Every finding on record at Harborside Health & Rehabilitation

Based on observations, record reviews and staff interviews, for one (1) of four (4) sampled residents, facility staff failed to ensure the accurate reconciliation of narcotic/controlled medications; and failed to ensure that the established system to enable the accurate reconciliation of all narcotic/controlled medications was followed. Resident #1. The findings included: The facility's Controlled Substances policy dated 12/09/25 documented in part:Nursing staff must court controlled medications at the end of each shift. The nurse going on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Facility staff failed to ensure the accurate reconciliation of Resident #1's controlled medications.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Metabolic Encephalopathy, Muscle Weakness and Chronic Kidney Disease. Review of the resident's medical record revealed the following: Physician's order dated 05/15/26 that directed, Oxycodone (narcotic pain medication) HCl (hydrochloride) capsule 5 MG (milligrams), give 1 tablet by mouth every 4 hours as needed (PRN) for moderate to severe pain; Acetaminophen (pain medication) tablet 325 MG, give 2 tablets by mouth every 4 hours as needed for pain, do not exceed 4 grams (GMs) in 24 hours; Gabapentin (pain medication) oral capsule, give 200 mg by mouth one time a day for pain. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderately impaired cognitive status; received scheduled pain medications in the last 5 days; did not receive any PRN pain medications in the last 5 days; resident had occasional pain or hurting in the last 5 days that she rated a 06 on a zero to ten scale, with zero being no pain and ten as the worst pain; and was ordered an opioid medication. A Facility Reported Incident (FRI), #3043356, submitted to the State Agency on 06/01/26 at 7:52 PM documented, Possible narcotics variance detected. Investigation initiated. A follow up to the FRI #3043356, submitted to the State Agency on 06/12/26 at 10:03 PM documented in part:Employee #6 (Licensed Practical Nurse/LPN) found the Oxycodone IR 5 mg tablet difficult to remove out of the pack. Upon further inspection of the pack, she discovered that back of the pack had been tampered with and taped closed with clear tape. The Oxycodone 5mg tablet had been replaced with Loratadine tablets which have a similar color, size, and shape to Oxycodone IR 5 mg. In total, five (5) tablets were noted missing. During a face-to-face interview on 06/16/26 at 12:02 PM with Employee #9 (LPN, signed off on 05/31/26 at 7 PM that the narcotic count was correct and there were no discrepancies), he stated, The process for narcotic count is to count and make sure that nothing has been tampered with and that the count is correct. Looking at the package from the front, everything looked fine and we both signed that the count is correct. Turning the blister packet over and inspecting it for any damage is not something we typically do. I don't recall if that was done that day. All the tablets were there, and I did not notice that anything was tampered with. During a telephone interview on 06/16/26 at 12:29 PM, Employee #6 stated, That morning (06/01/26), I went to do Resident #1's vitals and she complained of pain. When I went to go get the Oxycodone 5mg to give it to her, I realized it was hard to pop out. So, I turned the package to pop it from the back and that's when I saw that there was tape on it. There were five (5) spots with tape that looked like the pills had already been popped out and then taped back. I gave the resident PRN Acetaminophen and called the supervisor to report about what I found. When I did the count at the start of my shift (on 05/31/26 at 7 PM with Employee #9), I didn't pick up the mediation card to inspect it. I saw that the number of pills there was the same as on the sheet and so I signed off that it was correct. The evidence showed that facility staff failed to ensure the accurate reconciliation of Resident #1's controlled medications as evidence by Employees #6 and #9 not inspecting the medication blister pack during their narcotic reconciliation count on 05/31/26 at 7:00 PM. During a face-to-face interview on 06/16/26 at 12:53 PM, Employee #2 acknowledged the findings and stated that education has been started to ensure that all licensed nurses know the proper way to do the narcotic count. 2. Facility staff failed to ensure that the established system to enable the accurate reconciliation of all controlled medications was followed. During a narcotic reconciliation count on unit 3 west on 06/16/26 at 9:55 AM, Employee #4 (Licensed Practical Nurse/LPN) pulled out the narcotic logbook for medication cart #2. It was observed that he had not signed his name to indicate that the count was correct at the start of his shift at 7 AM. When asked why he did not sign off that the narcotic count was correct at the start of his shift with the outgoing nurse, Employee #4 stated, I must've forgotten. Review of the education record showed that Employee #4 completed the education on drug diversion/narcotic reconciliation on 06/01/26. The evidence showed that Employee #4 failed to ensure that the established system to enable the accurate reconciliation of all controlled medications was followed by not signing off with the outgoing nurse at the time that the narcotic reconciliation count was conducted. During a face-to-face interview on 06/16/26 at 12:53 PM, Employee #2 acknowledged the finding and made no comments. Cross Reference 22B DCMR Sec. 3224.3 (d)

Based on record review and staff interviews, facility staff failed to implement an effective training program for existing staff as evidenced by Employee #6 (Licensed Practical Nurse/LPN) working a shift after suspension without receiving education on drug diversion/narcotics reconciliation after she was involved in a reported incident of missing narcotics. The findings included: A Facility Reported Incident (FRI), #3043356, submitted to the State Agency on 06/01/26 at 7:52 PM documented, Possible narcotics variance detected. Investigation initiated. A follow up to the FRI #3043356, submitted to the State Agency on 06/12/26 at 10:03 PM documented in part:- Employee #6 found the Oxycodone (narcotic pain medication) IR 5 mg (milligrams) tablet difficult to remove out of the pack. Upon further inspection of the pack, she discovered that back of the pack had been tampered with and taped closed with clear tape. The Oxycodone 5mg tablet had been replaced with Loratadine tablets which have a similar color, size, and shape to Oxycodone IR 5 mg. - In total, five (5) tablets were noted missing tablets. - Employee #6 was suspended pending the outcome of investigation. Review of Employee #6's timecard showed that she returned from suspension and worked the night shift on 06/13/26 from 7:13 PM to 06/14/26 at 7:54 AM. Review of the education records provided to the surveyor on 06/16/26 at approximately 3:00 PM, showed no documented evidence that Employee #6 completed or received the education on drug diversion/narcotics reconciliation.During a face-to-face interview on 06/16/26 at 3:25 PM, Employee #2 (Director of Nursing/DON) and Employee #7 (Staff Development/Educator) acknowledged the finding. Employee #2 stated, The employee should have received the education prior to restarting work after her suspension.Cross Reference 22B DCMR Sec. 3214.1

Based on record reviews and staff interviews, for one (1) of 10 sampled residents, facility staff failed to accurately provide cardiopulmonary resuscitation (CPR) to Resident #5, who was found on the floor, without a pulse, not breathing, with a dislodged tracheostomy tube. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.24, Quality of Life, F678, Cardiopulmonary Resuscitation on February 25, 2026 at 3:40 PM. The facility's Administrator submitted an abatement plan to the Survey Team that was accepted on February 25, 2026 at 8:19 PM. The Survey Team verified implementation of the abatement plan while onsite and the immediate jeopardy was lifted on [DATE] at 10:45 AM. After removal of the immediacy, the deficient practice was lowered to a scope and severity level of D.The findings included: The facility's Emergency Procedure - Cardiopulmonary Resuscitation policy dated [DATE] documented in part:The facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR.Instruct a staff member to activate the emergency response system (code) and call 911.Instruct a staff member to retrieve the automatic external defibrillator.Breathing: After 30 chest compressions provide 2 breaths via Ambu bag or manually (with CPR shield). According to the AHA: - Do not leave a person alone who has collapsed and requires CPR. You must stay with them, perform continuous chest compressions, and have someone else call 911 and fetch an Automated External Defibrillator (AED) if possible. Only stop CPR if the person wakes up, begins breathing normally, or professional help takes over. - The only exception to leaving is if it is necessary to call for help when you are completely alone and have no phone, but you should return immediately to start CPR.- CPR for a person with a tracheostomy involves 30 chest compressions at a rate of 100-120 per minute, followed by 2 breaths directly into the tracheostomy tube using a bag-valve mask (Ambu bag) or mouth-to-trach, ensuring the chest rises. If the tube is dislodged or blocked, replace it or cover the stoma to provide rescue breathing.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute Respiratory Failure with Hypoxia, Epilepsy, Dysphagia Following Cerebral Infarction, Diabetes Mellitus and Schizophrenia.Review of the resident's medical record revealed the following: A physician's order dated [DATE] that directed, Full Code. Care plan focus area initiated on [DATE]: [Resident #5] is at risk for respiratory complications secondary to tracheostomy.Goal(s): The resident will be free from respiratory complications through the review period.Interventions: Administer medications as ordered; administer nebulizer treatments as ordered; administer oxygen as ordered; observe for signs and symptoms of respiratory complications through review period; vitals as needed. Care plan focus area initiated on [DATE]: [Resident #5] is at risk for cardiac complications secondary to hypertension.Goal(s): The resident will be free from cardiac complications through review period.Interventions: administer medications as ordered; cardiology referral as indicated per MD (medical doctor); diagnostics as ordered; labs as ordered; observe for signs and symptoms of cardiac complications; observe for signs and symptoms of fluid overload including pulmonary or lower extremity edema and shortness of breath and notify MD as indicated; pacemaker checks as scheduled; vital signs as needed. An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: able to make self understood; a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact, cognitive response; had functional limitation in range of motion in both upper extremities, no impairment in lower extremities; used a walked mobility device; required partial/moderate assist of one staff for lying to sitting on side of bed; required supervision or touching assistance for sit to stand, chair/bed-to-chair transfer; and received oxygen, tracheostomy care and respiratory therapy services. [DATE] at 3:00 AM Respiratory Therapy Note: Rapid Response was called to resident's room. Patient was found unresponsive on the floor by Nursing Supervisor. Cardiopulmonary resuscitation (CPR) was performed by Code Team.911 arrived continued with advanced Cardiovascular Life Support (ACLS) protocol.After several rounds of CPR, patient was pronounced deceased . [DATE] at 5:19 AM Nursing Note: During supervisor's round at 3 AM, resident was found on the floor by the door, lying in supine position unresponsive.CPR initiated and 911 was called. 911 arrived at 3:15 AM and took over and worked on him for about 30mins.The resident was pronounced dead at 3:51 AM. A Facility Reported Incident (FRI), intake #2785968, received by the State Agency on [DATE] at 7:26 PM documented, On February 22, 2026 at approximately 3 AM, [Resident #5] was found in the doorway of his room with his trach dislodged. An investigation is underway. During a telephone interview on [DATE] at 10:29 AM, Employee #6 (Nurse Supervisor) stated, I saw the resident on the floor, close to the door, unresponsive. I did a little assessment, checked for a pulse and respirations. The oxygen tubing was still connected but the inner cannula (tracheostomy tube) had come out. I started CPR initially, but I noticed I had to call for help, So I left the resident alone and went to the nurse's station where I saw nursing staff sitting there and asked them for help and they came. I then called for a 'Rapid Response'. It was easy for me to get help because there were people sitting at the nurse's station. When asked why she didn't use the call light or scream for help, she stated, I was not close to the call light. The normal protocol is to call or shout for help. But it was 3 AM, and I didn't want to wake up the other residents. The nursing station wasn't far from where I was, so I ran to get help and came back. My issue was I didn't want to scream and wake other residents up. When asked what she did for CPR, the employee stated that she provided chest compressions for about the 3 minutes and did not provide ventilation via the tracheostomy site using an Ambu bag or any other form of rescue breathing. The employee was further asked, why she called 'Rapid Response' versus a 'Code Blue' when she knew that Resident #5 was unresponsive, pulseless, not breathing and she had provided CPR for 3 minutes with no response. Employee #6 stated, Everything was happening quickly. I called the 'Rapid Response' to get more people to come help and then the 'Code Blue was called. Once the code team was there, they said to call 911. Review of Employee #6's employee file showed that she was last certified/trained to administer CPR/Basic Life Support (BLS) using the AHA guidelines on [DATE]. During a telephone interview on [DATE] at approximately 11:00 AM, Employee #9 (Respiratory Therapist/RT) stated, My first encounter with [Resident #5] was between 10:30 PM - 11 PM. He was in the bed. I suctioned him, didn't get a lot. I did my treatment and left. He was stable. I heard the call for 'Rapid Response' while I was on 3 east and then a 'Code Blue' call. When I got to his room, I saw that the resident was on the floor, on his back. There were a few people just standing there, not administering CPR. I am not sure who they were. Once I got closer, I did an assessment and saw that he was not breathing so I grabbed Ambu bag from the bedside, hooked it up to oxygen and started doing compressions with one hand and giving [rescue] breaths with the other hand. By then another RT came, who helped me bag the resident. The resident's trach had dislodged; it was on the floor when I first entered the room. I was easily able to reinsert the trach with no incident. We continued CPR until a doctor came with the code team. Then EMS (emergency medical services) came and took over until the he (Resident #5 was pronounced dead. When asked what the difference between a Rapid Response and a Code Blue call is, Employee #9 stated, A rapid response could be anything, low sugar, a really high blood pressure. A code blue is when someone is pulseless and breathless. A rapid response is what was called first that night ([DATE], date on the incident.During a face-to-face interview on [DATE] that started at 11:23 AM, Employee #2 (Director of Nursing/DON) stated, All staff are trained on what qualifies as a 'Rapid Response' versus a 'Code Blue.' I got that as part of my training. Code blue is automatic when someone collapses and there's no pulse and or they are not breathing. The evidence showed that facility staff failed to accurately provide CPR to Resident #5, who was found on the floor, without a pulse, not breathing, with a dislodged tracheostomy tube. Resident #5 was subsequently pronounced deceased on [DATE] at 3:51 AM. Due to these failures, an Immediate Jeopardy (IJ-J) was identified on [DATE] at 3:40 PM. An abatement plan was submitted to the State Agency on [DATE] at 8:19 PM that was approved that entailed: Immediate Actions to Protect Residents: Resident #5, cannot be retroactively corrected for this resident.Immediate Corrective Actions Taken:CPR Response & ComplianceEffective immediately:Employee #6 has been removed from resident care pending investigation and re-education.All licensed nurses will be re-educated on:AHA CPR/BLS requirementsContinuous chest compressions without leaving the residentProper ventilation for residents with tracheostomies (use of Ambu bag via trach; management of dislodged trach)Clear differentiation between Code Blue and Rapid ResponseEducation will include:30 compressions at 100-120/minuteRescue breathing via tracheostomyProcedure if trach becomes dislodgedCPR Response and complianceMonitoring - CPR CompetencyAll licensed staff must maintain current AHA BLS certification.Quarterly mock Code Blue drills will be implemented.Monitoring - Emergency CallsCode Blue vs Rapid Response criteria posted at nurses' stations.Fall & Safety Assessment ComplianceImmediate Chart Audit100% audit of all residents with physician orders for fall/safety assessments will be reviewed for appropriateness and implementation:All physician orders for fall/safety assessments will be verified on MAR/TAR that they are being implementedAny missing documentation will be addressed immediately.Nurses will be re-educated on required documentation of ordered assessments.Care Plan Review100% audit of residents at risk for falls Care plans will be updated to include more than one individualized, multi-factor fall prevention interventions.EducationCare PlansCode Blue vs. Rapid Response CPR Response and CompliancePhysician orders/ImplementationFall/Safety AssessmentsEducation will be provided by the educator/designee for all licensed staff starting night shift on [DATE]. Education for all other licensed staff will occur prior to or at the start of their shift. Training will be ongoing until all licensed staff have been educated. Date of compliance: February 27, 2026. Cross Reference 22B DCMR Sec. 3214.2

Based on record review and staff interviews, for one (1) of ten (10) sampled residents, facility staff failed to administer 10 doses of Resident #71's ordered anticonvulsant medication from 06/06/25 through 06/12/25. Due to these failures, Resident #71 suffered harm as evidenced by having three (3) seizures during that time frame and required hospitalization. The findings included: Review of the facility policy titled, Medication and Treatment Orders dated 12/09/25 documented in part:Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included: Convulsions, Hypertension and Spastic Hemiplegia Affecting Left Dominant Side. A physician's order dated 07/02/24 that directed, Lacosamide (antiseizure medication) oral tablet 200 MG (milligrams), give 1 tablet by mouth two times a day for Seizure precaution. A care plan reviewed on 04/22/25: [Resident #71] has Convulsion disorder related to head injury.Goal: Will be free from injury from seizure activity through the review date. Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive status; no rejection of care behaviors; had an active diagnosis of Epilepsy, unspecified, intractable, with status Epilepticus; and received anticonvulsant medications. A Controlled Substance Prescription document dated 06/06/25 showed that a Physician's Assistant (PA), wrote the prescription for Resident #71's Lacosamide 200 mg tablets. Review of the Resident #71's Lacosamide tablet 200 MG Controlled Drug Receipt/Record/Disposition Form dated 05/22/25 showed that the last available dose was administered on 06/06/25 at 10 PM by Employee #7 (Licensed Practical Nurse/LPN). The count documented 0 tablets remaining. 06/09/25 at 5:19 PM Nursing Progress Note: Security brought resident on the unit and stated that when he called resident name he did not respond like he used to. Writer and unit manager assess resident. Medical doctor made aware, assessed the resident, no new order given. 06/11/25 at 9:56 AM Health Status Note: Writer responded to a page to the first floor at 8 AM, security staff reported the resident took 2 puffs of smoke and started seizing. Resident was observed bleeding in his mouth coming from his tongue which he bit during the seizure.911 was called and the resident was transported to [Hospital Name]. 06/11/25 at 11:37 PM Nursing Progress Note: Resident returned from [Hospital Name] emergency room (ER) at 9:20 PM in stable condition. 06/12/25 at 7:36 AM: A fax report showed that the prescription written on 06/06/26 was faxed to the pharmacy for delivery. 06/12/25 at 8:24 AM Nursing Progress Note:MD notified that resident did not have Lacosamide 200 MG tablet. 06/12/25 at 8:52 AM Psychosocial Note: Asked to see the patient as per the nursing due to a change in mental status, upon arrival in the room, the patient was having a clinic tonic seizure, and a rapid response was called. 06/12/25 at 9:37 AM Health Status Note: Writer was notified in the morning by outgoing nursing staff (Employee #7/LPN) that the resident had a seizure and one episode of coffee brown emesis.MD had ordered STAT labs to be drawn; while putting in the orders resident had another seizure, rapid response was called.MD ordered to transfer the resident out to the hospital for evaluation.Resident was transported to [Hospital Name] ER by 911. Review of the Omnicell (automated medication and supply system) inventory for June 2025 showed that there were six (6) Lacosamide 200 mg tablets in stock and available in the facility. Review of the June 2025 Medication Administration Record (MAR) showed that facility staff documented 5 (5=Hold/See Progress Notes) and their initials at 10 AM on 06/07/25, 06/08/25 and 06/09/25; facility staff documented a 9 (9=Other/See Progress Notes) and their initials on 06/08/25 at 10 PM, 06/10/25 at 10 AM and 10 PM, and on 06/11/25 at 10 AM, meaning that Lacosamide oral tablet 200 MG was not administered to Resident #71. Further review of the June 2025 MAR showed that Employee #7 documented a check mark and her initials to indicate that she administered Lacosamide 200 MG tablet to Resident #71 on 06/07/25 at 10 PM, 06/09/25 at 10 PM, and on 06/11/25 at 10 PM. However, there is no documented evidence that the Lacosamide tablets were taken out of the Omnicell or that the medication had been delivered from the pharmacy. A Facility Reported Incident (FRI), intake #231646, submitted online to the State Agency on 06/13/25 at 5:33 PM documented, On 6/12/2025 I was informed that a nurse taking care of [Resident #71] had signed off that she had administered his Lacosamide tab 200 mg anticonvulsant 6/7, 6/9, 6/11/2025 however when I reviewed the controlled drug disposition form the last dose was administered on 6/6/25. The nurse signed that the medication was administered but upon investigation the patient had not received the medication. A follow-up to FRI #231646 received by the State Agency on 06/20/25 at 3:17 PM documented in part: On June 12, 2025, the facility was informed of a medication administration discrepancy involving [Resident #71].[Employee #7/LPN) documented the administration of Lacosamide 200 mg on June 7, June 9, and June 11, 2025. However, upon review of the medication administration records and pharmacy records, it was determined that the last verified dose was administered on June 6, 2025. The pharmacy further confirmed that no additional doses had been ordered or delivered after that date. This indicates that the resident did not receive his prescribed seizure medication as scheduled. As a result, the resident was transferred to the hospital for evaluation and treatment. 06/20/25 Hospital Discharge Summary: Reason for visit - seizures. 06/20/25 at 10:32 PM Nursing Progress Note: Resident was admitted to the facility at 7:25 PM from [Hospital Name] after being treated for seizure and bacteremia. The evidence showed that Resident #71 missed a total of 10 doses of his ordered Lacosamide 200 MG tablets. The evidence also showed that facility staff failed to (1): fax Resident #71's Lacosamide 200 MG prescription to the pharmacy on 06/06/25; (2) administer the resident's Lacosamide 200 MG tablet even though there were 6 doses available in the facility's Omnicell; and (3) make the resident's physician aware that he missed multiple doses of his medication. During a face-to-face interview on 02/26/26 at 12:56 PM, Employee #1 (Administrator) and #2 (Director of Nursing/DON), they acknowledged the findings with Employee #1 stating, The nurse (Employee #7) was fired because of the incident. All licensed nurses were provided with education on accurate documentation practices, controlled substances handling procedures and consequences of falsification of documents. The doctor should've been made aware as soon as the resident had missed a medication dose, regardless of the reason. All licensed nurses have access to the Omnicell. Cross Reference 22B DCMR Sec. 3211.1

Based on record review and staff interviews, facility staff failed to meet the State requirement of providing a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day on 02/22/26, when an Immediate Jeopardy was identified. The census on that day was 117.The findings included:A Facility Reported Incident (FRI), intake #2785968, received by the State Agency on 02/22/26 at 7:26 PM documented, On February 22, 2026 at approximately 3 AM, [Resident #5] was found in the doorway of his room with his trach dislodged. An investigation is underway.An Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.24, Quality of Life, F678, Cardiopulmonary Resuscitation on February 25, 2026 at 3:40 PM.Review of the staffing showed that on 02/22/26, the facility's total direct care staffing level was at 4.0. The state requirement is a minimum of 4.1. During a face-to-face interview on 03/03/26 at 10:38 AM, Employee #8 (Staffing Coordinator) calculated the total direct care staff, acknowledged that the 4.1 requirement was not met and stated, The staffing has been pretty good. Some days we just can't get replacements for the people who call out.Cross Reference 22B DCMR Sec. 3211.5

Based on observation, record review and staff interviews, for one (1) of ten (10) sampled residents, facility staff failed to have an extra tracheostomy tube at Resident #6's bedside in the event of an accidental dislodgment or decannulation.The findings included: A facility policy titled, Unplanned Decannulation: Risk Assessment, Precautions and Interventions dated 12/09/25 documented in part: A replacement airway must be kept at the bedside for all airway patients. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease and Hyperkalemia. Review of the resident's medical record showed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognitive response; received oxygen therapy, suctioning, and tracheostomy (trach) care. Care plan focus area initiated on 01/08/26: The resident is at risk for respiratory complications secondary to Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure.Goal: the resident will be free from respiratory complications through the review period.Interventions: administer oxygen as ordered; head of bed elevated to prevent shortness of breath as tolerated; observe for signs and symptoms of respiratory complications through review period. A physician's order dated 02/24/26 that directed, FiO2 (Fraction of Inspired Oxygen): 28%;Trach Type - Shiley; Trach Size- 6.5 cuffless, every shift for Respiratory Failure, wean FIO2 as tolerated and to keep sats greater than 92%. During an observation on 02/24/26 at 10:34 AM, Resident #6 was observed in her room, sitting in a black wheelchair. The resident had a tracheostomy with a speaking valve on. Upon inspection, it was noted that there was not a spare trach tube anywhere in the resident's room.At 10:36 AM, Employee #3 (Licensed Practical Nurse/LPN), Resident #6's assigned nurse was called to the resident's room and asked where the resident's spare tracheostomy tube is located. The employee looked behind the bed, on the bed, in the bedside drawers, and did not find a spare tracheostomy. I didn't know she didn't have one. Maybe there's one for her in the respiratory cart.During a face-to-face interview on 02/24/26 at 11:48 AM, Employee #4 (Director of Respiratory Therapy) stated, Respiratory therapy is responsible for setting up and placing spare tracheostomy (trach) and any other emergency equipment at the resident's bedside like an Ambu bag (a handheld, manual resuscitator used to provide positive pressure ventilation to individuals with inadequate or stopped breathing). All airway patients, except laryngectomy patients, must have a spare trach at their bedside in case of accidental dislodgement. The surveyor informed Employee #4 that Resident #6 did not have one. Employee #4 then got on the phone with Employee #5 (Respiratory Therapist/RT) who was the assigned RT for the unit Resident #6 was on. Employee #4 instructed Employee #5 to go to Resident #6's room, look and make sure that there was a spare trach at her bedside. Employee #4 placed Employee #5 on speaker as he went to Resident #6's room. Upon searching, Employee #5 stated over the phone, There's no spare trach for Resident #6. When asked why the resident did not have a spare trach at her bedside, Employee #5 stated, I don't know, I just got here.The evidence showed that facility staff failed to have emergency equipment available for accidental dislodgment for a Resident #6 who has a tracheostomy. Cross Reference 22B Sec. 3215.6

Based on record review and staff interview, for one (1) of ten (10) sampled residents, facility staff failed to report, within two (2) hours, an incident that resulted in serious bodily injury, harm and or death. Resident #5.The findings included: The facility's Abuse Investigation and Reporting policy dated [DATE] documented in part:An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute Respiratory Failure with Hypoxia, Epilepsy, Dysphagia Following Cerebral Infarction, Diabetes Mellitus and Schizophrenia.Review of the resident's medical record showed the following: [DATE] at 3:00 AM Respiratory Therapy Note: Rapid Response was called to resident's room. Patient was found unresponsive on the floor by Nursing Supervisor. Cardiopulmonary resuscitation (CPR) was performed by Code Team.911 arrived continued with advanced Cardiovascular Life Support (ACLS) protocol.After several rounds of CPR, patient was pronounced deceased . [DATE] at 5:19 AM Nursing Note: During supervisor's round at 3 AM, resident was found on the floor by the door, lying in supine position unresponsive.CPR initiated and 911 was called. 911 arrived at 3:15 AM and took over and worked on him for about 30mins.The resident was pronounced dead at 3:51 AM. A Facility Reported Incident (FRI), intake #2785968, received by the State Agency on [DATE] at 7:26 PM documented, On February 22, 2026 at approximately 3 AM, [Resident #5] was found in the doorway of his room with his trach dislodged. An investigation is underway. The evidence showed that at facility staff reported the incident of Resident #5 being found lying on the floor, at the doorway of his room, unresponsive, with his trach dislodged, to the State Agency 16 and half hours after the incident had occurred. The evidence also showed that at the time that the incident was reported to the State Agency, facility staff failed to disclose that Resident #5's fall resulted in serious injury, harm and or death, even though they had knowledge of it. During a face-to-face interview on [DATE] at 2:02 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and made no comment. Cross Reference 22B DCMR Sec. 3232.4

Based on record reviews and staff interviews, for two (2) of ten (10) sampled residents, facility staff failed to demonstrate the competencies and skills sets to provide safe nursing and related services. Residents' #5 and #71.The findings included:1.Facility staff failed to call for help, immediately activate a Code Blue and accurately provide cardiopulmonary resuscitation (CPR) to Resident #5, who was found on the floor, without a pulse, not breathing, with a dislodged tracheostomy tube. The facility's Emergency Procedure - Cardiopulmonary Resuscitation policy dated [DATE] documented in part:The facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR.Instruct a staff member to activate the emergency response system (code blue) and call 911.Instruct a staff member to retrieve the automatic external defibrillator.Breathing: After 30 chest compressions provide 2 breaths via Ambu bag or manually (with CPR shield). Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute Respiratory Failure with Hypoxia, Epilepsy, Dysphagia Following Cerebral Infarction, Diabetes Mellitus and Schizophrenia. Review of the resident's medical record revealed the following: A physician's order dated [DATE] that directed, Full Code. An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: able to make self understood; a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact, cognitive response; received oxygen, tracheostomy care and respiratory therapy services. [DATE] at 5:19 AM Nursing Note: During supervisor's round at 3 AM, resident was found on the floor by the door, lying in supine position unresponsive.CPR initiated and 911 was called. 911 arrived at 3:15 AM and took over and worked on him for about 30mins.The resident was pronounced dead at 3:51 AM. A Facility Reported Incident (FRI), intake #2785968, received by the State Agency on [DATE] at 7:26 PM documented, On February 22, 2026 at approximately 3 AM, [Resident #5] was found in the doorway of his room with his trach dislodged. An investigation is underway. During a telephone interview on [DATE] at 10:29 AM, Employee #6 (Nurse Supervisor) stated, I saw the resident on the floor, close to the door, unresponsive. I did a little assessment, checked for a pulse and respirations. The oxygen tubing was still connected but the inner cannula (tracheostomy tube) had come out. I started CPR initially, but I noticed I had to call for help, So I left the resident alone and went to the nurse's station where I saw nursing staff sitting there and asked them for help and they came. I then called for a 'Rapid Response'. It was easy for me to get help because there were people sitting at the nurse's station. When asked why she didn't use the call light or scream for help, she stated, I was not close to the call light. The normal protocol is to call or shout for help. But it was 3 AM, and I didn't want to wake up the other residents. The nursing station wasn't far from where I was, so I ran to get help and came back. My issue was I didn't want to scream and wake other residents up. When asked what she did for CPR, the employee stated that she provided chest compressions for about the 3 minutes and did not provide ventilation via the tracheostomy site using an Ambu bag or any other form of rescue breathing. The employee was further asked, why she called 'Rapid Response' versus a 'Code Blue' when she knew that Resident #5 was unresponsive, pulseless, not breathing and she had provided CPR for 3 minutes with no response. Employee #6 stated, Everything was happening quickly. I called the 'Rapid Response' to get more people to come help and then the 'Code Blue was called. Once the code team was there, they said to call 911. Review of Employee #6's employee file showed that she was last certified/trained to administer CPR/Basic Life Support (BLS) using the AHA guidelines on [DATE]. The evidence showed that facility staff failed to call for help, immediately activate a Code Blue and accurately provide CPR to Resident #5, who was found on the floor, without a pulse, not breathing, with a dislodged tracheostomy tube. Resident #5 was subsequently pronounced deceased on [DATE] at 3:51 AM. During a face-to-face interview on [DATE] that started at 11:23 AM, Employee #2 (Director of Nursing/DON) stated, All staff are trained on what qualifies as a 'Rapid Response' versus a 'Code Blue.' I got that as part of my training. Code blue is automatic when someone collapses and there's no pulse and or they are not breathing. 2. Facility staff failed to ensure that Resident #71 received his Lacosamide (anticonvulsant medication) 200 MG (milligrams) as ordered by the physician. Review of the facility policy titled, Medication and Treatment Orders dated [DATE] documented in part:Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included: Convulsions, Hypertension and Spastic Hemiplegia Affecting Left Dominant Side. A physician's order dated [DATE] that directed, Lacosamide oral tablet 200 MG, give 1 tablet by mouth two times a day for Seizure precaution. A care plan reviewed on [DATE]: [Resident #71] has Convulsion disorder related to head injury.Goal: Will be free from injury from seizure activity through the review date. Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 15, indicating intact cognitive status; no rejection of care behaviors; had an active diagnosis of Epilepsy, unspecified, intractable, with status Epilepticus; and received anticonvulsant medications. A Controlled Substance Prescription document dated [DATE] showed that a Physician's Assistant (PA), wrote the prescription for Resident #71's Lacosamide 200 mg tablets. Review of the Resident #71's Lacosamide tablet 200 MG Controlled Drug Receipt/Record/Disposition Form dated [DATE] showed that the last available dose was administered on [DATE] at 10 PM by Employee #7 (Licensed Practical Nurse/LPN). The count documented 0 tablets remaining. [DATE] at 9:56 AM Health Status Note: Writer responded to a page to the first floor at 8 AM, security staff reported the resident took 2 puffs of smoke and started seizing. Resident was observed bleeding in his mouth coming from his tongue which he bit during the seizure.911 was called and the resident was transported to [Hospital Name]. [DATE] at 11:37 PM Nursing Progress Note: Resident returned from [Hospital Name] emergency room (ER) at 9:20 PM in stable condition. [DATE] at 7:36 AM: A fax report showed that the prescription written on [DATE] was faxed to the pharmacy for delivery. [DATE] at 8:24 AM Nursing Progress Note:MD notified that resident did not have Lacosamide 200 MG tablet. [DATE] at 8:52 AM Psychosocial Note: Asked to see the patient as per the nursing due to a change in mental status, upon arrival in the room, the patient was having a clinic tonic seizure, and a rapid response was called. [DATE] at 9:37 AM Health Status Note: Writer was notified in the morning by outgoing nursing staff (Employee #7/LPN) that the resident had a seizure and one episode of coffee brown emesis.MD had ordered STAT labs to be drawn; while putting in the orders resident had another seizure, rapid response was called.MD ordered to transfer the resident out to the hospital for evaluation.Resident was transported to [Hospital Name] ER by 911. Review of the Omnicell (automated medication and supply system) inventory for [DATE] showed that there were six (6) Lacosamide 200 mg tablets in stock and available in the facility. Review of the [DATE] Medication Administration Record (MAR) showed that facility staff documented 5 (5=Hold/See Progress Notes) and their initials at 10 AM on [DATE], [DATE] and [DATE]; facility staff documented a 9 (9=Other/See Progress Notes) and their initials on [DATE] at 10 PM, [DATE] at 10 AM and 10 PM, and on [DATE] at 10 AM, meaning that Lacosamide oral tablet 200 MG was not administered to Resident #71. Further review of the [DATE] MAR showed that Employee #7 documented a check mark and her initials to indicate that she administered Lacosamide 200 MG tablet to Resident #71 on [DATE] at 10 PM, [DATE] at 10 PM, and on [DATE] at 10 PM. However, there is no documented evidence that the Lacosamide tablets were taken out of the Omnicell or that the medication had been delivered from the pharmacy. A Facility Reported Incident (FRI), intake #231646, submitted online to the State Agency on [DATE] at 5:33 PM documented, On [DATE] I was informed that a nurse taking care of [Resident #71] had signed off that she had administered his Lacosamide tab 200 mg anticonvulsant 6/7, 6/9, [DATE] however when I reviewed the controlled drug disposition form the last dose was administered on [DATE]. The nurse signed that the medication was administered but upon investigation the patient had not received the medication. The evidence showed that facility staff failed to fax Resident #71's Lacosamide 200 MG prescription to the pharmacy on [DATE]; failed to administer the resident's Lacosamide 200 MG tablet even though there were 6 doses available in the facility's Omnicell; and failed to make the resident's physician aware that he missed multiple doses of his medication. During a face-to-face interview on [DATE] at 12:56 PM, Employee #1 (Administrator) and #2 (Director of Nursing/DON), they acknowledged the findings with Employee #1 stating, The nurse (Employee #7) was fired because of the incident. All licensed nurses were provided with education on accurate documentation practices, controlled substances handling procedures and consequences of falsification of documents. The doctor should've been made aware as soon as the resident had missed a medication dose, regardless of the reason. All licensed nurses have access to the Omnicell. Cross Reference 22B DCMR Sec. 3210.4

Based on observations, record reviews and staff interviews, for three (3) of ten (10) sampled residents, facility staff failed to ensure controlled substances were reconciled as evidenced by not signing off the controlled medication forms when medications were administered. Residents' #9, #11, and #10. The findings included: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses that included: Neuralgia and Neuritis, Hypertension, and Encephalopathy. Review of the resident's medical record revealed the following: A physician's order dated 10/06/25 that directed, Tramadol (narcotic pain reliever) HCl (hydrochloride) oral tablet 50 MG (milligrams), give 1 tablet by mouth every 6 hours as needed (PRN) for right arm pain. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 05, indicating severely impaired cognitive response; received PRN pain medications; and was taking opioid mediations. During a controlled substances reconciliation on unit 2 east on 02/26/26 at 12:00 PM with Employee #3 (Licensed Practical Nurse/LPN), it was noted that Resident #9's controlled substance form for Tramadol 50 MG documented 2 tablets remaining. However, the blister packet had only 1 tablet remaining. Employee #3 stated, I just gave the medication to her (Resident #9), and I forgot to sign it off. I know I'm supposed to sign off the medication when I pop it to give. 2. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included Pain, Neuralgia, Neuritis, and Muscle Spasms. Review of the resident's medical record revealed the following: A physician's order dated 09/11/24 that directed, Pregabalin (narcotic medication for nerve pain) oral capsule 150 MG, give 1 capsule by mouth two times a day for neuropathy pain. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 15 indicating intact cognitive response and received opioid medications. During a controlled substances reconciliation on unit 2 east on 02/26/26 at 12:02 PM with Employee #3 (LPN), it was noted that Resident #11's controlled substance form for Pregabalin 150 MG capsule documented 18 tablets remaining. However, the blister packet had 17 tablets remaining. Employee #3 stated, I forgot to sign when I gave it. 3. Resident #10 was admitted to the facility on [DATE] with diagnoses that included: Conversion Disorder with Seizures or Convulsions, Chron's Disease, and Dementia. Review of the residents medical record revealed the following: A physician's order dated 04/09/23 that directed, Lacosamide oral tablet 200 MG, give 1 tablet by mouth two times a day for Seizure. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 04, indicating severe cognitive impairment and received anticonvulsant medications. During a controlled substances reconciliation on unit 3 west on 02/26/26 at 12:20 PM with Employee #10 (Registered Nurse/RN), it was noted that Resident #10's controlled substance form for Lacosamide 200 MG documented 18 tablets remaining. However, the blister packet had 17 tablets remaining. Employee #10 stated, I am supposed to sign the narcotic sheet when I pull the medicine to give it to the resident. The evidence showed that Employee #3 and #10 failed to ensure controlled substances were reconciled as evidenced by not signing off controlled medication forms when medications were administered to Residents' #9, #11, and #10. During a face-to-face interview on 02/26/26 at 3:28 PM, the findings were brought to the attention of Employee #2 (Director of Nursing/DON). The employee acknowledged the findings and stated, I am going to follow up with those nurses. Cross Reference 22B DCMR Sec. 3224.3.

Based on observation, record review and staff interviews, for one (1) of 10 sampled residents, facility staff failed to follow its policy and procedures for controlled substance disposal for Resident #8's Lacosamide (anticonvulsant medication) 100 MG (milligrams) tablets.The findings included: Review of the facility's Discarding and Destroying Medications policy dated 12/09/25 documented in part:Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included: Epilepsy, Acute Respiratory Failure and Dysphagia. Review of the resident's medical record showed the following: A physician's order dated 11/28/25 that directed, Lacosamide oral tablet 100 MG, give 1 tablet via PEG (percutaneous gastrostomy) -Tube two times a day for Seizure for 30 Days, 11/28/2025 to 12/28/2025. On 02/26/26 at 10:30 AM, Employee #1 (Administrator) provided the surveyor with document that listed all the residents in the facility that were currently prescribed and taking on Lacosamide. Resident #8 was not on that list. During a medication cart audit on unit 2 east on 02/26/26 at 12:10 PM with Employee #3 (LPN), it was noted that Resident #8 had 23 Lacosamide 100 MG tablets stored in the narcotic box. When asked why Resident #8's had Lacosamide tablets, Employee #3 stated, I don't know. He's not getting this medication. During a face-to-face interview on 02/26/26 at 3:28 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated, There should have been a cart audit that should've found and disposed of the medication the proper way. I am responsible for making sure that the unit managers get the cart audits done. Audits are supposed to be done at the beginning of each month. I'm not sure if one was done for January 2025. When asked if he was aware that Resident #8 still had Lacosamide 100 MG tablets still on hand despite the medication having been discontinued for 59 days, Employee #2 stated, No, The evidence showed that Resident #8's Lacosamide was discontinued on 12/28/25 and for 59 days, facility staff failed to dispose of the controlled substance as per their policy. Cross Reference 22B DCMR Sec. 3227.13

Based on record reviews and staff interviews, for one (1) of ten (10) sampled residents, facility staff falsely documented that they administered medications to Resident #71.The findings included: Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included: Convulsions, Hypertension and Spastic Hemiplegia Affecting Left Dominant Side. Review of the resident's medical record revealed the following: A physician's order dated 07/02/24 that directed, Lacosamide oral tablet 200 MG (milligrams), give 1 tablet by mouth two times a day for Seizure precaution. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive status; no rejection of care behaviors; had an active diagnosis of Epilepsy, unspecified, intractable, with status Epilepticus; and received anticonvulsant medications. Review of the Resident #71's Lacosamide tablet 200 MG Controlled Drug Receipt/Record/Disposition Form dated 05/22/25 showed that the last available dose was administered on 06/06/25 at 10 PM by Employee #7 (Licensed Practical Nurse/LPN). The count documented 0 tablets remaining. Review of the Omnicell (automated medication and supply system) inventory for June 2025 showed that there were six (6) Lacosamide 200 mg tablets in stock and available in the facility. Review of the June 2025 Medication Administration Record (MAR) showed that Employee #7 documented a check mark and her initials to indicate that she administered Lacosamide 200 MG tablet to Resident #71 on 06/07/25 at 10 PM, 06/09/25 at 10 PM, and on 06/11/25 at 10 PM. However, there is no documented evidence that the Lacosamide tablets were taken out of the Omnicell or that the medication had been delivered from the pharmacy. A Facility Reported Incident (FRI), intake #231646, submitted online to the State Agency on 06/13/25 at 5:33 PM documented, On 6/12/2025 I was informed that a nurse taking care of [Resident #71] had signed off that she had administered his Lacosamide tab 200 mg anticonvulsant 6/7, 6/9, 6/11/2025 however when I reviewed the controlled drug disposition form the last dose was administered on 6/6/25. The nurse signed that the medication was administered but upon investigation the patient had not received the medication. The evidence showed that Employee #7 falsely documented that she administered Resident #71's Lacosamide 200 MG. During a face-to-face interview on 02/26/26 at 12:56 PM, Employee #1 (Administrator) and #2 (Director of Nursing/DON), they acknowledged the findings with the Employee #1 stating, The nurse (Employee #7) was fired because of the incident. All licensed nurses were provided with education on accurate documentation practices, controlled substances handling procedures and consequences of falsification of documents. The doctor should've been made aware of any missed medication doses, regardless of the reason. All licensed nurses have access to the Omnicell.

Based on record reviews and staff interviews, for two (2) of seven (7) sampled residents, the facility staff failed to ensure residents' records contained accurate information. As evidence by:(1). Staff documented Resident #1 had a Gastrostomy Tube (G-tube) instead of a Jejunostomy Tube (J-Tube). (2) Staff documented Resident #4 had a right check bruise instead of a right eyebrow bruise. The findings included:1.Resident #1 was admitted on [DATE] with multiple diagnoses including Gastrostomy Status, Dysphagia, Encephalopathy, and Acute Respiratory with Hypoxia.A history and physical dated 07/25/25 documented in part, Gastrointestinal [system]-soft, non-distended, J-Tube.Assessment and Plan- Dysphagia Continue TF (tube feeding) per J-tube.A nursing progress note dated 07/29/25 at 5:28 PM documented in part, Abdomen is soft and non-tender with positive bowel sounds on all four quadrants . G- tube feeding is in progress. A nursing progress note dated 08/15/25 at 8:53 PM documented in part, On continuous G-tube feeding for nourishment. G-tube is intact, patent and infusing well. Abdomen is soft to slight touch, non-distended.A nursing note dated 09/05/25 at 7:50 AM documented in part, Resident is G-tube dependent, G-tube intact and patent. No foul smelling discharge noted at the G-tube site. Nepro infusing @ 40 ml(milliters)/ hr (hour)with hydration water flush 240 ml every 4 hrs. During a face-to-face interview on 09/19/25 at 10:35 AM, Employee #3 (RN/Unit Manger) stated that the staff documented g-tube in error. The resident had a J-tube and not a G-tube. 2.Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including Dementia. A nursing note dated 08/26/25 at 11:09 AM documented in part, It was brought to this writer attention that, [resident's name] has skin discoloration on the right side on the top of her eye.On head-to-toe assessment, skin alteration noted on the top of the resident right eye. Appear yellow purplish measuring 1.1cm x 1.1cm, and on resident right upper lateral harm 3 spot of same color.A nursing note dated 08/26/25 at 5:18 PM documented in part, Small discoloration to right cheek remains the same no discomfort noted or s/s of pain.A care plan dated 08/27/25 documented in part, Focus- [Resident's name] has [a] skin discoloration.Intervention-monitor the resident discoloration site on her right forehead.During a face-to-face interview on 09/19/25 at 2:25 PM, Employee #4 (RN/Unit Manager) stated that the nurses note dated 08/26/25 at 5:18 PM was an error. The resident had a bruise above her right eyebrow not her right cheek.

Based on record review and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to demonstrate competencies and skills to provide safe nursing care and services as evidenced by a nurse, who was not trained to do so, reinserting Resident #67's tracheostomy tube after decannulation. The findings included: The facility's Unplanned Decannulation: Risk Assessment, Precautions and Interventions policy with an effective date of December 2014 documented: - An unplanned decannulation is an unplanned removal or dislodgement of an artificial airway prior to its scheduled removal. - If unplanned decannulation occurs, the following will take place: call a Rapid Response (RRT); assess if the patient is stable without the trach tube, if not, the trach tube will be immediately reinserted to establish a patent airway by a qualified practitioner. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Encounter for Tracheostomy, Acute and Chronic Respiratory Failure with Hypercapnia, and Pyothorax Without Fistula, Review of the resident's medical record revealed the following Physician's orders dated 10/15/24 directing, Aspiration safety precautions, every shift; Monitor area under trach mask for signs of discoloration\edema\redness every shift; Trach care twice a day (BID) and as needed (PRN), two times a day for airway management; Maintain neck collar in place, check skin under neck collar every (q) shift for any changes and report to medical doctor (MD)/Nurse Practitioner (NP), every shift for safety; High Risk Airway, every day and night shift, post 'High Risk Airway' sign at resident's bedside; FIO2 (fraction of inspired oxygen): 28%, Trach type: Shiley, Trach size: 6.5 cuffless, every shift for Respiratory Failure, wean FIO2 as tolerated and to keep saturations greater than 92%. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded; severely impaired cognitive skills for decision making; received oxygen therapy, suctioning, and tracheostomy care. A Care plan focus area last reviewed on 11/26/24: [Resident #67] is at risk for decannulating her trach device. Goal: [Resident #67] will continue to be monitored closely so as not to allow her harm self via decannulation through the next review date. Interventions: Educate resident to understand the risk of removing the trach device. Frequent rounds. [Resident #67] and representative (RP) educated on risk of removing trach. Frequent rounding to ensure safety. Provide alternative activities to keep her attention away from the trach. A care plan focus area last reviewed on 12/02/24: [Resident #67] has a High-Risk Airway due to (d/t) self-decannulation, airway mass, and mittens. Goal: [Resident #67] will have a patent and intact airway though the review period. Interventions: Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, call a Rapid Response immediately, reinsert airway using an obturator. If the tube cannot be reinserted and the resident is able to breathe spontaneously and there are no signs/symptoms of acute respiratory distress, provide oxygen via nasal cannula to maintain O2 saturation greater than 92%. Cover stoma site with a dressing. Keep head of bed (HOB) 30-45 degrees and monitor the resident with pulse oximetry and end-tidal for at least 24 hours. Monitor/document for signs of respiratory distress. A 12/17/24 at 2:06 PM General Progress Note written by Employee #4 (Registered Nurse assigned to Resident #67): Patient alert, awake and non verbal. Vitals stable. Medicated as prescribed. Total care provided. writer called in room [ROOM NUMBER]A for trach concern. On assessment, writer noticed the gauze not in place, the trach tie loose holding the trach half way out. Writer tightened the neck tie and placed the gauze. No distress noted . A 12/17/24 at 3:00 PM: Speech Therapy Note documented: - Upon arrival, the patient had self-decannulated with trach [tube] near oxygen mask. - No signs of respiratory distress. - Alerted the nurse, two nurses entered the room and reinserted the trach. - The patient made a wincing face and attempted to vocalize, indicating pain. 12/17/24 at 3:40 PM Respiratory Treatment Care Assessment: - Trach intact. - Patient resting comfortably at this time after decannulation. - [Resident #67] self-decannulated again. - The nurse said that the tube was halfway out. - The two nurses working on 1 south re-inserted the tube successfully. - The patient is resting comfortably, no distress noted. An email correspondence from Employee #4 (Registered Nurse/RN) to Employee #1 (Administrator) dated 12/20/24 at 1:21 PM documented: - On 12/17/24, I arrived in 156A, the patient was in bed with no shortness of breath, no distress. - The gauze around the [trach] site wasn't in place and the trach was loose, the trach halfway out, visibly about 2 centimeters (cm). - The writer tightened the necktie and fixed the gauze to avoid irritation. Review of an employee statement written by Employee #5 (RN), dated 12/20/24 documented: - One of the therapists came to me and asked if I was [Resident #67's] nurse, I said not but went to the room. - I saw the resident with a loose trach tie and the trach [tube] was slightly out, no acute respiratory distress was noted. - I called [Employee #4]. - The nurse adjusted the trach [tube] and trach tie. - I left the room, leaving the nurse and the therapist in the room. An anonymous Complaint, DC~13353, was submitted to the State Agency on 12/26/24. During a face-to-face interview on 03/05/25 at 10:24 AM, Employee #3 (SLP) stated, I was going in to see [Resident #67] for a speech therapy session and when I walked in, I saw her trach [tube] had completely come out and was resting on the oxygen mask. I alerted the nursing staff so they can call respiratory. The resident had a history of picking at her trach, so I was very worried. I stayed in the room and two nurses walked in, and did not perform any hand hygiene. One nurse pinned down the resident while the other jammed the trach back in. The resident winced in pain when the trach was back in the way that they did. They did not check the resident's vital signs or anything and then they both left. I was very worried and reported it to my supervisor. During a face-to-face interview on 03/05/25 at 10:33 AM, Employee #5, stated, That day (12/17/24), one of the therapists came to me and said that [Resident #676] needed help. I went to the room and saw that the patient's trach [tube] was halfway out. I called her nurse, [Employee #4], who went into the room. [Employee #4] saw the trach [tube] was out and she reinserted it back in. She said she had it from there and I left the room. I left the patient, the nurse and the therapist in the room. When asked what the facility's protocol is for when a resident's trach tube is out, Employee #5 responded, We are supposed to call rapid response, if the respiratory therapist is not around. A rapid response was not called that day for Resident #67. During a telephone interview on 03/05/25 at 10:40 AM, Employee #4 stated, I was in another room, my colleague [Employee #5] called me and said she needed me in room [ROOM NUMBER]. I went into the room, I saw that [Resident #67]'s trach collar necktie was loose, and the trach [tube] was halfway out. I remember there was one white lady was in there, a therapist, who was standing there. What I did was, I moved [Resident #67]'s hands, tied the necktie and readjusted the trach [tube] back in place, and then went back to my duties. When asked the facility's protocol for when a trach tube comes out, Employee #4 responded, The facility's process is to not reinsert trach, we would call respiratory. The male RT (Respiratory Therapist) who was on the unit that day, was not on the floor at that time. I didn't call him because the trach [tube] did not come out completely. When asked if she checked for airway patency or oxygenation status before readjusting Resident #67's trach tube back in place, Employee #4 stated, No. Someone reported something to the Administration was made aware that something happened because they wrote me up and gave me an in-service. A face-to-face interview was conducted on 03/05/25 at 12:49 PM with Employee #1 (Administrator), Employee #2 (Director of Nursing/DON) and Employee #6 (Director of Respiratory) Employee #6 stated, The protocol is if a tube is dislodged, call a rapid response. While waiting for respiratory therapist or the response team to come, if the trach tube is completely out, cover the trach with gauze dressing, monitor the resident's breathing and oxygen and if required, provide the resident with supplemental breathing via an Ambu bag via nose or mouth. Once the respiratory therapist arrives, they do their assessment and reinsert the trach tube at the bedside. If not able to, the resident would get transferred out. Nurses are not trained to reinsert a trach tube. Each resident with an airway has a Tube Out intervention protocol written in their care plans that states exactly what to do. Whether the trach tube is partially or completely out, a respiratory therapist or trained staff would be the one to first check for airway in order to make the determination to reinsert the trach tube or not. We teach the tube out procedure to all nurses at the annual skills fair. Review of Employee #4's record on 03/05/25 for training/competencies showed no documented evidence that she was trained to be a qualified practitioner who can reinsert a resident's tracheostomy in the event of dislodgement/decannulation. It should be noted that Resident #67 did not suffer any harm from this deficient practice. Cross Reference 22B DCMR Section 3210.4

Based on record review and staff interviews, for one (1) of eight (8) sampled residents, facility staff failed to provide Resident #67 with the necessary respiratory care per the residents comprehensive care plan and the facility's policy after decannulation of her tracheostomy (trach) tube. The findings included: The facility's Unplanned Decannulation: Risk Assessment, Precautions and Interventions policy with an effective date of December 2014 documented: - An unplanned decannulation is an unplanned removal or dislodgement of an artificial airway prior to its scheduled removal. - If unplanned decannulation occurs, the following will take place: call a Rapid Response (RRT); assess if the patient is stable without the trach tube, if not, the trach tube will be immediately reinserted to establish a patent airway by a qualified practitioner. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Encounter for Tracheostomy, Acute and Chronic Respiratory Failure with Hypercapnia, and Pyothorax Without Fistula, Review of the resident's medical record revealed a Physician's order dated 10/15/24 directing, Aspiration safety precautions, every shift; Monitor area under trach mask for signs of discoloration\edema\redness every shift; Trach care twice a day (BID) and as needed (PRN), two times a day for airway management; Maintain neck collar in place, check skin under neck collar every (q) shift for any changes and report to medical doctor (MD)/Nurse Practitioner (NP), every shift for safety; High Risk Airway, every day and night shift, post 'High Risk Airway' sign at resident's bedside; FIO2 (fraction of inspired oxygen): 28%, Trach type: Shiley, Trach size: 6.5 cuffless, every shift for Respiratory Failure, wean FIO2 as tolerated and to keep saturations greater than 92%. A physician's order dated 10/16/24 directed, Suction trach as needed, every shift. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the resident as; severely impaired cognitive skills for decision making; received oxygen therapy, suctioning, and tracheostomy care. A Care plan focus area last reviewed on 11/26/24 documented: [Resident #67] is at risk for decannulating her trach device. Goal: [Resident #67] will continue to be monitored closely so as not to allow her harm self via decannulation through the next review date. Interventions: Educate resident to understand the risk of removing the trach device. Frequent rounds. [Resident #67] and representative (RP) educated on risk of removing trach. Frequent rounding to ensure safety. Provide alternative activities to keep her attention away from the trach. A care plan focus area last reviewed on 12/02/24: [Resident #67] has a High-Risk Airway due to (d/t) self-decannulation, airway mass, and mittens. Goal: [Resident #67] will have a patent and intact airway though the review period. Interventions: Tube out procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, call a Rapid Response immediately, reinsert airway using an obturator. If the tube cannot be reinserted and the resident is able to breathe spontaneously and there are no signs/symptoms of acute respiratory distress, provide oxygen via nasal cannula to maintain O2 saturation greater than 92%. Cover stoma site with a dressing. Keep head of bed (HOB) 30-45 degrees and monitor the resident with pulse oximetry and end-tidal for at least 24 hours. Monitor/document for signs of respiratory distress. A physician's order dated 12/12/24 directed, Speech Language Pathology (SLP) evaluation and treat 4x/week x 30 days. A 12/17/24 at 11:19 AM Pain Assessment in Advanced Dementia (PAINAD): score, 0. A 12/17/24 at 2:06 PM General Progress Note written by Employee #4 (Registered Nurse assigned to Resident #67): Patient alert, awake and non verbal. Vitals stable. Medicated as prescribed. Total care provided. writer called in room [ROOM NUMBER]A for trach concern. On assessment, writer noticed the gauze not in place, the trach tie loose holding the trach half way out. Writer tightened the neck tie and placed the gauze. No distress noted . A 12/17/24 at 3:00 PM: Speech Therapy Note: - Upon arrival, the patient had self-decannulated with trach [tube] near oxygen mask. - No signs of respiratory distress. - Alerted the nurse, two nurses entered the room and reinserted the trach. - The patient made a wincing face and attempted to vocalize, indicating pain. A12/17/24 at 3:40 PM Respiratory Treatment Care Assessment: - Trach intact. - Patient resting comfortably at this time after decannulation. - [Resident #67] self-decannulated again. - The nurse said that the tube was halfway out. - The two nurses working on 1 south re-inserted the tube successfully. - The patient is resting comfortably, no distress noted. An email correspondence from Employee #4 (Registered Nurse/RN) to Employee #1 (Administrator) dated 12/20/24 at 1:21 PM documented: - On 12/17/24, I arrived in 156A, the patient was in bed with no shortness of breath, no distress. - The gauze around the [trach] site wasn't in place and the trach was loose, the trach halfway out, visibly about 2 centimeters (cm). - The writer tightened the necktie and fixed the gauze to avoid irritation. Review of an employee statement written by Employee #5 (RN), dated 12/20/24 documented: - One of the therapists came to me and asked if I was [Resident #67's] nurse, I said not but went to the room. - I saw the resident with a loose trach tie and the trach [tube] was slightly out, no acute respiratory distress was noted. - I called [Employee #4]. - The nurse adjusted the trach [tube] and trach tie. - I left the room, leaving the nurse and the therapist in the room. An anonymous Complaint, DC~13353, was submitted to the State Agency on 12/26/24. During a face-to-face interview on 03/05/25 at 10:24 AM, Employee #3 (SLP) stated, I was going in to see [Resident #67] for a speech therapy session and when I walked in, I saw her trach [tube] had completely come out and was resting on the oxygen mask. I alerted the nursing staff so they can call respiratory. The resident had a history of picking at her trach, so I was very worried. I stayed in the room and two nurses walked in, and did not perform any hand hygiene. One nurse pinned down the resident while the other jammed the trach back in. The resident winced in pain when the trach was back in the way that they did. They did not check the resident's vital signs or anything and then they both left. I was very worried and reported it to my supervisor. During a face-to-face interview on 03/05/25 at 10:33 AM, Employee #5, stated, That day (12/17/24), one of the therapists came to me and said that [Resident #67] needed help. I went to the room and saw that the patient's trach [tube] was halfway out. I called her nurse, [Employee #4], who went into the room. [Employee #4] saw the trach [tube] was out and she reinserted it back in. She said she had it from there and I left the room. I left the patient, the nurse and the therapist in the room. When asked what the facility's protocol is for when a resident's trach tube is out, Employee #5 responded, We are supposed to call rapid response, if the respiratory therapist is not around. A rapid response was not called that day for Resident #67. During a telephone interview on 03/05/25 at 10:40 AM, Employee #4 stated, I was in another room, my colleague [Employee #5] called me and said she needed me in room [ROOM NUMBER]. I went into the room, I saw that [Resident #67]'s trach collar necktie was loose, and the trach [tube] was halfway out. I remember there was one white lady was in there, a therapist, who was standing there. What I did was, I moved [Resident #67]'s hands, tied the necktie and readjusted the trach [tube] back in place, and then went back to my duties. When asked the facility's protocol for when a trach tube comes out, Employee #4 responded, The facility's process is to not reinsert trach, we would call respiratory. The male RT (Respiratory Therapist) who was on the unit that day, was not on the floor at that time. I didn't call him because the trach [tube] did not come out completely. When asked if she checked for airway patency or oxygenation status before readjusting Resident #67's trach tube back in place, Employee #4 stated, No. Someone reported something to the Administration was made aware that something happened because they wrote me up and gave me an in-service. A face-to-face interview was conducted on 03/05/25 at 12:49 PM with Employee #1 (Administrator), Employee #2 (Director of Nursing/DON) and Employee #6 (Director of Respiratory) Employee #6 stated, The protocol is if a tube is dislodged, call a rapid response. While waiting for respiratory therapist or the response team to come, if the trach tube is completely out, cover the trach with gauze dressing, monitor the resident's breathing and oxygen and if required, provide the resident with supplemental breathing via an Ambu bag via nose or mouth. Once the respiratory therapist arrives, they do their assessment and reinsert the trach tube at the bedside. If not able to, the resident would get transferred out. Nurses are not trained to reinsert a trach tube. Each resident with an airway has a Tube Out intervention protocol written in their care plans that states exactly what to do. Whether the trach tube is partially or completely out, a respiratory therapist or trained staff would be the one to first check for airway in order to make the determination to reinsert the trach tube or not. We teach the tube out procedure to all nurses at the annual skills fair. Review of Employee #4's record on 03/05/25 for training/competencies showed no documented evidence that she was trained to be a qualified practitioner who can reinsert a resident's tracheostomy in the event of dislodgement/decannulation. It should be noted that Resident #67 did not suffer any harm from this deficient practice. Cross Reference 22B DCMR Section 3215.3

Based on record review and staff interview for one (1) of 55 sampled residents, facility staff failed to ensure that Resident #67 (who is dependent on staff for activities of daily living, bed mobility and transferring from bed to chair) received adequate supervision when staff failed to use two staff person(s) while attempting to transfer a resident from bed to chair, subsequently the resident fell from the bed to the floor and sustained a neck fracture. Actual harm was identified on 7/15/2024 for resident #67. The findings included: A facility policy titled 'Falls and Fall Risk, Managing' with a review date of 05/24/24 documented, Policy Statement - Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling and Definition: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level and Fall Risk Factors 2. Resident conditions that may contribute to the risk of falls include: c. delirium and other cognitive impairment; g. medication side effects; i. functional impairments; k. incontinence and 3. Medical factors that contribute to the risk of falls include: e. balance and gait disorders; etc. and Fall Risk Assessment - 7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. A facility policy titled 'Activities of Daily Living (ADLs), Supporting' with a review date of 05/24/2024 documented, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: b. Mobility (transfer and ambulation, including walking) and A resident's ability to perform ADLs will be measured using clinical tools, including the MDS (Minimum Data Set). Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: e. Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. A facility policy titled 'Dementia - Clinical Protocol' with a review date of 05/24/24 documented, Treatment/Management: 4. Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Restlessness/Agitation and Anxiety Disorder. A review of Resident #67's medical record revealed: A care plan dated 09/08/22 documented, Focus- [Resident's name] had an actual fall on 8/23/22 with a skin tear to the left elbow r/t (related to) muscle weakness. Goal- [Resident's name] will resume usual activities without further incident, an open skin tear to the left elbow will be healed without any complication through the review date. Interventions- Bed in lowest position when resident is in bed to minimize fall related injuries. Continue interventions on the at-risk plan. Monitor skin tear to left elbow every shift and notify MD if any s/s of infection is noted. Pharmacy consult to evaluate medications. PT (physical therapy) consult for strength and mobility. Mats to floor when resident is in bed to minimize fall related injuries Date Initiated: 10/12/2022. A care plan dated 09/08/22 documented, Focus-[Resident's name] has limited physical mobility r/t (relatd to) Disease Process. Goal-[Resident's name] will remain free of complications related to immobility, including fall-related injury through the next review date. Interventions- Provide supportive care, assistance with mobility; Provide gentle range of motion as tolerated. A care plan dated 09/08/22 documented, Focus-[Resident's name] has an alteration in musculoskeletal status r/t immobility, bedbound. Goal-[Resident's name] will remain free of injuries or complications related to the disease process. Interventions- Monitor/document for risk of falls. Educate resident/family /caregivers on safety measures that need to be taken in order to reduce risk of falls. (If resident has a care plan for falls, refer to this). A care plan dated 09/08/22 documented, Focus-[Resident's name] uses anti-anxiety medications r/t anxiety disorder. Goal-[Resident's name] will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions- Monitor/document/report PRN (as neded) clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. A care plan dated 11/05/2022 documented, Focus- [Resident's name] had actual fall no injury 06/28/2024 [Resident's name] had actual fall Resident found sitting on floor mat no injury. 7/15/2024 fall with injury. Interventions- For no apparent acute injury, determine and address causative factors of the fall. Frequent rounding when resident is in bed, reposition if resident is found close to the edge of the bed. Neuro-checks daily for 72 hours. A care plan dated 01/20/23 documented, Focus- [Resident's name] has an ADL (activities of daily living) self-care performance deficit r/t to disease process. Goal- [Resident's name] will improve current level of function in ADLs through the review date. Interventions- Bed Mobility: The resident is dependent on (2) staff for repositioning; BEDFAST: The resident is bedfast all or most of the time. A physician order dated 08/16/23 documented, Fall and Safety Precaution every shift. A physician order dated 08/16/23 documented, Side rails up x 2 while resident is in bed BID (twice daily) for bed mobility every shift. A physician order dated 09/05/23 documented, Antianxiety Medication - Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. A physician order dated 04/26/24 documented, Before lunch staff to Bring resident to nursing station in her geri chair and bring resident crochet supply to her while watching resident every shift. A physician order dated 05/06/24 documented, Psych Consult and PRN one time only for Agitation and restlessness. A physician order dated 05/11/24 documented, Escitalopram Oxalate Tablet 10 MG Give 1 tablet via G-Tube one time a day for Depression/agitation. A Quarterly and State Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Severely Impaired;' Functional Abilities and Goals documented: Two+ person physical assist with Bed mobility, Transfers and Toilet use; Walking was coded as '88,' indicating the activity was not attempted due to medical condition or safety concerns; Dependent for all Activities of Daily Living (ADLs) that included toileting hygiene, personal hygiene, oral hygiene, dressing and bathing; Mobility documented: Dependent for all mobile activities that included Chair/bed-to-chair transfer, Toilet/shower transfer, Roll left and right, Sit to lying, Lying to sitting on side of bed and Sit to stand. A physician order dated 05/28/24 documented, Behaviors - Monitor for the following: Restlessness (Agitation). A physician order dated 06/04/24 documented, clonazepam Oral Tablet Disintegrating 0.5 MG (milligram) (Clonazepam) Give 1 tablet via G(Gastrostomy)-Tube two times a day for Agitation and anxiety Hold for sedation. A care plan dated 06/28/24 documented, Focus -06/28/2024 [Resident's name] had actual fall Resident found sitting on floor mat no injury. Goal- [Resident's name] will resume usual activities without further incident Revision on: 07/12/2024. Interventions- Hourly checks for safety 6/28/2024. Rehab consult. A Morse Fall Scale dated 06/28/24 documented that Resident #67 had a history of falls, had impaired gait, overestimated or forgets limits to ambulate safely and had a Fall Risk Score of '55.0,' indicating the resident was a high risk for falls. A review of a Treatment Administration Record (TAR) dated Jul-24 (July 2024) revealed that Resident #67 was totally dependent on staff and required two (2) or more person physical assist for transferring, but was only provided with one (1) person physical assist when transferring the resident on 07/02/24, 07/03/24, 07/05/24 and 07/13/24. A physician order dated 07/12/24 documented, Hourly checks for safety due to recent fall every hour for poor safety awareness due to recent fall. A physician progress note dated 07/13/24 at 07:00AM documented, Dementia, Non-ambulatory and limited ROM (range of motion). A physician progress note dated 07/13/24 documented, Type of visit: Follow-Up and Dementia and Non-ambulatory and limited ROM (range of motion) and Restlessness/agitation-?d/t (due to) cognitive impairment. It should be noted that there was no documentation in the Treatment Administration Record on 07/15/24, the date of fall, when she sustained a neck fracture during a transfer from bed to Geri-chair by one (1) staff person. An SBAR (Situation, Background, Assessment, Request) Communication Form and progress note dated 07/15/24 at 14:55 (2:55PM) documented, Resident fell and [I] was reaching for the Geri (Geriatric) chair which was at the bed to position the chair for transfer the resident fell out of bed and [Resident #67 ' s name] was up in the bed at about a 45-degree position prior to me attempting to pull the Geri Chair closer to the bed to transfer her to the GERI-CHAIR. An eInteract Transfer Form dated 07/15/24 at 15:00 (3:00PM) documented, Sent to [Hospital Name] and Fall, unplanned and Alert, disoriented and Not ambulatory and Transfers Dependent. A care plan with a revision date of 07/15/24 documented, 7/15/2024 fall with injury. Interventions- Staff to ensure Geri chair is very close to bed prior to transfer. Two staff members to assist during transfers. A Morse Fall Scale dated 07/15/24 documented that Resident #67 had a history of falls, had impaired gait, overestimated or forgets limits to ambulate safely and had a Fall Risk Score of ' 55.0, ' indicating the resident was a high risk for falls. A Facility Reported Incident [Intake Number: DC00012974] received by the State Agency on 07/15/24 at 09:49AM documented, resident had a fall while being provided with care and FUP (follow-up) 7/16/24: I finished giving [Resident ' s name] a bed bath as I was reaching for Geri chair which was beside the bed to position the chair for transfer, the resident fell out of bedand [Resident ' s name] was sitting up in the bed at about 45-degree position prior to me attempting to pull the Geri chair closer to the bed to transfer her to the Geri-chair. An Employee Warning Notice dated 07/15/24 documented, [Employee Name] CNA (Certified Nursing Assistant), Reason For Notice: Failure to prevent a fall and Employee educated to ensure Geri chair and all frequently used items within reach prior to transfer and also to have two staff members at all times assist with transfer. A hospital summary with an admit date of 07/15/24 documented, Yes-bed confined: unable to get up from bed without assistance, unable to ambulate and unable to sit in a chair or wheelchair and No-Can this patient safely be transported by car or wheelchair van (i.e., seated during transport without a medical attendant or monitoring?) and patient is confused. A hospital summary with an admit date of 07/15/24 documented, CT (computed tomography) scan SPINE/CERV (cervical) W/O (without) CONTRAST and Clinical History: Fall and Findings: An acute fracture through the base of the Ondontoid Process is noted with mild separation of the fracture fragments and The neurosurgeon [Doctor ' s name] should be followed up in 2 weeks and the soft cervical collar should remain on until cleared by the neurosurgeon/spine surgeon. A review of a Treatment Administration Record (TAR) dated Jul-24 (July 2024) revealed that Resident #67 was totally dependent on staff and required two (2) or more person physical assist for transferring, after she sustained fall with fracture on 07/15/24, but was only provided with one (1) person physical assist when transferring the resident on 07/16/24, 07/17/24, 07/18/24, 07/29/24 and 07/30/24. During a face-to-face interview conducted on 10/18/24 at 2:46 PM Employee #42 (RN) acknowledged the findings and stated, The CNA was providing care alone at the time of the fall. She ' s [Resident #67] a high risk for falls. She's not a heavy patient, but if you ' re transferring her out of bed it ' s definitely a two (2) person assist. Cross reference: 22B DCMR § 3211.1(d)

6. A facility policy titled 'Response To Patient Call Light Activation' with a review date of December 2023 documented, 8. Answer the resident's call as soon as possible. A facility policy titled 'Activities of Daily Living (ADLs), Supporting' with a review date of 05/24/2024 documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene and A resident's ability to perform ADLs will be measured using clinical tools including the MDS (Minimum Data Set) and Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of ADL activity. Resident #377 was admitted to the facility on [DATE] with multiple diagnoses that included: Disorientation, Hemiplegia, Chronic Respiratory Failure, Dependence on Respirator and End Stage Renal Disease. A review of Resident #377's medical record revealed: An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15' indicating the resident was cognitively intact; Functional Abilities and Goals that documented: Dependent on staff for all Activities of Daily Living (ADLs) that included toileting, bathing, personal hygiene, oral hygiene and dressing; Dependent on staff for Bed Mobility-roll left to right, lying to sitting on side of bed/sit to lying, toilet transfer; and Bowel and Bladder that documented: Frequently incontinent, seven (7) or more episodes of urinary incontinence and two (2) or more episodes of bowel incontinence. A care plan dated 08/29/24 documented, [Resident's name] has an ADL self-care performance deficit r/t (related to) Confusion, Disease Process CVA (Cerebral Vascular Accident), and muscle weakness and [Resident's name] will improve her current level of function and BEDFAST: Resident is bedfast all or most of the time. A nursing progress note dated 09/12/24 at 19:01 (7:01 PM) documented, ADLS provided with two staffs. A nursing progress note dated 09/19/24 at 06:51 AM documented, Total care for ADLs. 09/03/24 at 09:45 AM documented, The patient is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for incontinence management. During an observation on 10/02/24 at 1:45PM upon entering Unit one (1) South, the State Surveyor noted the sound of the call bell device and observed the call light above Resident #377 door was illuminated outside of the resident's room. It should be noted that the call light from the resident's room went unanswered while a Certified Nursing Assistant (CNA) was seated at the nurse's station that was less than 10 feet from the resident's room reading from her personal journal. During a face-to-face interview conducted on 10/02/24 at 2:00 PM (Agency CNA) stated, I didn't hear the call bell ringing before going to the resident's room to provide incontinence care. During an observation on 10/03/24 at 1:30PM while on Unit one (1) South, the State Surveyor was seated in the charting area directly behind the nurse's station and witnessed staff not providing timely incontinent care for Resident #377 when requested. The following occurred: 1:34PM: Employee #22 (charge nurse) was notified by facility staff leaving the unit that the resident had called out to send a nurse to the room. 1:39PM: The same facility staff came back to the nurse's station and stated to Employee #22 that the resident don't need a nurse, she needed the CNA because she needed to be changed. Employee #22 replied okay and remained seated at the nurse's station. 1:48PM: The resident's husband came to the nurse's desk and asked Employee #22, who was still seated there, if the resident was on a stool softener because she was frequently incontinent of stool and Employee #22 stated, No. The resident's spouse returned to the resident's room while the Employee #22 remained seated at the nurse's desk. 1:54PM: The State Surveyor walked to the resident's room and was met at the door by Resident #377's husband who stated that no one had come to assist the resident and it always take a very long time before anybody answers the call bell and she has frequent diarrhea. 2:00PM: The State Surveyor walked back to the front desk and observed Employee #22 still seated at the desk, after being notified on three (3) different occasions, between 1:34PM and 1:48PM, that the resident needed assistance with incontinent care. During a face-to-face interview conducted on 10/03/24 at 2:00PM Employee #22 stated I'm the only nurse before going to the resident's room to provide incontinent care to the resident. During a face-to-face interview conducted on 10/03/24 at 3:00PM Employee #2 (Director of Nursing, DON) acknowledged the findings and stated, Call lights must be answered immediately and when the nursing staff is out on the unit they should be checking to see if call lights are on to see if the residents need assistance. Cross Reference 22B DCMR § 3211.1 5. Resident #105 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia And Hemiparesis, Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Parkinson's Disease, Encounter For Attention To Tracheostomy, Encounter for Attention to Gastrostomy, Human Immunodeficiency Virus [HIV] Disease, and Bipolar Disorder. The State Agency received a confidential complaint DC ~12955 on 07/10/24 that alleged: Resident #105 is being neglected and [the facility staff is] not taking care of him or other patients. I am afraid for Resident #105 along with a lot of patients there (here). The resident is non-verbal and has been left for extended periods of time soiled and wet down to his legs and fingernails). The medical team, the doctor or nurses never check in on [Resident #105]. No one is ever present at the nurse's station; the facility is under staff[ed]. They do not bathe the resident; Due to the resident not being turned properly he has bed sores. On 10/11/24 the following observations were made: 11:00 AM - Resident # 105 was observed lying supine (on the back) in bed with the height of the bed raised. The Resident was receiving oxygen via a tracheostomy tube and a ventilator. The Resident was also receiving a feeding through a G-tube (gastrostomy tube). In addition, the Resident had an indwelling urinary catheter. A privacy bag for the urinary catheter (Foley) was observed halfway on and halfway off, the bag attached to the bedrail and touching the floor. The surveyor notified the nurse who fixed the privacy bag. The nurse did not reposition nor turn the Resident, and he did not check the Resident ' s brief or provide incontinent care. 12:16 PM - Resident #105 was observed in the same position as the prior observation. Certified Nurse ' s Aide (CNA) assigned to Resident #105 was not observed on the unit. Employee #30 the Registered Nurse assigned to the Resident was observed across from the Resident ' s room at the medication cart beside the nurse 's station. 1:34 PM- Resident #105 was lying on [pronoun] back in the same position as the prior observations. The surveyor observed and reviewed that the Resident 's treatment administration record (TAR) showed that Employee had documented that at 2:00 PM the facility staff had provided incontinent care every two hours and PRN and the Resident had turned and repositioned every 2 hours. Employee was observed sitting at the nurse 's station across from Resident #105 ' s room. The Employee had not checked the Resident for incontinent care and had not turned or repositioned the Resident. 2:28 PM - Resident #105 was lying on [pronpoun] back in the same position as the prior observations. Employee # 31/Certified Nurse Aide (CNA) assigned to Resident #105, was observed back on the unit. Employee #30/Registered Nurse assigned to Resident #105, was observed on the unit standing at the medication cart near the nurse 's station. Employees #30 and #31 were not observed entering the Resident 's room on 10/11/24 from 11:00 AM to 2:28 PM. A review of Resident #105 ' s medical record revealed the following: A discharge minimum data set (MDS) assessment dated [DATE] documented that Resident #105 was severely cognitively impaired, was totally dependent and required assistance from two staff for bed mobility and all activities of daily living (ADLs- personal hygiene, grooming, bed mobility, toileting). A care plan initiated on 08/22/24 documented the following: Focus/Problem: [Resident #105] has an ADL self-care performance deficit r/t (related to) Disease Process, Musculoskeletal impairment; Goal: [Resident Name] will maintain the current level of function in through the review date. Date Initiated: 08/22/2024 Revision on: 09/18/2024 Target Date: 12/19/2024; Interventions: Bathing/Showering: The resident is totally dependent on 1-2 staff to provide care daily and as necessary. Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed every two hours and as necessary. Date Initiated: 08/22/2024 Revision Date: 08/22/2024. A physician ' s order dated 09/08/24 at 12:00 AM documented: Incontinent care every two hours and PRN (as needed). A physician ' s order dated 09/06/24 at 12:00 AM directed, Turn and reposition every 2 hours and as needed for skin (breakdown) prevention. A review of Resident #105 ' s treatment administration record (TAR) for October 2024 revealed that facility staff documented from 10/01/24 to 10/18/24 that they provided incontinent care to the resident every two (2) hours and prn (as needed) and that they turned and repositioned the Resident every 2 hours, and as needed. During a face-to-face interview on 10/11/24 at approximately 2:08 PM, Employee #30 stated that Resident # 105 is totally dependent on staff and requires assistance from two staff for incontinent care and turning and repositioning. When asked how often staff provide incontinent care and turn and reposition the Resident, the Employee replied that the tasks should be done every 2 hours and prn (as needed). When asked why the Resident had not been turned or repositioned and had not been checked for incontinence for 3.5 hours, the Employee responded, that the CNAs (Certified Nurse Aides) turn and reposition the resident and provide incontinent care. They will call the nurse if assistance is needed, otherwise the nurse doesn ' t get involved. I initialed that turning, repositioning, and incontinent care were done. I assumed that the CNA did it. If the CNAs did it I do not have to be involved. When asked why he signed that both tasks were done at 2:00 PM before 2:00 PM. the Employee gave no response. During a face-to-face interview on 10/11/24 at 2:28 PM, Employee #31 stated that This was my first time taking care of Resident # 105. When asked how much staff assistance the resident required, the Employee did not answer. When asked how often staff provide incontinent care and turn and reposition the Resident, the Employee stated, We check about every 2 hours and when needed. When asked why the resident had not been turned or repositioned and had not been checked for incontinent care for at least 3.5 hours, she responded, Resident # 105 has a Foley, and she stated that she had turned and repositioned him before leaving the floor. When asked who assisted her at that time, she stated, I just did it myself. She further commented that she had not talked to the CNA from the prior shift, or the nurse to ask how much assistance Resident # 105 required. During a face-to-face interview on 10/11/24 at 2:31 PM Employee #4/3- East Unit Manager was made aware of the surveyor ' s observations and interviews with Employees #30 and #31. She stated that both Employees had been educated on turning, repositioning, and incontinent care in the past and she would make sure they were educated again. 2. Resident #10 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Chron's Disease, and Conversion Disorder with Seizures or Convulsions. A physician's order dated 05/08/23 directed, Cardiac diet, Regular texture, Thin consistency. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 07, indicating severe cognitive impairment; required supervision and set up for eating; required extensive assistance of one staff for toilet use; functional limitation in range of motion on one side for upper and lower extremity; and active diagnoses of Stroke and Hemiplegia Affecting Left Dominant Side. The following was observed on unit 3 west on 10/02/24: 8:30 AM - breakfast trays were delivered. 8:32 AM - breakfast trays were passed out. 8:37 AM - Resident #10 was observed lying in bed, with breakfast tray on the overbed table, covered and untouched. 9:00 AM - Resident #10 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. 9:25 AM - Resident #10 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. 10:03 AM - Resident #10 was observed lying in bed with breakfast tray on the overbed table, still covered and untouched. During a face-to-face interview on 10/02/24 at 10:05 AM, Employee #9 (assigned Registered Nurse/RN) was asked why Resident #10's breakfast tray had not been set up for [pronoun] to be able to eat. The employee stated, [Pronoun] CNA (Certified Nurse Aide/ [Employee #18] is in another room feeding someone else. I can set up [Resident #10]'s tray now. The evidence showed that the even though breakfast trays were delivered to the unit at 8:30 AM on 10/02/24, Resident #10 was not provided with any assistance with her breakfast tray until it was brought to the attention of the staff, one hour and thirty-five minutes later. The following was observed on unit 3 west on 10/03/24: 12:17 PM - lunch trays were delivered. 12:20 PM - lunch trays were passed out. 12:32 PM - Resident #10 was observed lying in bed, with lunch tray on the overbed table, covered and untouched. 12:48 PM - Resident #10 was observed lying in bed, with lunch tray on the overbed table, still covered and untouched. 1:00 PM - Resident #10 was observed lying in bed, with lunch tray on the overbed table, still covered and untouched. 1:25 PM - Resident #10 was observed lying in bed with lunch tray on the overbed table, still covered and untouched. During a face-to-face interview on 10/03/24 at 1:30 PM, Employee #9 (RN) was made aware that that Resident #10 had not been assisted with [pronoun] lunch meal that was delivered over an hour ago. Employee #9 stated that Resident 10's assigned CNA was on lunch break as the reason for why the resident not being assisted with lunch and then proceeded to ask another staff member to assist Resident #10 with meal. The evidence showed that the even though lunch trays were delivered to the unit at 12:17 PM on 10/03/24, Resident #10 was not provided with any eating assistance until it was brought to the attention of the staff, one hour and thirteen minutes later. 3. Resident #29 was admitted to the facility on [DATE] with multiple diagnosis that included: Quadriplegia, Spinal Stenosis, Neuralgia and Neuritis. Review of the resident's medical record revealed the following: A physician's order dated 08/08/24 that directed, Regular diet, regular texture, thin consistency; Assist w (with)/meal tray set up such as: opening containers, mixing supplements, etc. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive response and required set-up for eating. Care plan focus area: [Resident #29] has an ADL self-care performance deficit r/t (related to) DX (diagnoses) Quadriplegia, Spinal Stenosis, Muscle Spasm, revised on 09/07/24 had interventions that included: eating - the resident is able to feed self with limited assistance by 1 staff. The following was observed on unit 3 west on 10/02/24: 8:30 AM - breakfast trays were delivered. 8:32 AM - breakfast trays were passed out. 8:37 AM - Resident #29 was observed lying in bed, with breakfast tray on the overbed table, covered and untouched. 9:00 AM - Resident #29 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. 9:25 AM - Resident #29 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. 9:45 AM - Resident #29 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. The resident stated, I need help eating. The lady said she was coming back to feed me, but I haven't seen her. During a face-to-face interview on 10/02/24 at 9:58 AM, Employee #18 (assigned Certified Nurse Aide/CNA) was asked why Resident #29 had not been fed. The employee stated, I was busy with other residents. I am going to feed him now. The evidence showed that the even though breakfast trays were delivered to the unit at 8:30 AM on 10/02/24, Resident #29 was not provided with any eating assistance until it was brought to the attention of the staff, one hour and thirty-five minutes later. 4. Resident #68 was admitted to the facility on 04/21//22 with multiple diagnoses that included: Age-Related Physical Debility, Dementia, and Cognitive Communication Deficit. Review of the resident's medical record revealed the following: A physician's order dated 07/18/23 that directed, Assist resident with feeding. Report to unit manager if resident refused feeding, every shift. A physician's order dated 01/08/24 that directed, Magic Cup, two times a day with lunch and dinner tray. Care plan focus area: [Resident #68] has a swallowing problem r/t (related to) swallowing assessment results - necessitating altered texture diet, revised on 02/02/24 had interventions that included - keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. A Complaint, DC~12688, submitted to the State Agency on 04/29/24 documented, . On Friday April 26, 2024, at approximately 1:27 p.m. I noticed a tall light complexion female pushing the food cart pass room [ROOM NUMBER]. I believe she was a CNA. I remember pulling out my cell phone several times looking at the time and thinking why was it taking much longer than it normally would take to deliver [Resident #68's] food. At approximately 1:58 p.m. a female in a light blue uniform left the food cart in front of room [ROOM NUMBER] and went to the dining room across the hall from room [ROOM NUMBER] and came out immediately . As I was sitting in the black fold up chair, I could see my mother quickly exiting the dining room and into the hall asking if the female in the light blue uniform was going to deliver food and told her 'no' without explanation. After sitting in room [ROOM NUMBER], I immediately got up and exit the room to witness the conversation with my mother and the Bridgepoint nursing staff in the area of the nurses station regarding [Resident #68] . not receiving their lunch I stated to her (former Unit Manager) that it was serious for my grandmother not to have lunch . It wasn't until approximately 2:18 p.m. when [Resident #68] lunch was delivered . A physician's order dated 06/18/24 directed, Regular diet, soft and bite sized texture, thin consistency ground vegetables; 1:1 feeding; fortified food with all meals. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 04, indicating severely impaired cognitive status; had functional limitation in range of motion on one side for upper extremity; and required extensive assistance of 1 staff for eating. The following was observed on unit 3 west on 10/02/24: 8:30 AM - breakfast trays were delivered. 8:32 AM - breakfast trays were passed out. 8:37 AM - Resident #68 was observed lying in bed, with breakfast tray on the overbed table, covered and untouched. 9:00 AM - Resident #68 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. 9:25 AM - Resident #68 was observed lying in bed, with breakfast tray on the overbed table, still covered and untouched. 10:03 AM - Resident #68 was observed lying in bed with breakfast tray on the overbed table, still covered and untouched. During a face-to-face interview on 10/02/24 at 10:05 AM, Employee #9 stated that Resident #68 requires full staff assistance to eat. [Pronoun] needs help setting up and to eat. When asked why the resident had not been assisted with breakfast meal, Employee #9 stated, [Pronoun]CNA is in another room feeding someone else. I will go feed resident now. The evidence showed that the even though breakfast trays were delivered to the unit at 8:30 AM on 10/02/24, Resident #68 was not provided with any eating assistance until it was brought to the attention of the staff, one hour and thirty-five minutes later. The following was observed on unit 3 west on 10/03/24: 12:17 PM - lunch trays were delivered. 12:20 PM - lunch trays were passed out. 12:32 PM - Resident #68 was observed lying in bed, with lunch tray on the overbed table, covered and untouched. 12:48 PM - Resident #68 was observed lying in bed, with lunch tray on the overbed table, still covered and untouched. 1:00 PM - Resident #68 was observed lying in bed, with lunch tray on the overbed table, still covered and untouched. 1:25 PM - Resident #68 was observed lying in bed with breakfast tray on the overbed table, still covered and untouched. During a face-to-face interview on 10/03/24 at 1:30 PM, Employee #9 (RN) was made aware that that Resident #68 had not been assisted with lunch meal that was delivered over an hour ago. Employee #9 stated that Resident #68's assigned CNA was on lunch break as the reason for why the resident not being assisted with lunch and then proceeded to ask another staff member to assist Resident #68 with meal. The evidence showed that the even though lunch trays were delivered to the unit at 12:17 PM on 10/03/24, Resident #68 was not provided with any eating assistance until it was brought to the attention of the staff, one hour and thirteen minutes later. A face-to-face interview was conducted on 10/03/24 at 2:01 PM with Employee #2 (Interim Director of Nursing/DON) and Employee #3 (Regional Director of Clinical Operation). The findings related to Residents' #10, #29 and #68 were brought to the employees attention. Both employees acknowledged the findings with Employee #2 stating, Nurses or CNA's can assist with meals. If a CNA is not available to assist with meals, the assigned nurse should take over that task. Cross Reference 22B DCMR Sec. 3211.1 Based on record review and staff and resident interviews, for four (4) of 55 sampled residents, the facility staff failed to provide: (1) documented evidence that Resident #44 who was dependent on staff for toileting hygiene was provided incontinent care within 12 hours on 10/01/24 and with eight hours on 10/02/24, (2) activities of daily living (ADL) care assistance for Resident #10, #29, #68, (3) incontinent care and turn and repostion Resident #105 every two (2) hours as perscibed, and (4) incontinent care in a timely manner for Resident #377. The findings included: 1. Resident #44 was admitted to the facility on [DATE] with multiple diagnoses including Weakness and Obesity. A physician order dated 10/19/21 instructed, Apply hydra guard barrier cream to perineal, sacral, buttocks area after each incontinent care for skin maintenance. A quarterly Minimum Data Set assessment dated [DATE] documented in part that the resident had a Brief Interview for Mental Status summary score of 15 indicating that the resident's cognitive status was intact. The assessment also coded the resident for always being incontinent of urine and bowel and required maximum assistance from toilet hygiene. A care plan with a revision date of 09/23/24 documented part, Problem-[Resident #8] has bladder incontinence related to impaired mobility .Interventions - clean peri-area with each incontinence episode . A review of hand-written notes that Resident #8 documented in part, October 1, Tuesday-5:30 PM, still not changed from day[shift]. Put on [call] light round 5 PM nurse showed up at 6:30 [PM] to explain CNA gone for the day.10/02/24-no change again. midnight CNA did not come back to change me again around 5 AM. According to the certified nursing assistant notes, incontinent care was provided at 6:58 A.M., 9:50 A.M., and 10:02 P.M. on 10/01/24. On 10/02/24, incontinent care was provided once at 3:42 p.m. A review of the staff assignment sheets showed the following: 10/01/24 (7 AM to 7 PM) revealed the resident census was 33. The staff were two licensed nurses and three certified nursing assistants. 10/01/24 (7PM to 7 AM) revealed the resident census was 33. The staff were two licensed nurses and two certified nursing assistants. 10/02/24 (7 AM to 7 PM) revealed the resident census was 34. The staff were two licensed nurses and three certified nursing assistants. 10/02/24 (7PM to 7 AM) revealed the resident census was 34. The staff were two licensed nurses and two certified nursing assistants. During a face-to-face interview on 10/02/24 at approximately 11 AM, the resident stated that she was not provided with incontinent care for 12 hours on 10/01/24 and eight hours on 10/02/24. The resident also said to avoid having to wait a long time for the night shift (7PM-7AM) staff to provide incontinent care, she prefers to be changed around 6 PM on dayshift (7AM-7PM). During a face-to-face interview on 10/15/24 at 1:45 PM, Employee # 43 (CNA) stated that she provided incontinent care one time on 10/01/24 at 9:58 AM. Around 12 PM, she was sent on an escort, and another CNA took over. According to the employee, incontinent care can only be documented once a shift even if it is provided multiple times. During a face-to-face interview on 10/16/24 at 10 AM, the DON reviewed the resident's CNAs documentation for 10/01/24 and 10/02/24 and stated that she believed that the resident was provided with incontinent care more times than what was documented. After her statement, the DON was provided with handwritten notes from the resident for 10/01/24 and 10/02/24 related to incontinent care to review. The DON then said that she would speak with the resident and let her know she can always call her if she is not provided with incontinent care in a timely manner.

4. Resident #381 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic respiratory failure, Major laceration of liver, Dysphagia, s/p (status post) Motor Vehicle Accident with Fracture of T-5/T-6 (Thoracic Spine) and Fracture of Pelvis. A review of Resident #381's medical record revealed: A nursing progress note dated 08/02/24 at 19:54 (7:54PM) documented, Resident has a f/u (follow-up) appointment with [Doctor's name], [NAME] (Audiology) for routine hearing exam (ENT (Ear, Nose & Throat) consult for bilateral hearing loss). A medical office appointment summary dated 08/19/24 documented, significant hearing loss noted possibly exacerbated by cerumen impaction No hx (history) of trauma or bleeding from ears no known hx of ear drum rupture. Improved hearing but unable to appreciate words well after irrigation. Request ENT eval. Advised patient's sister [RP] (responsible party) that may need audiolgy re-eval (evaluation) for hearing aides. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' indicating the resident was cognitively intact; Hearing, Speech, Vision that documented: Ability to hear-Adequate. It should be noted that the Quarterly MDS assessment dated [DATE] documented that Resident #381 had adequate hearing although there is documented evidence in the record of the resident's hearing loss. During a face-to-face interview conducted on 10/17/24 at 9:35 AM, Employee #15 acknowledged the findings and stated, We're responsible for Sections A, B, G, GG, J, L, M, N, O, P and responsible for assessing the resident. We do a head-to-toe assessment and look at nursing notes, then document. If nursing says a resident is hard of hearing, we go back to see if the documentation validates it. I will correct the MDS Assessment for that resident. Cross Reference 22B DCMR § 3231.11 Based on record review and staff interviews, for four (4) of fifty-five (55) sampled residents, the facility staff failed to ensure that a Resident's assessment accurately reflected the resident's nutrition status by documenting an inaccurate weight. Residents' #85, #71, #121 and #381. The findings included: 1. Resident #85 was admitted to the facility on [DATE] with diagnoses that included: Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Dislocation Of C1/C2 Cervical Vertebrae, Laceration of Diaphragm, Encounter for Attention to Tracheostomy, Encounter for Attention to Gastrostomy, and Dependence on Respirator/Ventilator. A review of Resident #85's medical record revealed the following: A census report that showed the resident was discharged from the facility to the hospital on [DATE] and was readmitted to the facility on [DATE]. A discharge minimum data set (MDS) assessment dated [DATE] documented that the Resident weighed 144 pounds. A nutrition assessment completed by Employee #29 (Dietician) documented, .Current body weight pending reweigh. A significant change minimum data set (MDS) assessment dated [DATE] documented that the Resident weighed 268 pounds. A weight report for Resident # 85 for August 2024 that showed the following: 08/07/2024 3:23 PM 153.2 Lbs (Mechanical Lift) 08/20/2024 5:06 PM 155.2 Lbs (Mechanical Lift) 08/21/2024 5:07 PM 155.0 Lbs (Mechanical Lift) 08/28/2024 5:07 PM 155.3 Lbs (Mechanical Lift) A significant change minimum data set (MDS) assessment dated [DATE] documented that the Resident weighed 268 pounds. The MDS assessment showed that it was completed by the dietician on 09/03/24. During a face-to-face interview on 10/16/24 at 10:35 AM with Employee #15 (MDS Coordinator), she stated that the weight came from a hospital Discharge summary dated [DATE]. She added that the dietician was responsible for recalculating the Resident's weight. During a face-to-face interview Employee #29 (Dietician) acknowledged that the weight was incorrect and did not reflect the Resident's nutritional status when she was readmitted to the facility in August. She added that she requested a reweight for the Resident. She did not explain why the Resident's assessment did not include the correct re-calculated weight, which she completed on 09/03/24. [DCMR cross-over tag 3231.12(l)] 2. Facility staff failed to accurately code Resident #71's Annual MDS to reflect that he is a tobacco user. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included: Spastic Hemiplegia Affecting Left Dominant Side, Contracture of Muscle, Left Hand, Weakness, and Difficulty in Walking. Review of the resident's medical record revealed the following: 07/29/24 Smoking Safety Screen: - IDT (interdisciplinary team) decisions: Resident had Dx (diagnosis): Schizophrenia and he forgot things a lot. Resident will need close supervision during smoking. - For safety, resident needs close supervision. - Score: 2.0; Safe to smoke with supervision. Care plan focus area: [Resident #71] uses tobacco products has been assessed for safety, revised on 09/03/24 had interventions that included: complete smoking assessment and provide education on risk of smoking to resident. An Annual MDS assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive status and no current tobacco use. The evidence showed that facility staff failed to accurately code Resident #71's Annual MDS assessment to reflect his current use of tobacco. During a face-to-face interview on 10/15/24 at 1:20 PM, Employee #15 (MDS coordinator) acknowledged the findings and stated that she did not see the smoking assessment that was completed on 07/29/24. 3. Facility staff failed to accurately code Resident #121's admission MDS assessment to reflect hemiplegia on his left side. admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure, Retention of Urine and Hemiplegia, Affecting Left Nondominant Side. Review of the resident's medical record revealed the following: An admission MDS assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderately impaired cognitive status; no functional limitations in range of motion; and had an active diagnosis of Hemiplegia or Hemiparesis. The evidence showed that facility staff failed to accurately code Resident #121's admission MDS assessment to reflect his hemiplegia/hemiparesis on the left side. During a face-to-face interview on 10/04/24 at 10:20 AM, Employee #15 reviewed the MDS, acknowledged the findings and stated, I will make the corrections.

Based on record review and staff interview for four (4) of 55 sampled residents, facility staff failed to develop a person-centered care plan with goals and interventions for residents with bowel and bladder incontinence, a resident with hearing loss, a resident with fall mats on both sides of the bed and for a resident's refusal of respiratory care/treatments. Residents' #377, #381, #71 and #121. The findingd inclued: 1. Resident #377 was admitted to the facility on [DATE] with multiple diagnoses that included: Disorientation, Hemiplegia, Chronic Respiratory Failure, Dependence on Respirator and End Stage Renal Disease. A review of Resident #377's medical record revealed: An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15' indicating the resident was cognitively intact; Functional Abilities and Goals that documented: Dependent on staff for all Activities of Daily Living (ADLs) that included toileting, bathing, personal hygiene, oral hygiene and dressing; Dependent on staff for Bed Mobility-roll left to right, lying to sitting on side of bed/sit to lying, toilet transfer; and Bowel and Bladder that documented: Frequently incontinent, seven (7) or more episodes of urinary incontinence and two (2) or more episodes of bowel incontinence. A care plan dated 08/29/24 documented, Focus-[Resident's name] has an ADL self-care performance deficit r/t (related to) Confusion, Disease Process CVA (Cerebral Vascular Accident), and muscle weakness and Goal-[Resident's name] will improve current level of function in washing [pronoun] face with help through the review date. The resident will be able to: wash her face and upper body without extensive assistance. and Interventions-BATHING/SHOWERING: Avoid scrubbing & pat dry sensitive skin. Check nail length and trim and clean. Use short, simple instructions. BEDFAST: Resident is bedfast all or most of the time. DRESSING: The resident is dependent on (1) staff for dressing. It should be noted that the ADL care plan dated 08/29/24 lacked documented evidence of goals and interventions that addressed Resident #377's frequent urinary and bowel incontinence. During a face-to-face interview conducted on 10/17/24 at 11:08 AM Employee #2 (Director of Nursing, DON) acknowledged the findings and stated The resident is totally dependent and needs help with everything, she cannot walk to the toilet, she's incontinent of urine and bowel. It wasn't intentional, maybe they [the nursing staff] forgot to update the care plan for the incontinence. 2. Resident #381 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic respiratory failure, Major laceration of liver, Dysphagia, s/p (status post) Motor Vehicle Accident with Fracture of T-5/T-6 (Thoracic Spine) and Fracture of Pelvis. A review of Resident #381's medical record revealed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' indicating the resident was cognitively intact; Bowel and Bladder that documented: Always incontinent of urine and bowel; Hearing, Speech, Vision that documented: Understanding Verbal Content, however able (with hearing aid or device if used)-Rarely/Never Understands. A care plan dated 06/08/24 documented, Focus-[Resident's name] has an ADL self-care performance deficit (Totally dependent in ADL) r/t weakness. Goal-[Resident's name] will maintain current level of function through the review date. Interventions- AM ROUTINE: The residents preferred dressing/grooming daily and PRN. BATHING/SHOWERING: Check nail length and trim and clean. BED MOBILITY: The resident requires 2 staff member[s] all times for turning and repositioning. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self, shoes are comfortable and not slippery. TRANSFER: The resident is totally dependent need 2 staff for transferring. A physician order dated 08/19/24 documented, Hourly checks for incontinence, nursing staff to perform incontinent care as needed every hour. It should be noted that the ADL care plan dated 06/08/24 lacked documented evidence of goals and interventions that addressed Resident #381's urinary and bowel as always incontinent. A Care plan dated 06/09/24 documented, Focus-[Resident's name] has a communication problem r/t (related to) Use of ventilator. Goal- Staff will establish method of communicating with resident to meet their needs. Interventions- COMMUNICATION: Resident is able to communicate in written [sic]. A nursing progress note dated 08/02/24 at 19:54 (7:54PM) documented, Resident has a f/u (follow-up) appointment with [Doctor's name], [NAME] (Audiology) for routine hearing exam (ENT (Ear, Nose & Throat) consult for bilateral hearing loss). Resident had hearing exam at [medical office name] on 08/19/24 that documented, significant hearing loss noted possibly exacerbated by cerumen impaction No hx (history) of trauma or bleeding from ears no known hx of ear drum rupture. Improved hearing but unable to appreciate words well after irrigation. Request ENT eval. Advised patient's sister [RP] (responsible party) that may need audiolgy re-eval for hearing aides. It should be noted that there was no person-centered care plan with goals and interventions that addressed Resident #381's hearing loss at the time of the State Surveyor's record review. During a face-to-face interview conducted on 10/17/24 at 11:08 AM Employee #2 (DON) acknowledged the findings and stated The resident is totally dependent and needs help with everything. It wasn't intentional, maybe they [the nursing staff] forgot to update the care plan for the incontinence and her hearing loss. 3. Facility staff failed to implement Resident #71's care plan intervention of having fall mats on both sides of his bed. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses that included: Spastic Hemiplegia Affecting Left Dominant Side, Contracture of Muscle, Left Hand, Weakness, and Difficulty in Walking. A physician's order dated 03/19/24 directed, Please keep [fall] mats bilaterally on the floor. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15 , indicating intact cognitive status; no rejection of care behaviors; functional limitations in range of motion on one side for upper and lower extremities; used a wheelchair mobility device; required extensive assistance of one person for bed mobility; transfers and toilet use; always incontinent of bowel and bladder; and no falls since prior assessment. 09/21/24 admission Morse Fall Scale: - Resident score: Moderate Risk for Falling, 35.0. - Scoring: High Risk 45 and higher; Moderate Risk 25-44; Low Risk 0-24. 09/27/2024 at 6:10 PM Situation Background Assessment Request (SBAR) Communication Form and Progress Note: - Situation: Fall - Nursing note: Resident noted sitting on the floor in front of the commode in the bathroom, asked what happened, resident stated, I forget to lock my wheelchair before transferring to the chair. On assessment, no apparent injury noted, resident denied hitting the head and was able to move extremities. Resident was helped back to the chair, ate his dinner and went downstairs to socialize. - Medical doctor and siter made aware. Neuro check in progress. 09/27/24 Post-fall Morse Fall Scale: - Resident score: Moderate Risk for Falling, 40.0. - Scoring: High Risk 45 and higher; Moderate Risk 25-44; Low Risk 0-24. Care plan focus area: [Resident #71] had an actual fall. He had an actual unwitnessed fall, 09/27/24, on the bathroom with no injury, revised 10/03/24 had interventions that included: floor mat bilaterally to the bed side when resident is in bed, to minimize injuries related to falls and licensed staff to check for and ensure that floor [fall] mat is always in place. During a unit tour on 10/01/24 at 11:30 AM, Resident #71 was observed in his room, sitting on the side of his bed, with one floor fall mat on the side of the bed closest to the door. During an observation on 10/03/24 at 1:25 PM, Resident #71 was observed in his room, sitting on the side bed, with one floor fall mat on the side of the bed closest to the door. During an observation on 10/15/24 at 12:55 PM, Resident #71 was observed in his room, sitting on the side of the bed, with one floor fall mat on the side of the bed closest to the door. The evidence showed that facility staff failed to implement the care plan intervention of having bilateral fall mats at Resident #71's bedside. During a face-to-face interview on 10/15/28 at 12:57 PM, Employee #16, (Licensed Practical Nurse/LPN) acknowledged the findings and stated, I don't know what happened to the other mat, maybe he removed it. 4. Facility staff failed to develop a care plan with goals and approaches to address Resident #121's refusal of respiratory care/treatments. admitted to the facility on [DATE] with multiple diagnoses that included: Acute and Chronic Respiratory Failure, Retention of Urine and Hemiplegia, Affecting Left Nondominant Side. Review of the resident's medical record showed the following: A physician's orders dated 08/20/24 directed, Suction trach (tracheostomy) BID (twice a day) and as needed. An admission MDS assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderately impaired cognitive status; and received oxygen, suctioning and tracheostomy care while a resident. Physician's orders dated 09/06/24 directed, Trach care BID and PRN (as needed) two times a day for airway management. 09/11/24 at 11:58 PM Respiratory Orders Administration Note: PT (patient) refused trach care and suctioning. 09/17/24 at 4:06 AM Respiratory Orders Administration Note: patient refused trach care and suctioning. 09/18/24 at 11:00 PM Respiratory Orders Administration Note: PT refused. 09/19/24 at 8:19 AM Respiratory Orders Administration Note: Refused. 09/19/24 at10:28 PM Respiratory Orders Administration Note: PT refused. 09/19/24 at6:58 AM Respiratory Orders Administration Note: PT refused. 09/26/24 at 7:32 AM Respiratory Orders Administration Note: PT sleeping did not want to be disturbed. 09/26/24 at 7:32 AM Respiratory Orders Administration Note: Refused. 09/27/24 at 4:44 AM Respiratory Orders Administration Note: Refused. 10/03/24 at 12:57 PM Respiratory Orders Administration Note: pt refused trach/care and suction RN (Registered Nurse) notified. Review of Resident #121's care plan on 10/10/24, there was documented evidence that facility staff developed a care plan to address the resident's refusal of respiratory care/treatments. During a face-to-face interview on 10/04/24 at 11:33 AM, Employee #2 (Interim Director of Nursing/DON) stated, The first time a resident refuses care or treatment, we call their physician and RP to inform them. If the behavior is continuous and ongoing - a care plan should be implemented. Respiratory Therapist (RT) are supposed to communicate any refusals to the nursing care team. The respiratory care plans for residents who have tracheostomies or ventilators is handled by the Respiratory Department. They do the care plans. It has not been communicated to us (nursing staff) that [Resident #121] has been consistently refusing his respiratory care/treatments. During a face-to-face interview on 10/04/24 at 12:00 PM, Employee #17 (Director of Respiratory Services) stated that she took over implementing and revising care plans for residents who have a tracheostomy/ventilator. If a resident is refusing respiratory care/treatments, it is reported to the nursing team and is also documented it in the respiratory notes. If the refusal is consistent, I would need to be made aware to develop a care plan with interventions. I was not made aware that [Resident #121] was refusing respiratory care on a consistent basis. That needs to be addressed, and I will do that now. Cross Reference 22B DCMR §3210.4(a)

2. Review of the facility's Transmission Based Isolation Precautions policy dated May 2024 documented: - Contact precautions (yellow sign) is used for specified residents known or suspected to be infected or colonized with multiple drug-resistant organisms (MDRO) transmitted by direct contact with resident such as hand or skin-to-skin; indirect contact, such as touching environmental surfaces or items in the resident's environment. Resident #277 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertensive Heart and Chronic Kidney Disease, Dependence on Respirator, and Anoxic Brain Injury. A care plan focus area: [Resident #277] has an ADL (activities of daily living) self-care performance deficit r/t (related to) Disease Process, initiated on 09/12/24 had interventions that included: The resident is totally dependent on 2 to 3 staff for dressing, personal hygiene, oral care and for toilet use. A care plan focus: [Resident #277] needs hemodialysis r/t Chronic Kidney Failure, initiated on 09/12/24 had interventions that included: Monitor vital signs every shift. An admission Minimum Data Set (MDS) dated [DATE] showed that facility staff coded: severely impaired cognitive skills for decision making; totally dependent on 2 staff for bed mobility and toilet use and received dialysis while a resident at the facility. A physician's order dated 10/02/24 directed, Maintain contact isolation precautions for Multi-Drug-Resistant Organism (MDRO) Acinetobacter baumannii in sputum and Methicillin-Resistant Staphylococcus Aureus (MRSA) in urine, every shift. A physician's order dated 10/03/24 directed, Dialysis three times a week; Monday, Wednesday and Friday. The following was observed on 10/11/24 on unit 3 east: 9:45 AM - a yellow sign on the outside of Resident #277's door that documented, Contact Precautions. Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. The following was observed on 10/11/24 on the dialysis unit: 9:56 AM - The two employees assigned to Resident #277, Employee #26 (Certified Nurse Aide/CNA) and Employee #27 (Registered Nurse/RN) perform hand hygiene, grab the Hoyer Lyft scale and proceeded to start positioning the Resident #277 onto the scale to be weighed. The surveyor stopped the employee's and asked them why they failed to don personal protective equipment (PPE) prior to performing a task that involved having physical contact with Resident #277, who is contact precautions. Neither of the employees responded and then proceeded to don gloves and gowns to weigh the resident. 9:58 AM - After Resident #277 was weighed, Employee #26 (CNA) passed the Hoyer Lyft to another staff member to use on another resident. The surveyor stopped the employees and asked them why they failed to disinfect the equipment in between resident use. Employee #26 did not respond, and the other employee proceeded to disinfect the Hoyer Lyft. It was at this point that the Employee #28 (Dialysis Nurse) asked the surveyor, What precautions is [Resident #277] on? I was not aware that he was on any isolation. During a face-to-face interview on 10/11/24 at 10:05 AM, Employee #28 stated, The most recent list of isolation precautions I have from the Infection Preventionist is dated 09/06/24 and [Resident #277] is not on this list at all. The evidence showed that facility staff failed to maintain infection prevention and control to help prevent the transmission of communicable diseases and infections as evidenced by failing to don PPE prior to weighing Resident #277, who was on contact precautions and failing to disinfect equipment in between resident use. During a face-to-face interview on 10/11/24 at 10:09 AM, Employee #14 (Infection Preventionist) acknowledged the findings and stated, All equipment should be disinfected in between patient use, regardless of if they are on isolation or not. PPE should be worn for any 'high contact activity' with a resident. When asked what kinds of tasks are high contact activity, Employee #14 stated, Suctioning, bagging, turning and repositioning. Anything where there is the potential for contact and contamination. The employee was further asked why the dialysis nurse had not been made aware that Resident #277 was on contact precautions. Employee #14 stated, She should've been aware, she has access to PCC (Point Click Care/the facility's electronic health record system) and there's a pop-up that comes up every time the resident's chart is accessed. Cross Reference 22B DCMR § 3217.6 Based on observation, record review and interview, for two (2) of 55 sampled residents, the facility staff failed to: (1) follow Infection Prevention and Control measures. As evidenced by, a staff member placing a gallon of tea that was in Resident #8's room who was Enhanced Barrier Precautions in the community refrigerator. 2. maintain infection prevention and control to help prevent the transmission of communicable diseases and infections as evidenced by failing to don PPE prior to weighing Resident #277, who was on contact precautions and failing to disinfect equipment in between use. The findings included: 1. According to Center for Disease Control Prevention, Infection Control Guidance: Candid Auris documented in part, Environmental Disinfection: The fungus has been found on high-touch surfaces, such as bedside tables .Reducing Transmission: Clean and disinfect environment surfaces on a more frequent schedule .thoroughly clean and disinfect the areas in the facility the patient came in contact with . https://www.cdc.gov/candida-auris/hcp/infection-control/index.html Resident #8 was admitted to the facility on [DATE] and had a history of multiple diagnoses, including unspecified candidiasis. A physician order dated 02/12/23, instructed Maintain Enhanced Barrier Precautions for Candida auris. Every shift related to Candidiasis, Unspecified. A care plan dated 02/12/23 documented in part, Problem- [Resident # 8] is on Enhanced Barrier Precautions for colonized multi-drug-resistant organism candida auris on the skin. Interventions .Educate the residents/family/caregivers regarding the importance of hand washing. Use antibacterial soap and disposable towels. Wash hands immediately after ADLs, care tasks and activities . During a medication administration observation on 10/02/24 at approximately 10 AM, Employee #3 (LPN) retrieved a gallon of tea from the community refrigerator per the resident's request to take his medication with tea he had purchased. Rather than bring a cup of tea to the room, she brought a container (gallon) of tea. When putting the tea container on the resident's bedside table, the employee failed to remove items from the table or disinfect the table. After administering the resident's medication, she removed the container of tea from the bedside and returned it to the community refrigerator without disinfecting it. The resident's room also had a sign posted on the door that read in part Stop .Enhanced Barrier Precautions . During a face-to-face interview on 10/02/24 at approximately 10:30 AM, the surveyor was asked by Employee #3 (assigned LPN) whether the container of tea should've been returned to the community refrigerator after being removed from Resident #8's room. The employee was instructed to ask the Administration what the facility's procedure for removing items from a resident's room who is on Enhanced Barrier Precautions. During a face-to-face interview on 10/02/24 at 1 PM, Employee #14 (Infection Preventionist/Director of QAPI) stated that the nurse should not have placed the tea back into the community refrigerator because the resident was on Enhanced Barrier Precautions. The employee then said that she would re-educate employees on the facility's policy and procedure for Enhanced Barrier Precautions and deep-clean the refrigerator.

Based on record review and staff interviews, for one (1) out of 55 sampled residents, facility staff failed to ensure that the resident's preference/choice was honored as evidence by failing to get the resident out of bed and into the Geri chair. Resident #72. The findings included: Resident #72 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Dysphagia, Acute and Chronic Respiratory Failure with Hypoxia, and Dementia. Review of the resident's medical record revealed the following: A face sheet that showed that the resident's son is listed as Responsible Party (RP), care and financial power of attorney (POA); care conference person; and emergency contact #1. An Annual Minimum Data Set (MDS) dated [DATE] showed that facility staff coded: no speech; rarely/never makes self-understood; rarely/never makes understands others; severely impaired cognitive skills for daily decision making; no refusal of care behaviors; functional limitations in range of motion on one side for upper extremity; and was totally dependent on two (2) staff for bed mobility and transfers. 08/15/24 at 11:12 AM Care Conference Note: - Resident's son would like resident out of bed at least 4x a week. 08/15/24 at 12:43 PM Care Conference Note: - Resident's son wants resident to get out of bed 4X/week. Told him we will try to accommodate his request but might not be possible every week. A Care plan focus area: [Resident #72] has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, limited range of motion, revised on 08/16/24, had interventions that included, resident to be up in Geri Chair five times weekly. A physician's order dated 09/25/24 directed, Have resident out of bed to Geri Chair on Tuesday, Thursday and Saturdays. Private duty aide to take resident outside for fresh air. License Nurse to ensure that C.N.A (Certified Nurse Aide) assist with getting resident out of bed to Geri Chair. 10/05/24 at 8:41 PM General Progress Note: - Total ADL care provided. Turned and repositioned every two hours for pressure relief and comfort. - Staff will continue with plan of care and monitor. 10/06/24 at 8:37 PM General Progress Note: - Resident was up in Geri chair this shift and taken downstairs by {pronouns} private aide. - Resident's son visited this shift, and no new complaint made. A Complaint, DC~13186, received by the State Agency on 10/09/24 documented, Problem as been ongoing for a year and a half. The facility is currently experiencing a CNA (Certified Nurse Aide) staffing shortage. On the 3rd floor, only two CNA's are responsible for the care of 30 to 35 patients. This shortage is negatively impacting patient care, leading to staff burnout and causing CNA's to leave their positions. [Resident #72] is nonverbal and nonmobile, and she enjoys being outside. She requires assistance with a lift to be placed in a special chair. Initially, she was being taken outside four times a week, which was later reduced to three times, if possible. Now it is reported that residents, are only going outside once or twice a week, with staff citing a lack of time as the reason. [Anonymous] is questioning how staff cannot spare the 10 minutes needed to assist in placing the resident in her chair, especially when the family is willing to take her outside themselves. No human being should be restricted from going outdoors. The family even pays for a private aide . Another issue is that CNA's are frequently pulled away from their duties on the 3rd floor to transport residents to the dialysis unit on the first floor. This raises concerns about the care of the other residents who are not receiving dialysis. Why is there insufficient staffing to cover both the dialysis transport and the care of the other residents? Medicare patients are being neglected for 6 hours, three days a week. During this time, they are not being changed or fed in a timely manner. While the facility itself is clean, and the nurses and doctors do their jobs well, the management, particularly upper management, is falling short in addressing these critical staffing and caring issues. During a face-to-face interview conducted on 10/10/24 at 3:10 PM, [Anonymous] stated, there is understaffing with CNAs that has led to push back in getting [Resident #72] outside for fresh air. Management has stated that they can only transfer her to the chair 4 times a week, then it decreased to now, three days a week. Residents should be allowed to go outside if that is their preference. They are taking CNAs from the floors to transport people to dialysis, and they stay there a long time. In turn, leaving the floors understaffed. This issue has been brought to management, and they say they just don't have the staff. Now we are settled, for now, on getting my mom up in the chair and outside, 3 days, the non-dialysis days, Tues, Thurs, Sat. This past Saturday (10/05/24) and the staff refused to get [Resident #72] out of bed. It feels like these residents are being warehoused and that's not right. During unit tour on 10/11/24 at 9:05 AM, [Resident #72] was observed lying in bed and had a sign over her bed that documented, 9/18/24 On Geri-Chair Schedule Tuesday Thursday Saturday. During a face-to-face interview on 10/11/24 at 2:50 PM, Employee #4 (3 East Unit Manager) stated, We (facility staff and resident's son) agreed on a contract with the son to get her out of bed, which was before we had dialysis residents on the unit. Lately, because of the dialysis residents, the nurses and CNAs have to take residents to dialysis and then go pick them up. The son has voiced the concerns to me and Employee #1 (Administrator). We talked about it, me, him, [Employee #1] and said we'd make sure [pronouns] gets up on the non-dialysis (Tues, Thurs, Sat) days and that [pronouns] is up early enough to be able to go outside. It's a lot on the nursing staff to do on the dialysis days. It was brought to the employee's attention that Resident #72 did not get out bed and into the chair on Saturday (10/05/24), a non-dialysis day. Employee #4 stated that [pronouns] was not aware that the resident was not put into the Geri chair and further stated, I follow up with staff and the private care giver to make sure we are not missing a day. When asked on Monday (10/07/24), the staff said she got up over the weekend. I don't know which day it was, but it should've been on Saturday. During a face-to-face interview on 10/11/24 at 3:25 PM, Employee #1 reviewed the nursing assignment for unit 3 east and stated that there were three (3) nurses, two (2) CNAs and two orienting CNAs on the unit for the day shift, 7:00 AM - 7:00 PM, with a resident census of 28. During a face-to-face interview on 10/11/24 at 3:45 PM, Employee #5 (assigned CNA for Resident #72 on 10/05/24, day shift) stated, I had an emergency and had to leave around 12:15 PM. I am not sure if anyone else came over to replace me. It was a hectic that morning, it was just the two of us. I had not provided her (Resident #72) ADL care before having to leave. During a face-to-face interview on 10/11/24 at 3:54 PM, Employee #6 (Registered Nurse/RN, assigned to Resident #72 on 10/05/24, day shift) stated, They (facility management) did not send someone to replace the CNA that left. The nursing supervisor came to help us and that's how we provided patient care that day. [Resident #72] did not get out of bed that day. We were too busy on the floor. The evidence showed that facility staff failed to ensure that the resident's preference/choice was honored by not getting Resident #72 out of bed and into the Geri chair on a non -dialysis day, Saturday, 10/05/24. Cross Reference 22B DCMR § 3269.1(h)

Based on observation, record review, and staff interviews, for one (1) of 11 sampled residents, the facility staff failed to ensure that Resident #1, who was at risk for falls, received adequate supervision during an episode of confusion with aggressive behavior as evidenced by the resident having a witnessed fall with injury. Actual harm was determined for Resident #1 on 03/14/2024. The findings included: Policy: Safety and Supervision of Residents last revised on July 2017, System Approach to Safety: - The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. - Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. - The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Age-Related Physical Disability, Unspecified Fall sequela, Unspecifid Fracture of Right Femur sequela, Hypertension, Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of Resident #1's medical record revealed the following: A physician's order dated 05/05/22 directed, Fall and safety precaution every shift. A focus care plan problem with a start date of 08/24/22 showed, [Resident name] is risk for falls r/t (related to) Confusion, Incontinence, Unaware of safety needs. Resident had actual fall 09/12/23. Interventions included, anticipate and meet the resident's needs. Morse Falls Risk assessment dated [DATE] showed: Resident#1 had fallen before. - Ambulatory aid: none/bedrest/wheelchair/nurse assistant. - Gait: Impaired (difficulty rising from chair, uses arms to get up, bounces to rise, keep head down when walking, watches the ground, - Grasps furniture, person or aid when ambulating - Mental status: overestimates or forgets limit. A Quarterly Minimum Data Set (MDS), with an Assessment Reference dated 02/02/24 documented the following: - Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 06, indicating severe cognitive impairment. - Section GG (Functional Status) - Mobility:01- Dependent (helper does all of the effort to complete the activity); Resident coded 01for chair/bed-to-chair transfer (the ability to transfer to and from a bed to a wheelchair); 88-Activity not attempted due to medical condition and safety; Resident coded 88 for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). - Section J (Health Conditions), 0 fall since admission/entry/reentry (05/04/22). A focus care plan problem with a start date of 02/29/24 showed: [Resident #1] had an episode of kicking and hitting, and had interventions that included, frequent rounding with turning and repositioning every two hours. Review of a Complaint, DC~12580, received by the State Agency on 03/14/24 documented: - I received a call from [Registered Nurse's name] reporting that grandma has fallen with bleeding head injuries. A Situation Background Assessment Request/Recommendation (SBAR) Communication Form dated 03/14/24 at 8:11 AM documented: Mental status change: Increased confusion, new or worsening behavioral symptoms. Assessment: 'Writer observed getting out of the chair, writer quickly trying to catch up with resident, by the time I trying to reach, she already on the floor.' Nursing note: Resident was noted with increase[d] agitation at 6:00 am trying to get out of bed on multiple times, resident was transfer[ed] to the wheelchair and placed at the nursing station for close monitoring, while [writer was] on the computer documenting, resident was getting out of the chair again, writer quickly trying to catch up with, by the time I reached her she was already on the floor, with laceration on the right side of her forehead, ice pack and pressure dsg [dressing] was applied. A Nursing Progress Note dated 03/14/24 at 8:51 AM documented, Writer received report from assign nurse, that resident fell on right forehead while sitting on wheelchair at 3 west nursing station' staff informed to follow facility protocol for fall. Resident observed with laceration on right forehead clean and covered with 4x4, call place to [Dr. Name], order receive to transfer resident to ER (emergency room) for further evaluation, non-emergency van called unable to get appointment, 911 call and pick up resident to [hospital name] around 8am. A Nursing Progress Note dated 03/14/24 at 10:19 AM documented, Resident was noted with increased agitation at 6:00am trying to get out of bed on multiple times. Resident was charged and offered water, and repositioned, Resident continued to yell and climbing out of bed. When asked what was going on? Resident continued to yell and kick. At 6:20am the resident was transferred to the W/C (wheelchair) and placed at the nursing station for close monitoring. Resident continued to get up from the wheelchair multiple times with anxiety. And was repositioned in the wheelchair so many times. At 6:30am, while the nurse was at the nursing station charting, resident got up the 4th time, before nurse could get to the resident, resident was on the floor on her right side, resident was noted with abrasion, pressure, icepack and dsg (dressing) applied. VS (vital signs) T (temperature) 97.6, P (pulse) 78, R (respirations) 18, B/P (blood pressure) 130/70, SPOX (oxygen saturation) 97, F/S (fingerstick) 152 MG/DL (milligrams/deciliter) taken, ROM (range of motion) exercise done able to follow command. Pain medication acetaminophen administered per order. Resident was assisted off the floor [Dr. Name] made aware order to transfer Resident to ER (Emergency Room) for evaluation RP [Responsible Party name] made aware. A Nursing Progress Note dated 03/14/24 at 12:19 PM documented, Writer informed that resident was restless and agitated and repeatedly attempting to get out of bed. Staff reported they brought resident to the nursing station for closer monitoring and had to repeated redirect resident to prevent fall. However, while staff was documenting at the end of shift, resident had a fall with a bruise/laceration to right side of head. Per reports, [Doctor's name] ordered resident to be transferred to the hospital and resident was transferred to (hospital name). Writer notified RP (responsible party name), that resident was transferred and was also updated that a CT (Computed Tomography) scan was negative. Nursing will continue monitoring resident upon return. Psych consult ordered for further evaluation. Radiology Report dated 03/14/24 at 3:41 PM documented, XR [x-ray right/hand; Findings: There is an acute, minimally displaced fracture of the distal head of the 2nd metacarpal. A Nursing Progress Note dated 03/14/24 at 4:17 PM documented, Resident returned from [hospital name] around 1500 (3:00 PM). Head-to-toe assessment done with primary nurse. Resident repositioned and made comfortable. Upon assessment, right hand in splint with laceration on right facial laceration. [RP Name], visiting and updated on interventions including [Dr. Name]'s notification to evaluate resident. Psych consult done. [Dr. Name], orthopedic consulted per d/c (discharge) recommendations. Wound consult done. He verbalized understanding but stated don't give my grandmom pain medication unless she is screaming and only Tylenol. Resident states she does not have pain at rest, only when moved and on her right lower extremity. Resident on Tylenol PRN [as needed]. Nursing to continue monitoring and implementing fall precautions. A Physician Progress Note dated 03/18/24 at 11:49 AM documented: - S/p (status/post) fall on 3/14 (March 14, 2024). - Treated in ER for facial laceration and right minimally displaced fracture of 2nd metacarpal. During a facility tour on 03/19/24 at 10:30 AM, Resident #1 was observed in bed with a bruise/laceration to the right side of her forehead. During a face-to-face interview on 03/19/24 at 11:15AM Employee #2 (Director of Nursing/DON) stated that if a resident is at risk of falling or had a fall, they are placed on frequent monitoring. When asked what she meant by Frequent monitoring, she stated, Everyone including the housekeeping and EVS (environment service) staff looks and checks on the resident. During a face-to-face interview on 03/20/24 at 1:00 PM, Employee #5, (Certified Nursing Assistant/CNA) who was assigned to care for and monitor Resident #1, was asked where she documented that she was monitoring Resident #1. The employee brought three forms titled Q (every) 2 hr (hour) Rounding Sheet dated from 03/11/24 to 03/20/24 that did not document Resident #1's name. The first form displayed another resident's name. The second form displayed the same resident's name with a line drawn through it. The third form lacked documented evidence of a resident name. When asked why Resident #1's name on the frequent monitoring forms dated 03/11/24 to 03/19/24, Employee #5 failed to provide an answer. During a telephone interview conducted on 03/21/24 at 2:05 PM Employee #4 (Licensed Practical Nurse/LPN), who was assigned to Resident #1, stated, The resident's chair could not come into the nursing station where I was seated so, the resident was seated outside of the nursing station where she was being monitored. I was monitoring the resident when she got up from her wheelchair and fell on the floor before I could get to her. Blood was coming out from her right forehead. Other staff were in their assigned rooms taking care of other residents. I was by myself. An observation made by the Surveyor on 03/21/24 at 2:15 PM of the nurse's station where Employee #4 stated she was seated and where Resident #1 was seated, showed that the nurse and the resident were not within arm's length of each other. In order for the nurse to reach the resident, she would have had to get up from her chair, walk around the side of the nurse's station desk, to the front of the desk. During a face-to-face interview on 03/21/24 at 2:50 PM Employee #2 (DON) stated, Resident #1 was on frequent monitoring and was moved to close monitoring when she became aggressive and was climbing out of the bed. We do not do 1:1 [one-to-one] monitoring. We do close monitoring. Close monitoring is when the at-risk resident's behavior threatens their safety, they are brought to areas such as the nursing station to be monitored. The employee further stated that close monitoring means that the resident and the facility staff are within arm's length of each other. Of note, the facility had no written policy relating to close monitoring. During a face-to-face interview conducted on 03/21/24 at 3:15 PM, Employee #2 (Director of Nursing) acknowledged the finding and stated, The resident was brought to the nursing station for close monitoring but where the nurse was seated, she could not reach the resident who stood up out of her wheelchair and fell to the floor. We will educate staff on the process for closely monitoring residents.

Based on record review and staff interviews, for three (3) of eight (8) sampled residents, facility staff failed to 1. review physician's orders in advance of administering cardio pulmonary resuscitation to a resident who had a physicians order stating Do Not Resuscitate (Resident #4), 2. ensure one resident was not delayed care and treatment for an injury of unknown source (Resident #7), and 3. implement one resident's care plan intervention and physician's order of having floor mats at her bedside for fall/safety precautions (Resident #8). These failures resulted in actual harm for Resident #4 and #7. The findings included: 1. Review of the policy Advance Directives revised in [DATE] documented, .A resident will not be treated against his or her own wishes .Do Not Resuscitate indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, heath care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used . Resident #4 was admitted to the facility on [DATE] with multiple diagnoses that included: Subarachnoid Hemorrhage, Encounter for Tracheostomy, Fracture of Sixth Cervical Vertebra and Weakness. Review of Resident #4's medical record revealed the following: [DATE] [physician's order] Full Code (discontinued on [DATE]) [DATE] at 1:55 PM [Psychosocial Note] In review of residents advanced directives that have been provided by the family. Resident wishes are to be a DNR writer explained directives to family residents code status will be changed to DNR physician will be made aware. DC (District of [NAME]) Medical Orders for Scope of Treatment (MOST) form signed and dated on [DATE] documented, .Do Not Attempt Resuscitation (DNAR)/Allow Natural Death (AND) . Care Plan focus area initiated on [DATE] [Resident #4]'s end of life wishes remain a DNR . with interventions that included: .Document in medical record .honor spiritual and cultural wishes . Misc (Miscellaneous) tab of the electronic health record (EHR) showed that Resident #4's MOST form and Advance Directive documents were uploaded on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderately impaired cognition and was totally dependent with two person's physical assist for personal hygiene. [DATE] [physician's order] DNR (Do Not Resuscitate) [DATE] at 2:04 PM [Care Conference Note] IDT (interdisciplinary team) met with .residents family to review plan of care. Residents current condition remains stable resident remains vent dependent and DNR all documentation is on medical record . [DATE] at 1:30 PM [Change in Condition Note] Around 12:07 PM, Resident' wife at the bedside requested patient to be changed as he had BM (bowel movement). Assigned aide presented to room [ROOM NUMBER]B and the patient's wife and the daughter stepped out so patient can be changed .nursing assistant observed that resident was not breathing and nursing assistant called charge nurse immediately. Upon notification, the assigned nurse assessed patient and notice no pulse, no respiration .One nurse checked code status and resident was noted to be full code from the patient's face sheet in the resident's chart; Rapid response called, Code blue called, at 12:10 PM CPR initiated, 911 also called immediately. At 12:16 pm Paramedic arrived to the facility, then staff turned over CPR to paramedic. Upon reassessment by paramedics patient noted with pulse and respiration. Resident transported to [Hospital Name] ER (emergency room ) at about 1:00pm . Review of a Complaint, DC00011342, received by the State Agency on [DATE] documented, .concerns . [Resident #4] .had mittens on his hands and could not use the call light. He had a massive bowel movement .She [Resident #4's daughter] went to the nurse station to request someone to assist and clean her father. She and her mother waited in the hall about ten minutes passed when they heard a rapid response called to her father's room .that later turned to a code blue. CPR was performed, and her father was revived, but he had a DNR and advanced directives. She states that both were on file with [Facility name] . During a telephone interview conducted on [DATE] at 9:15 AM, Employee #3 (assigned Registered Nurse on [DATE]) stated, I was the nurse for that patient [Resident #4] that day ([DATE] - day shift). The family was in the room, the wife and daughter, and wanted him cleaned up and changed, so I told the CNA (Certified Nurse Aide). The CNA went in to clean him while the family waited outside the door. The CNA came and told me that he looked off. I went to the room and saw that his color was off and was having difficulty breathing. I yelled for my colleague (Employee #5/Registered Nurse) to check his code status and to call a rapid response while I started CPR. My colleague said she was having trouble logging into the computer, so she checked his face sheet and it said full code. The rapid response then turned into a code blue. Employee #3 further stated, I normally go over each patient chart in my care to know their code status and any other important information at the start of my shift but that day ([DATE]) it was not done. We were short [staffed]. It was two (2) nurses instead of the usual four (4). If I knew he was a DNR, I would have stopped giving him CPR. Even if the family insisted on doing everything to save him, I would have reminded them of the patient wishes to be DNR. During a face-to-face interview on [DATE] at 10:27 AM, Employee #4 (Social Worker) was asked who is responsible for updating the resident's physical chart when there is a change in code status or Advance Directives (AD). Employee #4 stated, It's a joint effort between Social Services, nursing and the unit clerks. Employee #4 was then asked what the process is for when there is a change in a resident's code status/AD. Employee #4 explained, On admission and as needed, code status is discussed with the resident, their family and the medical doctor. Once a decision is made, it is entered on the homepage in PCC (Point Click Care- facility's electronic health record system), the doctor writes the order, the MOST form is placed in the Advanced Directives section of the physical chart and the unit clerk prints out the new face sheet with the updated code status displayed at the bottom. The documents are uploaded into PCC and the originals are kept in the physical chart. Employee #4 was asked who audits resident face sheets to ensure that the code status reflected is accurate. Employee #4 stated, There's no regularly audit that is done but once a code status changes, it [face sheet] should be checked for accuracy. When asked if Resident #4's face sheet was checked for accuracy, Employee #4 stated, No. I didn't check his face sheet to see if it was changed after he became a DNR (on [DATE]). During a telephone interview conducted on [DATE] at 11:15 AM, Employee #5 (Registered Nurse) stated, The patient [Resident #4] was found unresponsive and his nurse [Employee #3] asked me to check his code status. I was at the nurse's station and PCC was taking a long time to log me in. I looked in the physical chart and the face sheet showed 'full code'. I didn't check the Advance Directive section of the [physical] chart. Employee #5 was asked at what point they were aware that Resident #4 had a DNR order. Employee #5 stated, The resident was revived and was getting ready for transfer to the hospital. When the ambulance came to take him, they [Emergency Medical Service/EMS] needed copies of documents and we handed him the [physical] chart and that's when he saw the paper that said DNR, but I don't remember what paperwork it was that EMS saw. During a face-to-face interview conducted on [DATE] at 2:00 PM, Employee #2 (Director of nursing/DON) acknowledged the findings and made no further comments. 2. Review of the policy Imaging Service revised in [DATE] documented, . The Radiologist must communicate critical findings to the ordering physician or designee as soon as critical finding is identified . Upon completion of dictated report, the transcribed report is auto-transmitted to the Imaging Services department where it is printed and downloaded by the technologist and placed into the EMR (Electronic medical record) within 24 hours of being read . Resident #7 was admitted to the facility on [DATE] with multiple diagnoses that included: Osteomyelitis of Vertebra Sacral and Sacrococcygeal Region, Multiple Sclerosis (MS), Protein Calorie Malnutrition, Quadriplegia, Encounter for Attention Tracheostomy and Gastrostomy. Review of Resident #7's medical revealed the following documentation: Care Plans: Focus area [Resident #7] has an ADL (activities of daily living) self-care performance deficit r/t (related to) limited mobility, immobility, chronic respiratory failure, advanced MS initiated on [DATE] had an intervention of; .The resident requires skin inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse Physician's orders: [DATE] Turn and reposition every 2 hours and as needed for comfort and to prevent pressure injury A Quarterly MDS dated [DATE] showed facility staff coded: a cognitive skills for daily decision making score of 3, indicating severely impaired; required extensive assistance with one person physical assist for bed mobility and dressing; required two plus persons physical assist for transfers; was totally dependent with one person physical assist for toilet use, dressing and personal hygiene; had functional impairment on both sides for upper and lower extremities; had an indwelling catheter; always incontinent of bowel; received scheduled and PRN (as needed) pain medications; received non-medication intervention for pain; no falls since admission; and had six (6) Stage 4 pressure ulcers. [DATE] [physician's order] Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube every day shift for pain 60 minutes before wound treatment [DATE] at 9:30 AM [Pain Level Summary] Value 8; Scale Numerical [DATE] at 9:30 AM [Administration Note] Oxycodone HCl Tablet 5 MG .for pain noted facial grimaces [DATE] at 1:15 PM [Nursing Daily Skilled Charting] .No distress and no discomfort noted . [DATE] at 4:33 PM [Progress Note- MD .(Medical Doctor) ./NP (Nurse Practitioner)] .37 yo (year old) male with advanced MS, anemia, DVT (deep vein thrombosis) of LLE (left lower extremity) .Opioid dependency -decline expected -pain control while on prn Oxycodone, Fentanyl patch .assess nonverbal cues for pain . Left leg DVT -continue Eliquis (blood thinner) . [DATE] at 4:42 PM [Administration Note] Oxycodone .was effective. [DATE] [physician's order] Venous Doppler of B/L (bilateral) lower extremities one time only for eval (evaluation) DVT for 3 Days [DATE] at 3:47 PM [Nursing Daily Skilled Charting] . Orders: Venous Doppler on B/L (bilateral) lowers extremities . [DATE] at 4:26 PM, the Medication Administration Record (MAR) showed facility staff initialed to indicate a new Fentanyl Patch 72 hour 50 MCG/HR was applied. [DATE] at 7:45 PM [Pain Level Summary] Value 8; Scale numerical [DATE] at 7:45 PM [Administration Note] Oxycodone HCl Tablet 5 MG .for pain. [DATE] at 11:25 PM [Administration Note] PRN Administration was: Effective; Follow-up Pain Scale was 0 [DATE] at 8:15 AM [General Progress Note] Resident received in bed .Routine care provided .Turned and repositioned every 2 hours and prn .Doppler of LE (lower extremity) faxed to be done . [DATE] at 8:48 AM [Progress Note - MD .NP] .noted to have new onset right thigh swelling. Venous Dopplers ordered yesterday but results not available .Right thigh swelling-new onset, will need to get Venous Doppler results ASAP (as soon as possible). Add Xray of right femur and right hip .Monitor for increase swelling . [DATE] at 8:54 AM [Pain Level Summary] Value 4; Scale PAINAD (Pain in Advanced Dementia) [DATE] at 8:54 AM [Administration Note] oxycodone HCl Tablet 5 MG .given for gen (general) pain [DATE] at 10:00 AM [Administration Note] PRN Administration was: Effective [DATE] at 3:24 PM [physician's order] Xray right hip and right femur STAT for localized swelling of right thigh [DATE] at 4:48 PM [Nursing Daily Skilled Charting] .X-ray rights right lower extremity [DATE] at 5:08 PM [X-ray results] Exam type Femur .two frontal views femur radiographs .findings there is complete transverse oblique proximal femoral diaphysis fracture with overlap, and elevation of the femoral shaft . Electronically signed by [Radiologist Name] [October] 08, 2022 17:08 (5:08 PM) . [DATE] at 5:10 PM [X-ray results] Exam type Hip . Addendum findings are called to housestaff officer at [Facility Name] at the time of this dictation by 5:15 P.M. [DATE]. Electronically signed by [Radiologist Name] ([DATE] 17:16 (5:14 PM) .End addendum .two frontal view right hip radiographs .findings there is complete transverse fracture through the proximal femoral shaft laterally towards the femoral head level . Osteopenia is identified suggest disuse .Electronically signed . [DATE] 17:10 (5:10 PM) . [DATE] at 7:01 PM [SBAR (situation background assessment request) Communication Form .] .right lower extremities Swollen and [painful] .Resident was noted to have right hip swollen and [painful]during care .NP in house was made aware and she came to assess resident in room. New order was noted for X-ray, which was done and awaiting results Pain meds given as ordered. with effective results. [DATE] at 7:48 PM [PAINAD] Description - Initial; Score 5.0 . Review of unit 3 East 24 hour summaries document for [DATE] showed no documented evidence that facility staff followed up with the radiology department regarding Resident #7's x-ray results. [DATE] at 12:12 PM [Pain Level Summary] Value 7; Scale PAINAD [DATE] at 12:12 PM [Administration Note] Oxycodone HCl Tablet 5 MG .pain med (medication) given [DATE] at 4:00 PM [Pain Level Summary] Value 9; Scale PAINAD [DATE] at 4:00 PM [Administration Note] Oxycodone HCl Tablet 5 MG .pain med given [DATE] at 6:56 PM [Administration Note] PRN Administration was: Effective; Follow-up Pain Scale was: 0 Review of unit 3 East 24 hour summaries document for [DATE], showed no documented evidence that facility staff followed up with the radiology department regarding Resident #7's x-ray results. [DATE] at 4:12 PM [Progress Note - MD .NP] . f/u (follow up) right thigh swelling- [x-ray] ordered on ,d+[DATE]. Results not available for review. Discussed with nurse who contacted radiology. Xray was completed and they stated that they would fax over results. Patient seen today. Right thigh remains swollen and tender touch. No injury or falls reported .Right thigh swelling-first noted on [DATE] . Awaiting results of Xray and Doppler's ordered to proceed with plan of care. Monitor for increase swelling . [DATE] [physician's order] Please obtain .Xray results ordered of right leg ASAP; Notify .provider on call with results today . [DATE] at 6:22 PM [General Progress Note] . Alert, non-verbal, but responsive to touch with no apparent sign of acute change noted in condition .ADLs care provided . Multiple dressing done as per order. Turned and repositioned, made comfortable in bed . Review of the Misc (miscellaneous) section of Resident #7's electronic health record (EHR) showed that the x-ray results were uploaded on [DATE] (no time indicated) by Employee #9 (Radiology Technician). Review of unit 3 East 24 hour summaries document for [DATE], showed no documented evidence that facility staff followed up with the radiology department regarding Resident #7's x-ray results. Review of Resident #7's [DATE] Treatment Administration Record (TAR) showed that facility staff initialed to indicate the following tasks were completed daily from [DATE] through [DATE]: Left ischium wound dressing change, left trochanter wound dressing change, right ischium wound dressing change, float heels with pillow continuously while in bed, leg strap to stabilize Foley catheter, turn and reposition every 2 hours; facility staff initialed to indicate the following tasks were completed on [DATE] and [DATE] at 10:00 AM: right lateral malleolus wound dressing change; and facility staff initialed to indicate the following tasks were completed on [DATE] at 10:00 AM, sacral injury wound dressing change. Review of Resident #7's [DATE] Certified Nurse Aide (CNA) documentation showed that from [DATE] through [DATE], facility staff initialed to indicate that the following interventions/tasks were performed daily: dressing and personal hygiene. Review of a facility reported incident, DC00011023, received by the State Agency on [DATE] documented, . On [DATE] resident noted to have right hip swollen and painful during care .orders for X-ray of right femur and right hip .Nursing continued to monitor resident and administer pain medication as needed. X-ray results conclusion- Positive for complete transverse oblique fracture through the proximal femoral diaphysis . Osteopenia is identifiable suggest disuse. [DATE] [Medical Doctor's Name] notified per nurse notes . stated he will see the patient in am (morning) of [DATE] to make proper medical decision. Orders received on [DATE] from NP (Nurse Practitioner) .to transfer resident to the hospital due to fracture . Further medical record review revealed the following: [DATE] at 12:47 AM [General Progress Note] Received resident X-Ray result of hip and femur .There is a transverse oblique proximal diaphysis fracture with overlap and elevation of the femoral shaft . [Medical Doctor] was made aware of these finding. Resident was assessed and pain medication given for possible pain and discomfort. Lying in bed with body in a relaxed position at this time . [DATE] at 4:09 AM [SBAR Communication Form .] .Situation - X-Ray result of hip and femur shows transverse oblique proximal diaphysis fracture with overlap and elevation of the femoral shaft .swelling of the right hip .Pain meds given for pain and comfort with good effect. [Medical Doctor] was made aware of these finding . [DATE] at 7:22 AM [General Progress Note] [Medical Doctor] will be coming to evaluate patient. [DATE] at 7:37 AM [General Progress Note] [Medical Doctor] was notified of patient X-Ray result. MD informed writer that he will see patient this morning to make proper medical decision. [DATE] at 9:36 AM [Progress Note - MD .NP] .Assessment Date and Time: [DATE] [at] 0912 (9:12 AM) . Received report of X-rays of hips: Positive for complete transverse oblique proximal femoral diaphysis fracture, with overlap, and elevation of the fractured femoral shaft laterally and superiorly . [DATE] [physician's order] Please send patient to ER for eval/management .There is complete transverse fracture through the proximal femoral diaphysis with elevation of the femoral shaft laterally towards the femoral head .STAT . [DATE] at 3:38 PM [General Progress Note] X ray results 2 views of the right thigh received by the previous shift, addressed by [Medical Doctor] and [Nurse Practitioner] respectively during the previous shift. Order was given to transfer resident to the ER for further evaluation . Resident left the unit at 1350 (1:50 PM) via stretcher . Review of a Complaint, DC00011027, received by the State Agency on [DATE] documented, This patient [Resident #7] has advanced multiple sclerosis and is vent dependent (has a tracheostomy) .presented from [Facility Name] with a right hip fracture. This is highly concerning because he is bed bound and it is unclear how this injury could have happened . It's also concerning that the reported fracture happened on [DATE] and he didn't present to the ED until [[DATE]]. Resident #7's hospital discharge summary dated [DATE] at 6:36 AM documented, .Hospital course .x-rays confirmed a R (right) sub trochanteric femur fracture and ortho (orthopedic) was consulted and underwent a R femur cephalomedullary nail insertion (surgical stabilization of a fracture) on [DATE] . During a face-to-face interview on [DATE] at 4:21 PM, Employee #10 (Director of Radiology) was asked what their process is for when an x-ray requisition is received. Employee #10 explained, Requisitions get faxed and called in by the clinical staff to our department. STATS [orders] get done usually within half an hour. On [DATE], the tech (technician) was on the unit at 4:18 PM to do the x-ray [for Resident #7]. For STAT orders, the results take 30 minutes to an hour to get read by the radiologist and can take up to 24 hours for routine [orders]. Once the results are read and signed off by the radiologist, they get uploaded into PCC (Point Click Care- the facility's electric health record system). The process is to upload the results immediately once they are received. Critical findings are called in to the clinical staff by the radiologist. Employee #10 further explained, After 4:30 PM, there is no x-ray tech in house; there's someone on call until the next day when a tech comes in for a regular shift. Any results that are read after 4:30 PM would not get uploaded until the following day. When asked why Resident #7's x-ray results from [DATE] (Saturday) were not uploaded into his EHR until [DATE], 2 days later, Employee #10 stated that he did not know. Whoever came in on [DATE] should have uploaded the results into PCC. On [DATE] at 10:10 AM, a face-to-face conference was held with Employee #2 (Director of Nursing/DON), Employee #8 (Regional Director of Clinical Operations) and Employee #11 (Infection Preventionist/Quality Assurance). Employee #2 stated, The process for getting lab or x-ray results is to look in PCC under 'Results' tab for labs and 'Misc' for x-rays. If there is any delay in getting results, especially STAT orders, the nurse must call and follow-up with the lab team or x-ray to determine the cause of the delay and document it. Nursing is aware that after 4:30 PM, the radiology techs are on call until the next day. The radiology schedule and on-call list is posted at all the nursing units. The nurse's know they are to call to follow-up for x-ray results that are not reflected in PCC. When asked if the facility's investigation determined that Resident #7 was delayed in getting proper treatment, care and services in accordance with professional standards of quality and practice, Employee #8 stated, Yes. The investigation saw there was delay in the resident getting care based on the time line of [x-ray] results being known by the nurses. It should be noted that there no interviews were conducted with any of the radiology staff (technician on duty on [DATE] or the radiologist on duty on [DATE]) as part of the facility's investigation. During a telephone interview on [DATE] at 9:50 AM, Employee #9 (Radiology Technician) stated, The process is at the beginning of the shift, you log in 'Med Anywhere (browser based medical management system) ', type in a patient's name and check to see if the x-ray results from the previous day or on your shift have been read by the radiologist. If they have not been read, we call the radiologist to follow-up, especially for GI (gastrointestinal) images of feeding tubes. If the results have been read and signed, we save the image and attach it to the resident's chart in PCC. That's what I did when I came in on Monday ([DATE]); I saw the results were not in the system so I went into Med Anywhere, got the results and uploaded them to the patient's chart. Employee #9 was asked if he remembered around what time he uploaded Resident #7's x-ray results into PCC. The responded, Monday through Friday I work 8:00 AM to 4:30 PM, so any x-ray results were most likely uploaded at the beginning of my shift an but definitely before I left at 4:30 PM. If the computer system isn't working, I'd call IT (information technology) help desk and let them know and then walk over a copy of the results to the nursing unit to put in the residents [physical] chart. We do not fax results. The employee also stated that he didn't know why the employee who worked on [DATE] failed to upload Resident #7's x-ray results to his electronic medical record. 3. Facility staff failed to implement Resident #8's care plan intervention and physician's order of having floor mats at her bedside for fall/safety precautions. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Weakness, Muscle Spasm, Acute and Chronic Respiratory Failure. Review of Resident #8's medical record revealed: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderately impaired cognition; no behavior symptoms; required extensive assistant with one person physical assist for bed mobility and personal hygiene; was totally dependent with one person physical assist for toilet use; functional impairment in range of motion for both lower extremities; did not use any mobility devices; had an Ostomy appliance for bowels; always incontinent of bladder; and no falls since admission/reentry of prior assessment. Review of a Facility Reported Incident (FRI), DC00011236, received by the State Agency on [DATE] documented, On [DATE] at 04:10 am, resident was observed lying on the floor near the beside in a supine position. Resident stated that she was trying to go and turn off stove and get coffee. Patient has mild confusion .Ordered bilateral X-Ray of the legs/hips due compliant of mild pain . Further review of Resident #7's medical record revealed the following: [DATE] at 4:10 AM [SBAR (situation background assessment request) Communication Form .] .Situation unwitnessed fall lying on the floor beside her bed, assessment done transfer with Hoyer lift, complain of pain to bilateral legs/hips .Resident noted lying on the floor beside her bed. Stated that I want to turn off the stove, to go and get coffee in the kitchen. Complain of pain to lower extremities legs/hips. Alert and oriented with intermitted confusion. Neuro check initiated per facility protocol .X-Ray order STAT for bilateral hips/legs . [DATE] at 4:17 PM [X-ray results] . bilateral hips .findings moderately displaced fracture of the left proximal femur . [DATE] at 4:52 PM [X-ray results] .right knee .moderately displaced fracture of the distal femur . [DATE] [physician's order] Transfer resident to ER for evaluation S/P (status/post) fall with fractures Care plan focus area [Resident #8] has had actual fall . revised on [DATE] had the following intervention .Floor mats to the floor to minimize fall related injuries . [DATE] [physician's order] Place floor mat by resident's bedside bilaterally every shift related to . fall. During an observation on [DATE] at 2:01 PM, Resident #8 was observed in her room, in bed but there were no floor mats noted on either side of her bed. During a face-to-face interview conducted at the time of the observation, Employee #12 (Registered Nurse assigned to Resident #8) reviewed Resident #8's physician's order and care plan, acknowledged the findings and stated, I was not aware that [Resident #8] is supposed to have floor mats. I will call and get them now. Cross reference: 22-B DCMR sec. 3211.1

Based on a review of clinical records, facility documentation, facility policies, and resident and staff interviews, for one (1) of 44 sampled residents, the facility's staff failed to prevent and protect Resident #105 from psychological and physical abuse by Employee #5 and because of the Employee's employment history, there is a likelihood of the employee abusing other residents. Due to these failures, an immediate jeopardy situation was identified on September 8, 2021 at 1:55 PM. The facility submitted a plan of action to the survey team that was on onsite at 7:32 PM on September 8, 2021, and the plan was accepted. The survey team returned on September 16, 2021 to validate the facility's plan, and the immediate jeopardy was lifted on September 16, 2021, at 7:52 PM. After removal of the immediacy, the deficient practice remained at a harm level and the scope and severity was lowered to an H. The findings include: Review of the facility's policy entitled, Abuse Investigation and Reporting with a review date of 08/2020 revealed, . The administrator will ensure that further potential abuse, neglect exploitation or mistreatment is prevented . Review of the facility's policy entitled, Abuse and Neglect- Clinical Protocol with a review date of 08/2020 revealed, . The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect . Facility staff failed to provide a safe environment to prevent and protect Resident #105 from the likelihood of abuse from Employee #5. Resident #105 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/19/2021 a complaint was received by the State Agency that documented, [Resident #105 . reported to the Ombudsman . on the night of August 18th [2021] the nursing Aide stuffed [Resident #105's] brief with pieces from a chuck (incontinence pad) and said 'I am not changing you again tonight' . Review of a memo from Employee #1 (Administrator) dated 08/24/2021, documented, . We interviewed the staff and other residents on the unit (3 west) along with examining the medical chart. The abuse and neglect investigation has concluded, and it was determined from the investigation there was no evidence presented to prove abuse and neglect was committed towards the resident [Resident #105] in question. Therefore, the case has been unsubstantiated due to these findings. On 08/27/2021, a complaint was received by the State Agency that documented, [Resident name] .The residents daughter reported to the Ombudsman . C.N.A. (Certified Nurse's Aide) . told the resident 'she caused him three days of pay, and that she talks too much. Review of Resident #105's Significant Change Minimum Data Set (MDS) dated [DATE], revealed that facility staff coded the following: · In Section C (Cognitive Patterns), Brief Interview for Mental Status (BIMS) score 15, indicating intact cognitive response. · In Section E (Behavior), Hallucinations (perceptual experiences in the absence of real external sensory stimuli) No; Delusions (misconceptions or beliefs that are firmly held, contrary to reality) No; · and in Section GG (Functional Abilities and Goals), Toileting hygiene . total dependence . one-person physical assist. During a face-to-face interview conducted on 08/30/2021 at 9:06 AM, Employee #1 (Administrator) stated, The staff member [Employee #5] and the Nurse Supervisor knew not to assign him to work with the resident (Resident #105). There was obviously a breakdown in the system. The involved CNA was floated to 3 west (where Resident #105 resided). He was not originally assigned to that unit. He [Employee #5] reported that he did not say anything to [Resident #105] while he was providing care. The supervisor is getting reprimanded, and the involved CNA was suspended (on 08/27/2021) and is being terminated as of today. During a face-to-face interview conducted on 08/30/2021 at 9:17 AM with Employee #2 (Director of Nursing), she stated, We don't tolerate abuse. I do hand-off (transfer of patient care and responsibility from one healthcare provider to another) communication with the supervisors during the week. The supervisors were made aware that the CNA involved was not to work on the third floor at all. During a telephone interview conducted on 08/30/2021 at 10:36 AM, Employee #6 (Nurse Supervisor) stated, The CNA [Employee #5] was floated to 3 west because we didn't have a CNA for that unit. I was told that the CNA shouldn't be floated to 3 east. I was not made aware about the issues on 3 west. During a telephone interview conducted on 08/30/2021 at 10:50 AM, Employee #5 stated, I was working on 2 East and was pulled to 3 West because they were short. I was told the investigation was resolved and no issues were found, so I went to the unit (3 west). I was taking care of the roommate (room [ROOM NUMBER] bed B) when [Resident #105] stated that she was wet and needed assistance as well. I reminded her that she made a report on me and that I didn't want any problems. The resident stated that she wanted me to help her and so I did. There were no issues during the ADL (activities of daily living) care. I have been doing this for [AGE] years. I have never done anything to her nor intimidate her in any way. Review of Employee #5's personnel file on 09/08/2021 revealed a form entitled; [Facility's Name] Employee Warning Notice dated 07/29/2020. The form revealed that Employee #5 received a verbal warning on (07/16/2020) and a written warning on (07/20/2020) for violation of policy/procedure. Attached to the previously mentioned warning notice was a document written by the (previous) Director of Nursing that revealed the following: On the morning of July16, 2020, it was brought to the attention of the Director of Nursing by Wound Care Team member . a resident [that resided on unit 3 east] was observed with a urine filled incontinence brief on and a urine saturated [MEDICATION(S)] (under pads) in the incontinence Brief. CNA (Employee #5) . was asked about the use of the under pads inside of the resident ' s diaper. [Employee #5] said [Resident's Name] is a heavy wetter . On the morning of July 20 [2020] . [Resident #105] had a urine stained [MEDICATION(S)] under pad taped together to form a incontinence brief and was taped to the resident's skin .[Resident 105's roommate] was observed with the same makeshift incontinence brief and in addition urine soaked towel was found between the resident's legs . This is the second occurrence within one week where [Employee #5] provided care to residents in a manner . The type of care provided by [Employee #5] to the residents is a Type B Offense . Acting in a way that can be considered abuse or neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the investigation notes and documents revealed there was no documented evidence that the facility's staff reviewed Employee #5's personnel record or implemented measures to protect all residents including Resident #105, from the potential of abuse or neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Employee #5's personnel record failed to outline why the employee was not allowed to work on unit 3 East. During a face-to-face interview on 09/08/2021 at approximately 10:30 AM, Employee #7 (Director of Human Resources) stated, The previous disciplinary actions (that occurred in 07/2020) were not mentioned to the Director of Nursing until a meeting that occurred on 08/31/2021 when termination (of Employee #5) was discussed. During a face-to-face interview on 09/08/2021 at approximately 10:30 AM, Employee #2 (Director of Nursing) stated, I was not aware of any previous allegations made for Employee #5 (CNA) until the meeting on 08/31/2021. During a face-to-face interview on 09/08/2021 at approximately 10:30 AM, Employee #1 (Administrator) stated, I was not aware of any previous allegations or disciplinary actions for the employee (Employee #5). I did not review his personnel file as part my investigation. Based on these findings, on September 8, 2021, at 1:55 PM an Immediate Jeopardy (IJ)-K situation was identified. On September 8, 2021 at 7:32 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team, which included: 1. Identified resident #105 was interviewed 9-8-2021 and signed the attestation. The identified Aide was terminated on 9-01-2021. 2. An audit will be conducted on all SNF [Skilled Nursing Facility] personnel files to identify if any have been under investigation for allegations of abuse, neglect, exploitation, or mistreatment to ensure all identified corrective disciplinary and follow up interviews and investigations were completed to prevent and protect residents from further abuse, neglect, exploitation, or mistreatment from occurring. The facility will also audit all IRF's [Incidences Reported by the Facility], complaints, grievances from January of 2021 to ensure all pertinent staff and residents were interviewed to reevaluate the complaint or incident. 3. Education/Designee will in-service all staff and leadership on the Abuse Policy and procedures. All future employees with allegations of abuse, neglect, exploitation, or mistreatment will receive immediate in servicing on the facilities Abuse Policies and procedure. All future IRF allegations conclusions will be forwarded by email/writing the LNHA/HR/DON/Departmental Supervisor [Licensed Nursing Home Administrator/Human Resource/Director of Nursing] with the results and preventative measures that have been put in place to protect the resident. 4. LNHA/ Designee will conduct an audit all IRF's weekly for two months to ensure the facility has completed a thorough investigation of the alleged violation; prevented further abuse, neglect, exploitation and mistreatment from occurring while the investigation was in progress; and took appropriate corrective action, as a result of investigation findings. Results of finding will be forward to QAA for review and recommendations. 5. All actions to be completed by 9-15-2021 The State Agency Survey Team returned to the facility and verified that the plan of correction was in place on 09/16/2021, at 7:52 PM, and the Immediate Jeopardy was removed.

Based on observation, record reviews and staff interviews, facility staff failed to ensure that staff were reporting and documenting changes in resident skin condition as so identified. Subsequently, five (5) of five (5) residents identified by the facility as high risk for developing pressure ulcers had pressure ulcers/injuries first observed by staff at an advance stage (Stage 3, Stage 4 and Unstageable). (Residents' #87, #83, #73, #62, and #42) Due to these failures an immediate jeopardy situation was identified on September 8, 2021 at 2:01 PM. The facility submitted a plan of action to the survey team on site at 7:31 PM on September 8, 2021 and the plan was accepted. The survey team returned on September 16, 2021 to validate the facility's plan, and the immediate jeopardy was lifted on September 16, 2021 at 7:52 PM. After removal of the immediacy, the deficient practice remained at a harm level and the scope and severity was lowered to an H. The findings include: Review of the facility policy entitled, Prevention of Pressure Ulcers/Injuries with a revision date of 07/2017 revealed the policy instructed staff to, .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (Activities of Daily Living) . turn and reposition bedbound resident at least every two hours . 1. Resident #87 was readmitted to the facility on [DATE]. The medical record showed the resident had several diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revealed the following focus: Anti-coagulant Therapy with a revision date of 11/20/2020. Intervention: . daily skin inspections . Review of the medical record revealed the following: -02/26/2021 Physician's order- Turn and reposition every 2 hrs (hours) and as needed to prevent pressure injury. Every day and night shift. [Facility staff worked 12-hour shifts]. -02/26/2021 Physician's order- Daily head to toe skin assessments Q (every) shift. Notify MD/NP (medical doctor/nurse practitioner) of any abnormalities and document your assessment -03/19/2021 Braden Scale - [Resident #87] scored an 8 indicating that the resident was at very high risk for developing pressure ulcers/injuries. -05/04/2021 Skin & Wound Evaluation - Pressure (injury), Stage 4 (full-thickness skin and tissue loss), Left ear, new, in-house acquired, wound measurements - length 0.9 cm (centimeters), width 0.9 cm, depth not applicable, undermining not applicable, tunneling not applicable, wound bed-100% granulation, exudate - light, serosanguineous, no odor Resident seen by wound care staff for weekly assessment. Stage 4 pressure injury to left ear . -06/19/2021 Braden Scale - [Resident #87] scored an 8 indicating that the resident was at very high risk for developing pressure ulcers/injuries. -07/02/2021 weight record: 265.9 [pounds]. -07/06/2021 Skin & Wound Evaluation - Pressure (injury), Unstageable (Obscured full-thickness skin and tissue loss), Right calf lateral, new, in-house acquired, wound measurements - length 3.0 cm (centimeters), width 2.9 cm, depth not applicable, undermining not applicable, tunneling not applicable, wound bed-100% slough (a mass of dead tissue in, or cast out from, living tissue), exudate - none Resident seen by wound care staff for weekly assessment .Noted new pressure injury to right lateral calf, unit manager made aware . Review of the Treatment Administration Record (TAR) for May, June and July 2021 showed nurses signed their initials indicating that they had conducted head to toe skin assessments for Resident #87 twice a day (day and night shift). Review of all progress notes (nursing, physician, dietary) from 04/19/2021 to 05/03/2021 and 06/21/2021 to 07/05/2021 lacked documented evidence that Resident #87's Stage 4 Left Ear pressure (injury) and the Unstageable Right Calf pressure (injury) were observed by staff prior to the assessments conducted by the wound team on 05/04/2021 and 07/06/2021 [when the wounds were first observed at an advanced stage]. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed the following: In Section C (Cognitive Patterns) the BIMS (Brief Interview for Mental Status) summary Score was blank. In Section G (Functional Status - Bed mobility), the resident was coded as 4 and 2 indicating that the resident was totally dependent on the staff and required one-person physical assist for bed mobility. In section M (Skin Condition), the resident was coded for have one (1) Stage 3 pressure ulcer, one (1) Stage 4 pressure ulcer, one (1) unstageable pressure ulcer and one (1) unstageable Deep Tissue Injury. Further review of the care revealed the following focus: Pressure Injury (Stage 4 left ear, Stage 4 sacrum, Stage 2 right heel, and Unstageable right lateral calf) with a revision date of 07/30/2021. Interventions: . the resident needs total assistance to turn/reposition at least every 2 hours, more often as need . On 08/25/2021 at approximately 3:30 PM, Employee #16 (Unit Manager) and Employee #20 (Registered Nurse) were observed providing wound care for Resident #87's Stage 4 sacral pressure injury/wound, Stage 4 Right Calf pressure injury/wound, and Right Heel Deep Tissue Injury. During an observation on 08/26/2021 from 8:10 AM to 12:40 PM (4 ½ hours) the following was noted: -At 8:10 AM, Resident #87 was observed in her room, in bed, laying on her right side. -At 10:46 AM, Resident #87 remained in bed, lying on her right side. -At 12:40 PM, Resident #87 was observed to still be lying on her right side in the bed. During the four and half hours of the observation, facility staff failed to reposition Resident #87. Although the facility's nursing staff documented that they conducted head-to-toe assessments on the resident daily, there was no evidence that facility staff identified changes in the residents' skin condition and failed to implement approaches identified in the resident's care plan (turn and reposition). Subsequently, Resident #87 developed in-house acquired wounds (Left ear and Right Calf Lateral) Stage 4 pressure injuries/ulcers. During a face-to-face interview conducted on 08/26/2021 at 12:45 PM, Employee #16 (Registered Nurse) stated, The resident should be turned and repositioned every 2 hours and as needed. The CNA (certified nurse's aide) is working her way down to the resident's room now to provide care. It should be noted that Resident #87''s left calf Stage 4 pressure injury/ulcer required bedside serial excisional debridement (the use of a scalpel to remove devitalized [slough/necrotic] tissue) on 08/31/2021. During a face-to-face interview conducted on 09/08/2021 at approximately 10:00 AM, Employee #2 (Director of Nursing) was asked how did residents' wounds (pressure injuries) get to advanced stages before staff (wound team) observed them, Employee #2 stated, I'm looking for nursing staff to have good assessment skills. I believe that there is a need for (nursing) training. When asked how often IS residents' skin assessed by nursing staff, Employee #2 stated that nursing staff assess residents' skin at least twice-a-week during bathing times. During a face-to-face interview conducted on 09/08/2021 at approximately 5:30 PM, Employee #15 (Registered Nurse) was asked how often does she assess residents' skin, the employee stated that she conducts a head-to-toe assessment of the residents one (1) to two (2) times per shift depending on her workload. When asked if she noticed any new skin integrity issues with Resident #87 in the months of May 2021 and July 2021, the employee stated, No. During a face-to-face interview on 09/08/2021 at approximately 5:30 PM, Employee #14 (Unit Manager/ RN) was asked how often she assess' residents' skin. The employee stated that when she is assigned a team, she conducts a head-to-toe assessment of the residents every shift. When asked if she noticed any new skin integrity issues with Resident #87 in the months of May 2021 and July 2021, the employee stated, No. 2. Resident #83 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Admission MDS dated [DATE], Resident #83 was coded as rarely/never understood under Section C (Cognitive Patterns). Under Section G (Functional Status), G0400, the resident was coded as total dependence on staff for bed mobility, eating toilet use, and personal hygiene, G0400, Functional Limitation in Range of Motion the resident was coded for no impairment to upper and lower extremities. In Section M (Skin Conditions), the resident was coded as at risk for pressure ulcer/injury and one (1) unhealed pressure ulcer that was present on admission to the facility. According to the Braden Scale, on 07/21/2021 the resident was assessed and scored at a 10 indicating that the resident was high risk for skin breakdown. Review of the care plans showed the following: Focus area, . Stage 4 pressure injury to the sacrum; Interventions: the resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested dated 07/21/2021. Focus area, . ADL self-care performance deficit r/t (related to) [CONDITION(S)] ([CONDITION(S)]), MI ([CONDITION(S)]), Impaired cognition . Interventions: Skin Inspection: the residents skin requires skin inspection q shift, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse initiated on 7/21/2021. Review of the physician's orders show the following: 07/20/2021 Daily head-to-toe skin assessment q (every) shift. Notify MD/NP for any abnormalities and document your assessment two times a day 07/21/2021 Turned and reposition every 2 hours and as needed to prevent pressure injury . 08/17/2021 Cleanse wound right shoulder with [MEDICATION(S)] wound cleanser spray . then apply [MEDICATION(S)] wound gel cover with 4x4 and secure with border gauze daily every night shift for wound care- start date Review of the TAR from 07/20/2021, to 08/17/2021, showed that facility staff signed that they: performed daily head to toe skin assessment Q shift (twice daily), would notify MD/NP of any abnormalities and document the assessment and turned and repositioned the resident every two hours and as needed to prevent pressure injury . However, review of the Skin and Wound Evaluation V5.0 form dated 08/17/2021 showed the following: . Stage- unstageable: obscured full thickness skin and tissue loss; 22. Location: right shoulder; In-house acquired; Exact Date- [left blank]; Wound Measurements= Area-7.8 cm, length 4.3 cm x width 2.4 cm x depth not applicable .slough- 100%, .Progress -New .Notes: Resident seen on wound rounds, noted new pressure injury to right shoulder, wound is 100% slough covered. Periwound area has intact blister and redness . Facility staff were signing in the medical record that they were assessing Resident #83's skin daily and turned and repositioned the resident every two hours. However, Resident #83 developed an in-house acquired pressure injury noted at an advanced stage (unstageable pressure injury to his right shoulder at the first observation and assessment). During a face-to-face interview conducted on 09/08/2021 at approximately 10:15 AM, Employee #9 (Director of Wound Care) was asked how do residents' wounds (pressure injuries) evolve to an advanced stage before staff observed them? Employee #9 stated, I can't speak to why the (pressure injuries) are found at advanced stages. I speak up when we (wound team) see issues with a resident's skin. I know that over the last couple of months, I have been bringing up in our Performance Improvement Meetings that nursing staff is not bathing residents. 3. Resident #73 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed the following: 03/11/2020 [Braden Scale] - Resident #73 scored a 9 indicating that the resident was at very high risk for developing pressure ulcers/injuries. 04/28/2020 [Physician Order]- Weekly skin assessment and report any abnormality to the MD (medical doctor)/NP (nurse practitioner) 04/28/2020 [Physician Order]-Moisturize skin with hydroguard (skin lotion) every shift 04/28/2020 [Physician Order]- Turn and reposition q (every) two hours. 04/29/2020 [Physician Order]- Administer bed bath or sponge bath to resident daily and as needed . 07/19/2020 [Braden Scale] - Resident #73 scored a 9 indicating that the resident was at very high risk for developing pressure ulcers/injuries. 07/30/2020- [Physician Order] - Apply skin prep to DTI (Deep Tissue Injury) left heel twice a day, monitor, and report any redness or drainage every day and night shift for wound care. 07/30/2020 [Physician Order] - Cleanse right heel wounds with Anesept spray (wound cleanser) pat dry then apply Anesept gel (antimicrobial skin gel) . off load both heels with pillows continuously every 12 hours . 08/18/2020 [Skin & Wound Evaluation]- Left lateral malleolus . Resident seen by wound care staff for weekly assessment. New Stage 4 pressure injury noted to left malleolus area has 0.5 cm (centimeters) area of slough also able to palpate bone in wound bed. Unit manager made aware . 08/18/2020 [Skin & Wound Evaluation] -Right lateral malleolus . Resident seen by wound care staff for weekly assessment. New unstageable pressure injury to right malleolus noted. wound is dry eschar, with no redness or drainage noted at edges . Review of all progress notes (such as, nursing, physician, dietary) from 07/01/2020 to 08/17/2020 lacked documented evidence that Resident #73 ' s Stage 4 Left Malleolus pressure injury and the Unstageable Right Malleolus pressure injury was observed by staff prior to the wound team ' s assessment on 08/18/2020. Review of the Treatment Administration Record (TAR) from 08/01/2020 to 08/18/2020 revealed that facility staff documented that Resident #73; received a bed or sponge during the day shift, bilateral heels were off loaded during the day and at night, skin was moisturized during the day, evening and night shifts, and was being turned and repositioned every two hours at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM and 10:00 PM. Review of Resident #73's CNA Activity of Daily Living (ADL) Notes from 08/01/2021 to 08/18/2021 revealed that facility staff documented No to the question that asked, Is there a new skin condition? Review of the Admission MDS dated [DATE] revealed that facility staff coded the following: In Section G (Functional Status), bed mobility . total dependence . two+ (plus) persons physical assist . In Section H (Bowel and Bladder), urinary continence . bowel continence . always incontinent . In Section M (Skin Conditions), . risk of pressure ulcers .yes .; . resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/ device .no ., .is this resident at risk of developing pressure ulcers/injuries? . yes, . does this resident have one or more unhealed pressure ulcers/injuries? . no Review of the Care Plan revealed the following: Focus: Activities of Daily Living Self-care Performance Deficit dated 03/11/2020 revealed several interventions including, provide sponge bath when a full bath or shower cannot be tolerated .bed mobility, and the resident is totally dependent on staff for repositioning and turning in bed every 2 hour. Focus: Alteration in Neurological Status dated 03/12/2020 revealed several interventions including . skin inspections daily and report any findings to the nurse. Although the facility implemented approaches identified in the resident care plan (turn and reposition and inspect skin daily). Subsequently, Resident #73 developed an in-house acquired Stage 4 Left Malleolus pressure injury and a Unstageable Right Malleolus pressure on 08/18/2020. During a face-to-face interview conducted on 09/08/2021 at approximately at 9:35 AM, Employee #9 (Director of Wound Care) stated, The wound team has educated the nursing staff multiple times on assessment, documenting and reporting of resident ' s skin. I have brought this issue of the nursing staff not documenting or making the wound team aware of skin issues at an early stage to the attention of the Director of Nursing and the Administrator. 4. Resident #62 was readmitted to the facility on [DATE]. The medical record showed the resident had several diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 08/24/2021 starting at 12:12 PM, the wound care team provided wound care for Resident #62's wounds for the left hip, left leg, back and sacrum. Review of the medical record revealed the following: 05/07/2021 [Braden Scale] - Resident #62 scored a 10 indicating that the resident was at very high risk for developing pressure ulcers/injuries. 05/08/2021 [Physician Order] - Turn and reposition every 2hrs (hours) for comfort and to help prevent pressure injury every shift. 05/08/2021 at 4:15 AM (Nursing Admission Summary Note) - Resident .admitted . at 7pm .Resident has a sacral wound stage IV (4), (6cm (centimeters) X 5(cm) X 1 (cm) deep). Moderate amount of serosa (serosanguinous) drainage noted. (Left lower leg wound 0.6cm X 1.0cm). (Left buttock pressure 0.1cm) .with multiple scattered wound. Multiple scars noted to bilateral lower extremities. Old surgical sites to chest and abdomen. 05/09/2021 at 2:16 AM (Nursing Progress Note)- Resident alert and responsive, 2nd day of readmission .skin warm and dry to touch .ADL and wound cares (sp) provided . turn (sp) and reposition (sp) every two hours and as needed to prevent pressure ulcer . 05/10/2021 at 1:06 PM (Nursing Progress Note) - Resident is alert and responsive, skin warm and dry to touch .ADL care provided, turning, and repositioning every two hours as needed to prevent pressure ulcer (sp) . 05/10/2021 1:58 PM (Skin & Wound Evaluation)- new, in-house acquired, Left calf, Stage 3 (Full-thickness skin loss), pressure(injury), length 3.2 cm (centimeters), width 2.7 cm, depth 0.1 cm, undermining not applicable, tunneling not applicable. wound bed 100% granulation -pink or red, exudate light, seropurulent . Review of the Treatment Administration Records for May 2021 revealed the following: Nursing staff signed their initials indicating that they had turned and repositioned Resident #62 every (2) hours from 05/08/2021 to 05/10/2021. Review of the Care Plans revealed the following: Focus: Skin Impairment related to Immobility with am initial date of 05/07/2021, outlined multiple interventions including turn and reposition resident to prevent pressure injuries. Review of the Minimum Data Set, dated dated dated [DATE] revealed, In section C (Cognitive Patterns), Brief Interview for Mental Status summary score was blank. In section G (Functional Status - Bed mobility) the resident was coded as a 4 indicating that the resident was totally dependent on the staff. The support section was left blank. In section M (Skin Condition), the resident was coded to having four (4) Stage 3 pressure ulcers, three (3) Stage 4 pressure ulcers, one (1) unstageable pressure ulcer and one (1) unstageable Deep Tissue Injury. Although the facility implemented approaches identified in the resident care plan (turn and reposition). Subsequently, Resident #62 developed in-house acquired wound (Left Calf) Stage 3 pressure injury within 48 hours of his re-admitted [DATE]. During a face-to-face interview on 09/08/2021 at approximately 10:30 AM, Employee #10 (Wound Team Nurse) stated that on 05/10/2021 she assessed Resident #62 ' s skin and observed an in-house acquired Stage #3 pressure injury on the resident ' s left calf. During a face-to-face interview on 09/08/2021 at approximately 10:15 AM, Employee #9 (Director of Wound Care) was asked how do residents' wounds (pressure injuries) evolve to an advanced stage before staff observed them? Employee #9 stated, I can't speak to why the (pressure injuries) are found at advanced stages. I speak up when we (wound team) see issues with a resident's skin. I know that over the last couple of months, I have been bringing up in our Performance Improvement Meetings that nursing staff is not bathing residents. 5. Resident #42 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Quarterly MDS dated [DATE] the resident was coded as rarely/never understood under Section C (Cognitive Patterns); Under Section G (Functional Status), G0400, the resident was coded as total dependence on staff for bed mobility, eating, toilet use, and personal hygiene; Functional Limitation in Range of Motion the resident was coded for impairment to upper and lower extremities. Section M (Skin Conditions), the resident was coded as at risk for pressure ulcers and one (1) unhealed pressure ulcer. According to the Braden Scale, Resident #42 was assessed and scored at a 9 indicating that she was very high risk for skin breakdown on 04/03/2021 and was assessed and scored at a 10 indicating high risk for skin breakdown on 07/03/2021. Review of the care plan with the focus area, Stage 4 pressure injury to left lateral malleolus revealed the following interventions, the resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested dated 07/23/2021, Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician ' s orders revealed the following: 06/11/2021 Cleanse left medial heel wound with [MEDICATION(S)] wound cleanser spray . every day and PRN (as needed). Please float heels continuously to prevent pressure every night shift for wound care 09/13/2020 Float heels while in bed with a pillow to prevent skin breakdown and pressure every shift (day, evening , night) 09/13/2020 Daily head to skin assessments per protocol every shift and as needed, and they would notify MD (medical doctor) for any abnormality every day and night shift 05/30/2021 Turn and reposition every 2 hours and as needed for relieving and redistribution Review of the Treatment Administration Record from 07/01/2021 to 07/14/2021 showed that facility staff signed that they: performed wound care to the resident ' s left heel, floated the resident ' s heels twice daily, performed head-to-toe notify MD (medical doctor) for any abnormality every day and night shift, and turned and repositioned the resident every two hours and as needed for reliving and retribution. However, review of the Skin and Wound Evaluation V5.0 form dated 07/14/2021 showed the following: . Stage 4 full thickness and tissue loss . Location: Left Lateral Malleolus (ankle) . Acquired; In-house acquired . Exact Date- 7/14/21; Wound Measurements= Area-2.5 cm, length 2.2cm x width 1.8 cm x 0.5 depth, undermining 1.0 cm; Wound bed -slough 100% of wound filled; exudate-light; type seropurulent; Notes: Resident seen by wound care team, noted development of new pressure injury to left lateral malleolus (sp). Wound is stage 4, full thickness with palpable bone in wound bed full description and pictures in PPC (point click care) . Facility staff were signing that they: conducted wound treatments to the residents left heel twice daily, were assessing the residents skin daily, floated the resident ' s heels twice daily, and turned and repositioned the resident every two hours. However, Resident #42 developed an in-house acquired pressure injury noted at an advanced stage (stage 4 pressure ulcer to the Left Lateral Malleolus). During a face-to-face interview conducted on 09/08/2021 at approximately 10:15 AM, Employee #9 (Director of Wound Care) was asked how do residents' wounds (pressure injuries) evolve to an advanced stage before staff observed them? Employee #9 stated, I can't speak to why the (pressure injuries) are found at advanced stages. I speak up when we (wound team) see issues with a resident's skin. I know that over the last couple of months, I have been bringing up in our Performance Improvement Meetings that nursing staff is not bathing residents. Based on these findings, on September 8, 2021 at 2:01 PM an immediate jeopardy (IJ) situation was identified. On September 8, 2021 at 7:31 PM, the facility's administrator provided a corrective action plan to the State Agency Survey team which included: 1. Facility will complete house wide skins assessments by 9-09-2021, going forward skin assessments will be performed twice a week by the License Nursing staff during the resident ' s showers to document any changes in the resident ' s skin condition. The assessments will be documented and stored in the departmental shower books and the DON/Designee will audit for completion twice a week for two months. The corporate wound nurse or designee will in-service All Nursing staff including registry on the process of reporting head and toe assessment and reporting documenting changes in resident ' s skin condition to the Physician and wound team as soon as identified. An in-service including a sign-in sheet will be provided to track Nursing staff. 2. All Nursing Staff including registry will be in-serviced on Wound Policy and procedures. The Corporate wound nurse will educate the Director of Nursing on the Wound policy and procedures. 3. Turning and repositioning will be monitored every two hours by the nursing supervisor to ensure proper turning and repositioning is being conducted. A turning and reposition audit tool will be used to monitor turning and reposition. Wounds found during the skin assessments a RCA (Root Cause Analysis) to investigate the Nursing staff responsible for not properly documenting skin assessments, and conducting turning and repositioning. 4. This will be monitored by The Director of Nursing and Nursing Supervisors. A skin tag violation card will be implemented to address any staff found not doing proper turning and repositioning of residents. Nursing staff with over 3 violations will be taken off the floor immediately for training and a weekly Quality Audit will be conducted by the QAPI team. All finding will be addressed at the weekly QAPI meeting for two months. 5. QA Audits of skin assessment documentation done weekly for two months to ensure skin assessments will be completed to ensure timely and appropriately. This will be monitored by the Administrator, Director of Nursing and the Quality Director and addressed in the weekly QAPI meetings. All Items to be completed by 9-15-2021. The State Agency Survey team returned to the facility and verified that the plan of correction was in place on September 16, 2021 at 7:52 PM, and the immediate jeopardy was removed.

Based on observation, record review, and staff interviews, the facility failed to ensure that frozen foods were stored frozen solid until ready for use to prevent the risk of a foodborne illness outbreak in a highly susceptible population. This failure occurred for frozen raw meats and food items that were stored for use to prepare meals for 40 of 59 residents receiving oral nutrition from October 8-13, 2017. The failure was evidenced by the presence of thawed meats such as fish, beef, with puddles of bloody juices dripping onto the freezer floor. The internal freezer temperature observed at 40 degrees Fahrenheit. Also, six (6) of six (6) dented sixth pans. The findings include: An Immediate Jeopardy (IJ) identified at 42 CFR§ 483.60(i) (2) Food Safety Requirements; F-371- Store, prepare, distribute and serve food. The facility's Administrator provided a letter documenting a corrective action plan to include staff training and competency. On October 16, 2017, at 8:30 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an E. During the initial tour of the kitchen on 10/12/2017 at 9:10 AM, the surveyor observed the facility's only freezer internal temperature at 40 degrees Fahrenheit. The external freezer thermometer reading was 36 degrees Fahrenheit, a four (4) degrees difference from the internal temperature observed at 9:10 AM. The freezer contained large volumes of raw meats and food items in a thawed state (not frozen solid to touch). The food items stored in the freezer at the time of the observation included large vacuum-sealed beef portions, chicken, large vacuum-sealed pork portions, ricotta cheese, fish, lo mein noodles, and seafood products such as shrimp. The food items physically inspected by touch were found to be soft allowing an approximately one (1) inch indention when pressure was applied. Also, boxed item's outer surfaces and vacuum-sealed meat items packaging were moist with a bloody substance dripping directly onto the floor beneath the storage rack. The food items were stacked on top of one another preventing the flow of air around the frozen food item in a thawing state. The raw meats were not stored separately in a drip-proof container. Record review of the facility's temperature monitoring tool titled, Nutrition Freezer Temperature Log, dated October 2017 with data from October 1 through 11, 2017, showed the facility's staff recorded freezer temperatures greater than zero degrees as follows: a. October 1, 2017: three (3) degrees Fahrenheit (ºF) in the morning and two (2) ºF in the afternoon b. October 4, 2017: one (1) ºF in the afternoon (no morning temperature documented) c. October 5, 2017: one (1) ºF in the morning d. October 6, 2017: one (1) ºF in the afternoon. e. October 8, 2017: three (3) ºF in the morning and one (1) ºF in the afternoon f. October 9, 2017: three (3) ºF in the morning and afternoon g. October 10, 2017: 28 ºF in the afternoon (no morning temperature documented) h. October 11, 2017: Negative two (-2) ºF in the afternoon (no morning temperature documented) The facility's Nutrition Freezer Temperature Log identified the acceptable freezer temperature range of zero to -10 degrees ºF. The area reserved for the facility's staff to document the corrective actions taken when temperatures are out of range was left blank except for October 8, 9, and 11, 2017, which indicated Engineering was notified. The freezer temperature monitoring tool does not contain any information related to the status of the frozen foods (i.e., firmness of meat and food items) on the dates and times, when the freezer temperatures were documented greater than zero degrees Fahrenheit. During an interview on October 12, 2017, at approximately10:30 AM, Employee #7, Food Service Manager, stated, he was not aware that the freezer was not working as intended before the discovery during the initial kitchen tour. Employee #7 stated that the dietary staff monitors and records the freezer temperatures twice daily; once in the morning and once in the afternoon. The morning shift's hours are 6:30 AM to 3:00 PM and the afternoon shift's hours are 11:30 AM to 8:00 PM. An exact time or designated time for performing the freezer temperature monitoring varies. When asked about the timeline for the incident, Employee # 7 indicated that further information gathering was needed to adequately answer questions surrounding the freezer malfunction and status of food temperatures. At approximately 2:30 PM on October 12, 2017, during the follow-up telephone conference with the facility's administrative team to include Employee #7, he stated the facility's dietary staff identified an issue with the freezer (temperature: 3 ºF) on October 8, 2017, for which the executive chef notified Plant Operations. On October 9, 2017, a preventative maintenance service vendor was contacted to evaluate the freezer. The preventative maintenance vendor provided recommendations for needed freezer repairs. The vendor did not perform recommended repairs during the October 9, 2017, service call. On the afternoon of October 10, 2017, the freezer temperature was documented as 28 ºF. The facility staff placed a call to a second freezer repair vendor for concerns regarding the freezer temperatures. The vendor performed some repairs. When asked direct questions regarding the monitoring and storage of the frozen foods, Employee #7 stated that the food items located in the freezer were acceptable for use since the freezer temperatures did not rise above 41 ºF. According to Employee #7, the foods were in a thawing state and under refrigeration since the temperature in the malfunctioning freezer was below 41 ºF. Employee # 7 stated the facility did not check the temperature of the food nor did they monitor the frozen food for firmness. Employee #7 further stated that it would take approximately five (5) days for the large portions of meats to thaw in the refrigerator. Regarding the raw meats and food items observed thawed, he was unable to explain how long the raw meats were maintained without proper freezing temperatures to cause the level of thawing noted. Employee # 10, Infection Preventionist, was present during the telephone conference on October 12, 2017, at approximately 2:30 PM. When asked about the facility's policy for frozen raw foods which are no longer frozen solid, Employee # 10 stated that the facility is expected to discard frozen raw food items that are no longer frozen solid for more than 12 to 16 hours. Also, Employee # 10 stated that while the freezer repairs were being performed on October 10, 2017, the foods were removed from the freezer. However, the facility was unable to provide insight as to where the frozen raw meats and food items were stored during the repairs. Employee #10 further stated that the facility would discard the thawed raw meats and food items located in the malfunctioning freezer. The facility was unable to provide insight or explanation for the raw meat products and food items stored on the wire shelving in the freezer with bloody juices dripping onto the floor and moisture saturated cardboard boxes containing raw meats. The administrative team to include the Administrator, Director of Nursing, Infection Preventionist and Food Service Manager acknowledged not being aware of the status of raw foods stored in the freezer, which placed residents at risk of developing a foodborne illness. Furthermore, the facility failed to establish policies and procedures to govern the facility's practice for monitoring frozen food firmness, in the absence of a properly function freezer, to ensure frozen foods remain solid to prevent the risk for a foodborne illness. The facility was aware of the failed practice which created the potential for harm related to unsafety food storage exposing residents to foodborne pathogens. On October 12, 2017 at 6:20 PM, the State Agency verbally notified the facility of the Immediate Jeopardy (IJ). The facility was made aware of the seriousness of the deficient practice. At 7:57 PM on October 12, 2017, the facility submitted their first plan of correction. The plan of correction failed to show immediate implement corrective measure to prevent a reoccurrence of the situation. The plan of correction was rejected by the State Agency. Plan of correction #2 submitted on October 13, 2017, was rejected and facility was asked to provide evidence of the staff training and competency to address the deficient practice. On October 14, 2017 at 1:10 PM, the facility submitted a copy of the Training Module intended for use to educate and establish competency of the facility staff. The module lacked sufficient information to ensure staff competency and consequently was rejected. On October 16, 2017, at 8:30 PM, the final plan of correction submitted was inclusive of the Facility's Action Plan as it pertains to Dietary Services, Food and Nutrition Services policy and procedure item FNS.300, dietary services training module, in-service staff roster (training sessions on the new FNS.300 policy and procedure), evidence (Invoice) for freezer repair (Compressor), contract for an external freezer/trailer, and Daily Freezer temperature logs. The State Agency confirmed implementation of the corrective action plan and the Immediate Jeopardy (IJ) was abated. 2. Six (6) of Six (6) sixth pans were dented. These observations were made in the presence of Employee #9 and/or Employee #7 who confirmed the findings.

Based on observation, record review, and staff interviews, the facility failed to ensure that the facility's only freezer was operational to ensure that frozen foods were kept frozen solid until ready for the cooking process. The failed practice impacted raw meats and food items intended for use to prepare meals for 40 of 59 residents receiving oral nutrition from October 8 through 13, 2017. The findings include: An Immediate Jeopardy (IJ) identified at 42 CFR §483.90 (d)(2)(e) Physical Environment Space and Equipment; F-456 Maintain all mechanical, electrical, and patient care equipment in safe operating condition. The facility's Administrator provided a letter documenting a corrective action plan to include staff training and competency, policy revisions and equipment repairs. The facility's Administrator provided a letter documenting a corrective action plan to include staff training and competency. On October 16, 2017, at 8:30 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an E. During the initial tour of the kitchen on 10/12/2017 at 9:10 AM, the surveyor observed the facility's only freezer internal temperature at 40 degrees Fahrenheit. The external freezer thermometer reading was 36 degrees Fahrenheit, a four (4) degrees difference from the internal temperature observed at 9:10 AM. The freezer contained large volumes of raw meats and food items in a thawed state (not frozen solid to touch). Record review of the facility's temperature monitoring tool titled, Nutrition Freezer Temperature Log, dated October 2017 with data from October 1 through 11, 2017, showed the facility's staff recorded freezer temperatures greater than zero degrees as follows: a. October 1, 2017: three (3) degrees Fahrenheit (ºF) in the morning and two (2) ºF in the afternoon b. October 4, 2017: one (1) ºF in the afternoon (no morning temperature documented) c. October 5, 2017: one (1) ºF in the morning d. October 6, 2017: one (1) ºF in the afternoon e. October 8, 2017: three (3) ºF in the morning and one (1) ºF in the afternoon f. October 9, 2017: three (3) ºF in the morning and afternoon g. October 10, 2017: 28 ºF in the afternoon (no morning temperature documented) h. October 11, 2017: Negative two (-2) ºF in the afternoon (no morning temperature documented) The facility's Nutrition Freezer Temperature Log identified the acceptable freezer temperature range of zero to -10 degrees ºF. The area reserved for the facility's staff to document the corrective action to address the actions taken when temperatures are out of range was left blank except for October 8, 9, and 11, 2017, which indicated Engineering was notified. During an interview on October 12, 2017, at approximately10:30 AM, Employee #7, Food Service Manager, stated, he was not aware that the freezer was not working as intended before the discovery during the initial kitchen tour. Employee # 7 stated that the dietary staff monitors and records the freezer temperatures twice daily; once in the morning and once in the afternoon. The morning shift's hours are 6:30 AM to 3:00 PM and the afternoon shift's hours are 11:30 AM to 8:00 PM. An exact time or designated time for performing the freezer temperature monitoring varies. When asked about the timeline for the incident, Employee # 7 indicated that further information gathering was needed to adequately answer questions surrounding the freezer malfunction and status of food temperatures. At approximately 2:30 PM on October 12, 2017, during the follow-up telephone conference with the facility's administrative team to include Employee #7, he stated the facility's dietary staff identified an issue with the freezer (temperature: 3 ºF) on October 8, 2017, for which the executive chef notified Plant Operations about the freezer temperature. On October 9, 2017, a preventative maintenance service vendor was contacted to evaluate the freezer. The preventative maintenance vendor provided a recommendation for needed freezer repairs. The vendor did not perform recommended repairs during the October 9, 2017, service call. On the afternoon of October 10, 2017, the freezer temperature was documented as 28 ºF. The facility staff placed a call to a second freezer repair vendor for concerns regarding the freezer temperatures. The vendor performed some repairs. According to the Maintenance Order from the (Preventative Maintenance Vendor) dated October 9, 2017at 8:30 AM, the work requested included a check of the walk-in freezer. The discharge temperature was very high and the refrigerant needed to be charged. The document does not show that the recommended work was completed on October 9, 2017. On October 10, 2017, at 2:45 PM, another freezer repair vendor serviced the walk-in freezer. The Invoice documented repairs completed. The repairs included the replacement of a transducer, and the freezer was turned back on. According to the invoice, the box came down in temp. During a telephonic interview on October 12, 2017, at approximately 2:30 PM, Employee #11, Plant Operations Manager, was questioned about the procedures taken to address the malfunctioning freezer. Employee # 11 stated that when notified of out of range freezer temperatures, the engineering department's staff places a call to an outside vendor for repairs. Freezer temperatures are not checked by engineering to confirm accuracy of information reported by the dietary staff. Clarification was requested from Employee #11 to explain the documentation from the repair vendor on October 10, 2017; which stated the box came down in temp. He could not provide further insight into the meaning of the vendor's note neither could he demonstrate that the freezer temperature was checked by the vendor or the facility after the repairs. Furthermore, the engineering department did not notify administration of the walk-in freezer's failure to maintain raw meats and food items in a solid state. The walk-in freezer temperature was noted to be out of range on 11 out 24 observations. The failure to ensure the walk-in freezer operated, as intended, placed the raw meats and food items at risk of growing bacteria that causes foodborne illnesses when ingested. On October 12, 2017 at 6:20 PM, the State Agency verbally notified the facility of the Immediate Jeopardy (IJ). The facility was made aware of the seriousness of the deficient practice. At 7:57 PM on October 12, 2017, the facility submitted their first plan of correction. The plan of correction failed to show immediate implement corrective measure to prevent a reoccurrence of the situation. The plan of correction was rejected by the State Agency. Plan of correction #2 submitted on October 13, 2017, was rejected and facility was asked to provide evidence of the staff training and competency to address the deficient practice. On October 14, 2017 at 1:10 PM, the facility submitted a copy of the Training Module intended for use to educate and establish competency of the facility staff. The module lacked sufficient information to ensure staff competency and consequently was rejected. On October 16, 2017, at 8:30 PM, the final plan of correction submitted was inclusive of the Facility's Action Plan as it pertains to Dietary Services, Food and Nutrition Services policy and procedure item FNS.300, dietary services training module, in-service staff roster (training sessions on the new FNS.300 policy and procedure), evidence (Invoice) for freezer repair (Compressor), contract for an external freezer/trailer, and Daily Freezer temperature logs. The State Agency confirmed implementation of the corrective action plan and the Immediate Jeopardy (IJ) was abated.

Based on observation, record review, and staff interviews for one (1) of 26 sampled residents, it was determined that facility staff failed to ensure that Resident #39 received necessary treatment and services to prevent the development of pressure ulcer(s) Resident #39. The findings include: The quarterly Minimum Data Set, dated dated dated [DATE] revealed that in Section C (Cognitive Patterns) the resident was coded as severely impaired. In Section G (Functional Status) the resident was coded as totally dependent, requiring assistance of one or two people in bed mobility, dressing, eating, toilet use, and personal hygiene. In Section G0400 (Functional Limitation and Range of Motion) the resident was coded as being impaired on both sides (upper and lower) extremities. In Section I (Active Diagnoses) the resident was coded as having Non-Alzheimer's Dementia. Under Section M 0300 (Current Number of Unhealed Pressure Ulcers) the resident was coded as having one (1) Stage 2 pressure ulcer and two (2) unstageble pressure ulcers. The "Alteration in Skin Integrity" care plan initiated September 25, 2013 revealed, "Approaches: Determination etiology of skin breakdown. Monitor boney prominences. Assess resident for pain/discomfort." Observation Resident #39 was observed on January 22, 2014 at 3:10 PM lying in bed with bilateral contractures to upper and lower extremities. Mittens covered resident's hands and wrist areas and were tied in place. The resident was observed attempting to remove the hand mittens with his/her teeth. A face-to-face interview was conducted with Employee #15 on January 22, 2014 at approximately 11:30 AM. Employee #15 was queried if the resident currently had one or more pressure ulcers? He/she responded, "Yes, the left buttock has a healing Stage II (wound) that measured 1.5 x 1.0 cm (centimeter), and an unstageble (wound) to the left hand. It was a blister that became unstageble. It must have developed from rubbing (his/her) hands against the mittens." A review of the physician's order [REDACTED]. "October 25, 2013 at 1630 (4:30 PM) ...Mitten L (left) hand to prevent itching " . "October 29, 2013 at 9:00 AM ...mittens bilat (bilateral) hands- r/t (related to) scratching. Discontinue order for mitten (left) hand. " "December 30, 2013 at (no time indicated), clean area on left thumb (with) NS (normal saline) apply hydrogel (water in a gel base, which helps regulate fluid exchange from the wound surface) to Stage II ulcer daily until healed. 4x4 tape, and [MEDICATION NAME] (a transparent dressing) to open blister area (every) three days until healed. Have consulted with (wound doctor) ... " January 1, 2014 at 3:30 PM, " 1) discontinue previous treatments on (left) metacarpals-thumb area ...2) (left) metacarpal-thumb area cleans (with) NS and cover (with) [MEDICATION NAME] and change (every) three days. " January 9, 2014 at 3:40 AM, " X-ray of (left) hand to rule out osteo[DIAGNOSES REDACTED] ... " A review of the Medication Administration Records from December 2013 to January 2014 revealed that facility staff signed in the allotted spaces, indicating that treatments were done to the resident ' s left metacarpal-thumb as per the physician's orders [REDACTED]. A review of the nursing notes revealed the following: October 25, 2013 at 10:00 PM, " Also has order for [MEDICATION NAME] and mittens see (POS) (physician order [REDACTED]. November 3, 2013 at 11:00 PM, " ...mittens in place ... " November 5, 2013 at 10:00 PM, " ...mitts (mittens) hands on as per orders ... " November 22, 2013 at 7:00 AM, " worker noted skin tear on left hand. Measures 0.1x 1cm (centimeter) order for [MEDICATION NAME] q (every) three days and wound nurse to assess. RP (responsible party) called no answer. AM nurse to follow up. " November 26, 2013 at 11:00 PM, " ...mittens in place ... " November 28, 2013 at 5:00 AM, " hand mittens in place, hourly rounds made ... " December 3, 2013 at 4:00 AM, " bilateral hand (mittens) in place ... " December 4, 2013 at 4:40 AM, " bilateral hand (mittens) in place ... " December 5, 2013 at 5:00 AM, " bilateral hand (mittens) in place ... " December 8, 2013 at 5:00 AM, " bilateral mittens in place, monitored hourly ... " December 9, 2013 at 5:00 AM, " hand mittens in place ... " December 10, 2013 at 5:00 AM, " resident remains with mittens on to prevent pulling GT (Gastrostomy tube) out ... " December 14, 2013 at 4:30 AM, " ...bil. (bilateral) hand mittens restraints is being observed ... " December 17, 2013 at 6:00 AM, " ...Resident remains (with) mittens on hands. Wounds done by previous nurse ... " December 18, 2013 at 6:00 AM, " ...bilateral mittens in place ... " December 22, 2013 at 7:10 AM, " ...bilateral hand mittens applied ... " December 30, 2013 at 11:30 AM, " ...A call has been placed to resident (responsible party) to make (him/her) aware of resident noted to have an ulcer on left hand thumb. 1) Area noted to be stage II 1.5x (unable to read). 2) Area noted to be open blister, 1 [MEDICAL CONDITION] cm ... (responsible party) returned call and made aware ... " January 3, 2014 at 6:00 AM, " ...mittens to hands remain on and were replaced times one ... " January 4, 2014 at 3:40 AM, " ...mittens to hand ... " January 4, 2014 at 3:40 AM, " ...mittens to hand ... " January 6, 2014 at 7:25 AM, " ...bilateral mittens on both hands to prevent scratching ... " January 9, 2014 at 6:30 PM, " ...Result of left hand x-ray to R/o (rule out) osteo[DIAGNOSES REDACTED] relayed to (wound doctor and attending physician) ... " January 10, 2014 at 6:00 AM, " ...mittens remain hand " January 11, 2014 at 6:00 AM, " ...bilateral mitten in place ... " January 14, 2014 at 5:00 AM, " ...resident continue to wear mittens and checked every 2 hours for circulation ... " January 15, 2014 at 5:00 AM, " ...hand mitten in place on both arm ... " January 19, 2014 at 6:00 AM, " ...bilateral mitten in place per scheduled ... " January 26, 2014 at 7:30 AM, " ...bilateral mitten in place ... " The Medication Administration Records from October 2013 to January 2014 revealed the facility staff signed to indicate the mittens were applied daily, as ordered by the physician. Restraint A review of the "Restraint Interventions" forms from November 2013 to January 2014 revealed the forms were not completed daily. The forms lacked evidenced that staff consistently completed the form in its entirety in the following areas: Indications for use of restraints; Alternative intervention(s) prior to application (of the restraint); Alternative measures effective; Type and location of restraint in use; and the Observation flow sheet to include skin check, range of motion, circulation checks and release of restraints every two hours. There was no evidence that the " Restraint Intervention " forms were completed for December 2013, the month the resident acquired a pressure sore to his/her left first metacarpal-thumb. The wound assessment sheets revealed the following: " January 1, 2014-Wound type pressure; location of wound-first metacarpal; Stage of wound - unstageble; Acquired 12/30/13; measurements 1.5 x 2 cm; Serosanguineous, 50% slough, 50% pink; Treatment-[MEDICATION NAME] " " January 8, 2014-Wound type pressure; location of wound-first metacarpal; Stage of wound - unstageble; Acquired 12/30/13; measurements 1.5 x 2cm; Serosanguineous, 50% slough, 50% pink; Treatment- [MEDICATION NAME] " " January 15, 2014-Wound type pressure; location of wound-first metacarpal; Stage of wound - unstageble; Acquired 12/30/13; measurements 1.3 x 1.2cm; Serosanguineous, 10% slough; Treatment- [MEDICATION NAME] " The AHRQ (Agency for Healthcare Research and Quality) wound assessment dated , January 22, 2014- " Classification: In-house acquired; Location of wound-first metacarpal (base of thumb); Size of wound 1x1x0.1 cm; Current stage III; Exudate type-Serosanguineous: then watery pale red/pink; Treatment cleansing and irrigation: saline, and dry gauze " A review of the clinical record revealed that on October 29, 2013 a physician's order [REDACTED].#39 to have bilateral mittens applied. There was no order or protocol from the physician for staff to implement ongoing preventive measures to preserve the resident ' s skin integrity while using bilateral mittens. There was no evidence that facility staff accurately and consistently completed the " Restraint Interventions " form. Subsequently, on December 30, 2013 Resident #39 was assessed with [REDACTED]. On January 1, 2014 the wound to the left metacarpal-thumb had progressed to unstageble and described as measuring at 1.5 x 2 cm with Serosanguineous drainage, 50% slough, and 50% pink. There was no evidence that facility staff provided necessary treatment and services to prevent the development of pressure sores for Resident #39. The integrity of the resident ' s left thumb became altered and there was no evidence that facility staff implemented alternate plans or approaches to manage the impairment. Facility staff continued to use the mittens and the pressure sore worsened. A face-to-face interview was conducted on January 28, 2014 at 4:35 PM with Employee #4. He/ she acknowledged there were no measures to alleviate pressure by loosening mittens or removing them all together when it was noted that the resident had developed a pressure ulcer to his/her left thumb. A face-to-face interview was conducted on January 29, 2014 at 2:00 PM with Employees # 2 and #4 regarding the aforementioned findings. The employees reviewed the clinical record related to the resident ' s episodes of itching, the use of mittens and the development of pressure ulcer on the resident's left hand. Employee #2 acknowledged the findings. The record was reviewed on January 29, 2014.

Based on observation, record review and staff interviews for three (3) of 26 sampled residents, it was determined that facility staff failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being as evidenced by failure to: assess one (1) resident for pain during a wound treatment and failed to stop and reassess when the resident exhibited signs of pain; ensure that one (1) resident was seen by a psychiatrist as prescribed and ensure that one (1) resident who expressed [MEDICAL CONDITION] received necessary care and services. Residents' # 39, #1 and #67. The findings include: 1. Facility staff failed to ensure that Resident #39 who received a wound treatment was assessed for pain prior to the start of the wound treatment and failed to reassess the resident for pain when he/she displayed signs and symptoms of pain during the treatment. The quarterly Minimum Data Set, dated dated dated [DATE] revealed that in Section C (Cognitive Patterns) the resident was coded as severely impaired. In Section G (Functional Status) the resident was coded as totally dependent, requiring assistance of one or two people in Bed mobility, dressing, eating, toilet use and personal hygiene. In Section G0400 (Functional Limitation and Range of Motion) the resident was coded Impairment on both sides to the upper and lower extremities. In Section I (Active Diagnoses) the resident was coded as having Non-Alzheimer ' s Dementia. Section M 0300 (Current Number of Unhealed Pressure Ulcers) was coded as the resident having one (1) Stage 2 pressure ulcers and two (2) unstageble pressure ulcers. The "Pain" care plan initiated on September 26, 2013 revealed, "Approaches: Monitor for effectiveness of medication. Monitor for non-verbal cues of pain." Resident #39 was observed on January 22, 1014 at 3:10 PM lying in bed with bilateral contractures to upper and lower extremities and with hand mittens tied in place. Resident #39 was moving about in bed attempting to remove the hand mittens with his/her teeth. The mittens covered resident's hands and wrist areas. A face-to-face interview was conducted with Employee #15 on January 22, 2014 at approximately 11:30 AM. Employee #15 was queried if the resident currently had one or more pressure ulcers? He/she responded, "Yes, a left buttock stage 2 1.5x1.0 healing, and an unstageble left hand. It was a blister that became unstageble. It must have developed from him/her rubbing hands against the mittens. " On January 27, 2014 at 3:45 PM, Employee # 15 was observed providing a wound treatment to Resident #39, he/she was accompanied by two other employees (Employee #16 and 17) who assisted with the treatment. Employee #15 stated that he/she pre-medicated the resident with [MEDICATION NAME] 325 mg with [MEDICATION NAME] via Gastrostomy tube at 3:15 PM (on the same day). Employee #17 turned Resident # 39 onto his/her left side. Employee #15 removed the old dressing and began the wound treatment procedure. At no time did Employee #15 assess Resident #39 for signs and symptoms of pain or discomfort. Resident #39 was observed to grimace when the wound to the buttocks was touched and cleansed by Employee #15. The resident ' s facial muscles relaxed when wound was not being touched. Employee #15 proceeded to perform the treatment to the resident ' s left hand. When Resident #39 made facial grimaces, opened eyes wider, and had muscle tightening to the body during the hand treatment, Employee #15 did not reassess the resident ' s response during the procedure. A face-to-face interview was conducted with Employee #17 on January 27, 2014 at approximately 4:30 PM. He/she agreed that "(Resident #39) demonstrated signs of pain during the procedure and that there was a change in (his/her) face when (his/her) wounds were being touched." A face-to-face interview was conducted with Employee #4 on January 27, 2014 at approximately 4: 45 PM. The employee was informed of the concerns regarding Employee #15 ' s lack of an initial pain assessment and reassessment(s) during the wound treatment to the buttocks and the left hand for Resident # 39. The second wound treatment observation On January 28, 2014 at approximately 4:15 PM, Employee #16 was observed providing wound treatment to Resident #39. The resident was pre-medicated with [MEDICATION NAME] 325mg with [MEDICATION NAME] ([MEDICATION NAME]) via Gastrostomy tube at approximately 3:45 PM. Resident #39 was repositioned on his/her back to conduct the wound treatment to the left hand. Employee #16 removed Resident #39's mittens and the resident immediately began scratching his/her left thigh. When the wound treatment was performed, Resident #39 was observed to have facial grimaces and tightening of the body (non-verbal indicators), and pulled his/her left hand away as Employee #16 removed the dressing. Employee #16 did not acknowledge the resident's non-verbal response. The employee continued to the next step in the treatment which was to clean the wound. The surveyor asked Employee #16 if he/she noticed the resident ' s response when the dressing was removed from the left hand. He /she stated, "Yes, he/she moved (his/her) hand away. I think (he/she) was in pain." Employee #16 agreed to stop the procedure to reassess the resident as it relates to pain management. Facility Employees #15 and 16 failed to assess Resident #39 prior to and during wound treatment to determine his/her pain status. The resident exhibited nonverbal signs of pain and staff failed to interrupt the treatment to determine the resident ' s tolerance. It was evident that the resident sustained [REDACTED]. A face-to-face interview was conducted on January 28, 2014 at 4:35 PM with Employee #4. He/ she acknowledged the aforementioned findings. The record was reviewed on January 29, 2014. 2. Facility staff failed to ensure that Resident #1 was seen by a psychiatrist as order by the Nurse Practitioner (NP). The Laboratory results signed and dated by the NP on December 30, 2013 revealed, " Prolactin Level " abnormal-98.76 ng/ml; reference ranges 2.10-17.10 ng/ml " The " Skilled Nursing physician progress notes [REDACTED]. " ...Elevated Prolactin level on Psych (psychiatric) med (medications) [MEDICATION NAME], Resperidal ...psych consult to evaluate psych meds " The physician's order [REDACTED]. A review of the consults revealed that there was no psychiatric visit/consult conducted after the order was written on December 20, 2013. There was no evidence that Resident #1 was seen by a psychiatrist to evaluate the elevated Prolactin Level for 29 days. A face-to-face interview was conducted with Employee #3 on January 28, 2014 at approximately 12:00 PM. He/she reviewed the documentation and acknowledged the findings. The record was reviewed on January 28, 2014. 3. Facility staff failed to ensure that Resident #67, who expressed [MEDICAL CONDITION] received necessary care and services to address the potential for self harm. The resident verbalized suicidal ideation on November 9, 2013 and a psychiatry consultation was conducted on January 28, 2014 following a query from the surveyor on January 27, 2014. A nursing progress note dated November 9, 2013 at 5:55 PM read: " Resident alert and responsive. CNA (Certified Nurse Aide) stated that resident said I want to kill myself. CNA told (him/her) don't say that, and the resident said I know, I know. Will continue to monitor resident supervisor is aware. " A telephone interview was conducted with Employee #7 (the nurse assigned to the resident) on January 27, 2014 at 4:23 PM. He/she stated, "I really can ' t remember what I wrote. I passed it on to the night shift. We were monitoring (him/her)." A face-to-face interview was conducted with Employee #8 (CNA assigned to resident) on January 27, 2014 at 3:55 PM. He/she stated, " I was passing by the room and I stopped and asked the resident are you ok. (The resident) said, yea. I stated you don't sound ok. Then (he/she) said I feel like I want to kill myself, are any of these windows open. Then I said don't say that, everything is going to be okay. I kept passing the room back and forth and (he/she) was asleep. I worked from 3-11:30 PM on this day. " A review of the facility ' s 24-hour report (log of unusual incidents and/or change in resident status) for November 9th and 10th, 2013 lacked evidence of documentation related to the suicidal ideation verbalized by Resident #67. The Treatment Administration Record (TAR) for November 2013 revealed facility staff monitored Resident #67 for behaviors (false beliefs, seeing, feeling or hearing things that are not there and persistent yelling or screaming) every shift and recorded the findings on the " Behavior Monitoring Flow Record. " Entries for each shift on November 9, 2013 were recorded as " 0, " indicative that no behaviors were exhibited. A review of the consult section of the clinical record revealed that the most recent psychiatric consultation was conducted on October 24, 2013. The resident ' s mental health [DIAGNOSES REDACTED]. According to Section I, Active [DIAGNOSES REDACTED].#67 ' s mental health [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #3 on January 27, 2014 at 3:30 PM. He/she stated, "This (suicidal ideation verbalized by Resident #67) was not brought to my attention. It was a Sunday. We usually put the resident on watch. " There was no evidence that facility staff implemented measures to protect Resident #67 from the potential for self-harm as verbalized on November 9, 2013. The record lacked evidence of consistent monitoring for behaviors related to suicidal ideation and/or the implementation of interventions to manage the potential for self harm. A psychiatric consultation was conducted on January 28, 2014 after the surveyor brought the lack of interventions to the facility ' s attention. A period of greater than 60 days lapsed from the time that the resident verbalized self harm to the time a psychiatric evaluation was conducted. A successive review of the clinical record on January 28, 2014 revealed the psychiatrist evaluated Resident #67 on January 28, 2014. The consult note included: " Psychiatric note, this is a follow up on this (ethnicity and gender) regarding suicidal ideation 11-9-13 ...Impression, the patient is not a danger to self and others (he/she) is stable. (He/she) will be monitored closely. " The record was reviewed on January 27, 2014.

Based on record and staff interview for two (2) of 29 sampled residents, it was determined there was no evidence facility staff notified Resident #30 ' s primary care physician of recommendations made by the Podiatrist consultant for Lac-Hydrin and heel protectors. The resident developed an alteration in skin integrity 8 days later with a new open wound on lateral posterior aspect of left foot. In addition the facility staff failed to update wound measurements to include all areas skin of impairment at least weekly for Resident #48. The findings include: 1. Facility staff failed to implement care and services to prevent alteration in skin integrity: " lateral posterior " aspect of left foot for Resident #30. Resident #30 was observed on December 19, 2011, at approximately 11:00 AM in the presence of Employee #16. The resident was lying on his/her back in bed that had a specialty air mattress. A left lateral dorsal open wound was noted to be red/ with slough. There was no odor or drainage from the wound bed. No heel protector was observed on left foot as recommended by the podiatrist consult on December 4, 2011. [DIAGNOSES REDACTED]. Chronic [MEDICAL CONDITION], status [REDACTED]. " The admission Minimum Data Set (MDS) dated [DATE] with an assessment reference date of November 7, 2011 coded Resident #30 as follows: Section G0110 (Functional Status) totally dependent with two person physical assistance in bed mobility, and totally dependent with two persons assistance in dressing, eating, toilet use and personal hygiene; G0400 (Functional Limitation in Range of Motion) the resident had impairment on both upper extremities and both lower extremities. Additionally, the admission MDS dated [DATE] coded Section M 0800 (Skin Conditions) as the resident having two (2) Stage 2 ulcers and one (1) Stage IV present on admission; Section M0800 (Worsening in Pressure Ulcer Status Since Prior Assessment) as one (1) Stage 2 pressure ulcer that was not present or was at a lesser stage on prior assessment. A review of a laboratory report dated October 25, 2011 revealed the followings: Hemoglobin 10.9, low (normal range 12.5-16.5), Hematocrit- 35.8, low (normal range 37.5-49.5). A subsequent laboratory report dated November 24, 2011 revealed the followings: Hemoglobin 7.3 (low), Hematocrit 22.9 (low). A physician's order [REDACTED]. A wound consult conducted on November 4, 2011 revealed: Labs: Total Protein 6.4, [MEDICATION NAME]- 2.7. " Normal range for Total Protein is 6.0-8.5; and [MEDICATION NAME]: 3.5-5.5. The Braden Scale for Predicating Pressure Sore Risk was 14 (indicating high risk) on October 25, 2011. A comprehensive review of the nurses ' notes revealed the following: November 4, 2011 at 3:00 PM- (Podiatrist) visited at around 10:00 AM today. (Medical doctor) visited for wound consult. New order given and carried out. " November 12, 2011 at 6:00 AM revealed: " noted open area on (left lateral (posterior) (and) 3rd, 4th, 5th toes, and in between toes. ... (Approximately) 3 x 1 x 0.1; noted bleed-(minimal). Cleanse with Normal Saline left open to dry. Call placed to PMD (Primary Care Physician). Call placed to RP (Responsible Party)...made aware of skin breakdown on (left) lateral 3rd, 4th, and 5th toes. " November 26, 2011 at 5:30 PM- " Dorsal aspect of (left) foot noted to be bleeding; clots noted on towel that foot is resting on. Wound cleansed, pressure dressing applied ... (Primary Medical Doctor) made aware of change in status. (Patient) prepared for transport to nearest (emergency room ). " A review of Resident #30 ' s " Pressure Ulcer Record and Weekly Skin Assessment " lacked evidence that care was provided for the left lateral posterior foot ulcer. A review of a Podiatry consultation dated November 11, 2011 at 10:10 AM revealed: Derm: Turgor was decreased in right and left foot. Texture was dry and scaly, right and left foot. Vascular: Posterior tibial pulses non-palpable, right and left foot. Assessment: Patient has rigid contracture of the lower extremity, negative ulcers; skin has xerosis and needs an [MEDICATION NAME]. Plan of Treatment: (1) Recommended heel protector on the patient ' s foot to prevent heel breakdown, (2) Recommended the patient to have Lac-Hydrin to be applied to his lower extremity for xerosis on a daily basis. " Employee #3 corrected the typed consultation date to November 4, 2011 to reflect the actual date the resident was seen by the Podiatrist. Employee #3 stated: " After talking to the Podiatrist, he/she stated that the clinical visit occurred on November 4, 2011; however, he/she dictated the note on November 11, 2011. " A physician progress notes [REDACTED]. Skin: Assessment: Pressure wound left foot toes x3 with some active bleeding. Pressure applied with control. Will re-enforce pressure dressing. Change daily, Follow-up Podiatry, Elevate left foot- off pressure. " The resident ' s clinical record, including the November, 2011 MAR (Medical Administration Record) and TAR (Treatment Administration Record) lacked evidence that facility staff acted on the Podiatrist ' s recommendations (made on December 4, 2011) for the application of Lac-Hydrin to the resident ' s lower extremities and heel protector on the resident ' s foot to prevent skin breakdown. Furthermore, the resident ' s clinical record lacked evidence that interventions were implemented during the period of November 11-26, 2011 to provide care for the left foot lateral posterior facility -acquired ulcer sustained by the resident. A face-to-face interview was conducted with Employees #5 and #8 on December 19, 2011 at approximately 10:00 AM. Both acknowledged the aforementioned findings. In summary, facility staff failed to follow-up on recommendations made by the Podiatrist on December 4, 2011, subsequently Resident #30 developed an alteration in skin integrity: new open wound on lateral posterior aspect of left foot identified on December 12, 2011. The record was reviewed December 19, 2011. 2. Facility staff failed to update the wound measurements to include all areas skin of impairment at least weekly for Resident #48. The resident was readmitted to the facility on [DATE]. The Pressure Ulcer Records revealed the following: Sacrum: 11/28/11 Sacrum, Stage IV, 10 x 9 (cm) 11/30/11 Sacral, Stage IV, 10 x 9 x1.5 (cm) 12/14/11 Sacrum, Stage IV 10 x 8 x 4 (cm) Right lower thigh: 11/30/11 Right Lower Thigh, Stage II, 4 x 4 cm and 2 x 2 (cm) 12/14/11 Right Lower Thigh, Stage II, 1.5 x 2 x 0 (cm) Right inner upper ischial/thigh: 11/28/11 Rt (right) inner upper (unable to read), Stage II, 1x1 (cm) 11/30/11 R (right) inner upper ischial, Stage II, 1 x1 (cm) 12/14/11 R upper thigh, Stage II, 0.5 x 1 (cm) According to the dates listed on the " Pressure Ulcer " Records for the sacrum, right lower thigh and right inner upper ischial/thigh, the wound measurements were updated on December 14, 2011 14 days after November 30, 2011. The facility ' s " Wound Care Management of Pressure Ulcer " policy last revised September 23, 2009 stipulated: "Procedure: 8. Assessment of every open area or pressure ulcer will be done weekly by a licensed nurse and recorded on the weekly skin sheet. Documentation will include evaluation of the effectiveness of the treatment and need for continuation, change or discontinuance. " There was no evidence that facility staff measured the aforementioned pressure ulcers at least weekly. A face-to-face interview was conducted on December 16, 2011 at approximately 9:51 AM with Employee # 5. He/she acknowledged that assessments and measurements for the aforementioned pressure ulcers were not updated at least weekly. The record was reviewed on December 16, 2011.