30 PM, Employee #7 reviewed and acknowledged the findings. B. Failed to show evidence of collaboration with hospice services to provide resident-directed care for two (2) residents (Residents #11, 187) 1. Resident# 11 was admitted to the facility on [DATE] (original admitted ) with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data set (MDS)dated [DATE] on [DATE] at 2:00 PM showed Section C1000 (Cognition Skills for Daily Decision Making) is coded as 3 which indicate severely impaired-never/rarely makes decisions. Section O (Special Treatments and Programs) is coded as Other-Hospice. Review of the care plan on showed the resident is dependent on staff for meeting all emotional, intellectual, physical and social needs related cognitive deficits. Review of a Social Worker Psychosocial note dated [DATE] showed a Resident Annual Care Conference was held today with (Hospice Name) resident continues on hospice. A further review of the care plans showed Hospice Program Interventions/Tasks Collaborate with hospice nurse/physician re: effectiveness of treatment plan medication and care, communicate with hospice nurse/social worker when they visiting and updates treatment/plan of care and in corporate knowledge of hospice process into all care activities. (sic) A review of Resident# 11 medical record failed to show documentation from hospice services. During an interview on [DATE] at 2:30 PM Employee# 4 was asked to provide evidence of ongoing communication and collaboration between facility staff and hospice staff. Employee# 4 stated they have a book they (hospice services) put their notes in and I don't see the book, I will call them (hospice) now. Employee#4 failed to show evidence of ongoing communication and or collaboration with hospice services. During an interview on [DATE] at 3:00 PM Employee# 4 stated the hospice book was on another floor, we just communicate with them (hospice) if there are any issues, I don't see a collaborative care plan with hospice. Facility staff failed to show evidence of collaboration with the hospice services and or the implementation of hospice care plan interventions to provide resident-directed care. During a face-to-face meeting on [DATE] at 3:00 PM Employee # 4 acknowledged the findings. 2. Resident #187 was admitted to the facility on (MONTH) 31, 2014 with [DIAGNOSES REDACTED]. Per documentation in the progress notes the resident was admitted into Hospice care in (MONTH) (YEAR) due to Advanced Dementia. Review of the care plan shows notes indicating that the resident receives Hospice care. However, there is no documentation on the care plans or in the progress notes identifying what aspects of the resident's services will be provided by the facility, which will be provided by Hospice and how all aspects of the resident's care will be coordinated. During a face-to-face interview with Employee #7 on (MONTH) 8, (YEAR) at approximately 11:00 AM the employee was asked whether Resident #187 receives Hospice care. The employee responded that she did. The employee was then asked for Hospice' assessment and documentation of the care provided to the resident. Employee #7 responded that Hospice has a separate chart for each resident and that all of their notes and care plans are kept in that chart. Employee #7 gave me a chart which was labelled with the resident's name and the name of the Hospice group. The chart contained documentation from various members of the Hospice staff. Another face-to-face interview was conducted with Employee#2 on (MONTH) 9, (YEAR) at approximately 2:00PM to discuss the absence of integration between the care provided by Hospice and the care provided by the facility. The employee acknowledged that the care plans lacked integration between the two services but added that she is currently working with Hospice to resolve that problem.

Based on record review and staff interview for one (1) of 20 Stage 2 sampled residents, it was determined that facility staff failed to consistently assess and monitor Resident #17 ' s right heel to ensure that necessary treatment and services were provided. Subsequently, the resident developed an Unstageable Pressure Ulcer that was initially identified at an advanced stage. Resident #17. The findings include: Policy: Skin Impairment, Effective Date May 13, 2010, Revisions: May 16, 2016 stipulated: Policy Statement: All residents will be assessed upon admission and then routinely for skin impairment. Skin impairment includes, but not restricted to: Skin tears, Pressure Ulcers, Vascular Ulcers . Policy Interpretation and Implementation: 1. Prevention (b) For those residents who are at Risk (a score of 18 or below) the following intervention will be instituted: (2) Resident will be turned and repositioned every 2 hours while in bed . (5) heels will be kept off mattress, (6) Skin will be moisturized at least twice a day . (7) Incontinent residents must have pericare with skin barrier at least once per shift. Licensed staff will assess skin and document weekly The history and physical examination [REDACTED]. According to the quarterly Minimum Data Set (MDS) dated [DATE], Resident #17 was coded in Section C (Cognitive Patterns) as severely impaired; Section G0110 and G0120 (Functional Status) the resident was coded as totally dependent, requiring assistance of one or two people for bed mobility, transfer, dressing, personal hygiene, bathing and wheelchair dependent for mobilization; Section H0300 (Urinary Continence) revealed resident was always incontinent. Section M (Skin Condition), the resident was coded as being at risk for developing pressure ulcers. In Section M 0210 (Current Number of Unhealed Pressure Ulcers) the resident was coded as 0 indicating that the resident did not have any unhealed pressure ulcer. A review of the subsequent, Significant Change MDS dated [DATE] revealed under Section M, Skin Conditions, Resident #17 was coded as having one (1) Unstageable pressure ulcer. The Pressure Ulcer care plan updated February 9, 2016 revealed Goal: Resident will remain free of skin breakdown through next review; Approach: . Air alternating pad on mattress, Body/skin audit at least biweekly on bath days, Braden Scale assessment quarterly and PRN (as needed), Assess all skin during AM/PM care and prn, notify nurse/MD for any open or discolored areas A review of the clinical record revealed the facility ' s Pressure Ulcer Risk Assessment tool combined with the Braden Scale - For Predicting Pressure Sore Risk (a tool utilized by health professionals, especially nurses to assess a patient's risk of developing a pressure ulcer) signed and dated by the Registered Nurse on February 24, 2016, revealed Resident #17 was assessed as High Risk for pressure ulcer development. A review of the Dietary Progress Notes dated February 2, 2016 revealed that Resident #17 ' s skin integrity was intact and that the resident was at risk for pressure ulcer(s) (secondary) to immobility. A review of nurse ' s notes revealed the following: March 20, 2016 -11:00 PM- Turned and repositioned q 2 (every 2 hours) as as needed . March 21, 2016- 6:52 AM- . skin warm and dry to touch. ADL (Activities of daily living) provided, turned and positioned as needed . March 21, 2016- 3:35 PM- . Turning and positioning per protocol. No skin breakdown noted. Skin warm and intact . March 21, 2016- 11:18 PM- . incontinent care done . March 22, 2016- 7AM- . Turned and repositioned (every) 2 hours, also other needed ADL ' s and nursing care were attended to . March 22, 2016- 11:20 PM- . incontinent care done . March 23, 2016- 7:02 AM- . incontinent care done . March 23, 2016- 11:00 PM- . incontinent care done . The clinical record lacked evidence of nurse ' s progress notes for the period of March 23, 2016 through March 27, 2016. March 28, 2016 7:30 AM nurse ' s entry: CNA (Certified Nursing Assistant) reported black area noted on the right heel during care. On assessment area noted with grayish black discoloration with intact skin measuring 2.3cm (centimeters) x (by) 1.8 cm. Surrounding area noted with redness. No facial expression of pain noted on palpitation to the area and no warmness noted on the area. MD (Medical Doctor) updated, order in place to apply skin prep to the area twice daily, and float the heel with Prevalon boot (pressure relieving heel protector) on while in bed. Order in place to turn and reposition resident every two (2) hours. Resident remains alert and oriented to self. No change or deviation from (his/her) baseline noted .skin prep applied to right heel as ordered. The clinical record lacked evidence that facility staff conducted body/skin assessments ' at least ' biweekly in accordance to the care plan. Through staff interview, it was determined that nursing staff were to utilize the facility ' s Weekly Skin Checklist form to record weekly skin assessments that were usually conducted on shower days. However, there was no evidence in Resident #17 ' s clinical records that Weekly Skin Checklist forms were completed. A review of the Pressure Ulcer Record revealed nursing staff recorded the following characteristics of the resident ' s right heel ulcer: Date First Observed: March 28, 2016, Stage: SDTI (Suspected Deep Tissue Injury), Color: grayish/black, Size: 2.3 cm x 1.8 cm, Granulation: No, Drainage: No, Odor: No . A face-to-face interview was conducted with Employee #5 on June 29, 2016 at approximately 3:00 PM. A query was made regarding the skin impairment of the resident ' s right heel. He/she stated the wound was first found unstageable then once the scab came off, it was assessed as a Stage III pressure ulcer. The employee further stated, the resident ' s shower days were Mondays and Thursdays. A telephone interview was conducted on July 1, 2016 with Employee #13 at approximately 4:15 PM. Employee #13 indicated that he/she works with the resident on the 7:00 AM to 3:00 PM shift and the day he/she saw the wound on the right heel (March 28, 2016) was the day he/she reported it. Employee #13 also reported that the right heel was not open, it was dark and was getting to be black. A telephone interview was conducted on July 1, 2016 with Employee #14 at approximately 4:30 PM. Employee #14 indicated that he/she works the evening shift from 3:00 PM to 11:00 PM and agreed that he/she was assigned to Resident #17 the evening of March 27, 2016. Employee #14 stated on our shift we put the resident to bed .we remove any clothes and wash the stockings for the morning. In response to a query regarding whether or not the resident was observed with any abnormality in the skin of the right heel, he/she stated that no discoloration or abnormality was observed. The employee could not recall if the resident ' s heels were floated on pillows. A face-to-face interview was conducted with Employee #1 on July 1, 2016 at approximately 3:00 PM. who stated there are no shower/skin sheets (Weekly Skin Checklist) for the resident. Resident #17 was assessed with [REDACTED]. The resident was assessed as high risk for developing skin impairment according to the Braden Scale. There was no evidence that facility staff consistently assessed and/or monitored the resident ' s skin and subsequently, he/she was assessed with [REDACTED]. A face-to- face interview was conducted with the Employees #1 #2 and #3 on July 1, 2016 at approximately 5:00 PM. After review of the clinical record, all acknowledged the aforementioned findings. The clinical record was reviewed on July 1, 2016.