Every finding on record at Inspire Rehabilitation and Health Center LLC

Based on record review and staff interviews for one (1) of 49 sampled residents, the facility staff failed to initiate discharge planning for one resident expressed a desire to return to the community. Resident #30. The findings included . Resident #30 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Epididymitis, Hydronephrosis, Muscle Weakness, Calculus in Ureter, Retention of Urine, Dysphagia Oral Phase, Abnormalities of Gait, Obstructive and Reflux Uropathy, Hypertension, Hyperlipidemia, and Adjustment Disorder with Mixed Anxiety and Depressed Mood.Review of the Minimum Data Set (MDS) dated [DATE] indicated the resident had a BIMS score of 12, indicating the resident has some level of cognition impairment.The MDS also documented the resident's overall goal was discharge to the community.Review of the medical record lacked documented evidence of discharge planning outlining the resident's anticipated discharge destination, services needed after discharge, or coordination with community providers.During a face-to-face interview on 3/5/2026 at approximately 2:20 PM, Resident #30 stated, I want to get the hell out of here; I want them to remove this thing [referring to the indwelling catheter he had on] and get the hell out here.During a face-to-face interview on 3/5/2026 at approximately 3:00 PM, Employee #6, Social Services Director, stated that discharge plans are typically documented in the progress notes and discussed during the Interdisciplinary Team (IDT) meeting, usually initiated within 7-10 days after admission. Employee #5 added that discharge planning includes determining equipment needs, anticipated discharge date , and contacting community agencies.Employee #6 further stated that Resident #30 does not have a place to go after discharge and that an application had been submitted to the Department of Aging for assisted living placement. However, Employee #6 acknowledged that communication with the resident regarding the discharge planning process had not been documented in the medical record, stating, I communicated with the resident, but it is not documented.Review of the Social Services progress notes dated 2/16/2026 documented: IDT meeting was conducted with resident. Resident was alert and oriented. Resident was in a bad mood and didn't have any questions or concerns. , but no discharge plan, anticipated discharge location, or post-discharge services were documented.During a face-to-face interview on 3/12/2026 at approximately 11:05 AM, Employee #2, Director of Nursing (DON) stated that discharge planning begins at admission and is followed-up during IDT meetings, and that discharge planning information should be documented in the electronic medical record (PointClickCare) under social services progress notes.Despite these statements, review of the medical record revealed no documented discharge plan for Resident #30, including anticipated discharge destination, post-discharge services, or documented communication with the resident regarding discharge planning, despite the resident's stated goal to discharge to the community and his expressed desire to leave the facility.

Based on record review, observations, and staff interviews, the facility failed to ensure a PASARR Level II evaluation was completed for one (1), who had a diagnosis of Bipolar Disorder, of 49 sampled residents. (Resident #50)Findings Include:Resident #50 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Neurosyphilis, Hypothyroidism, Displaced Intertrochanteric Fracture of the Right Femur, Muscle Weakness, Cognitive Communication Deficit, Anemia, Essential Hypertension, Osteoarthritis, and Tobacco Use.A review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated: BIMS score: 15, indicating the resident was cognitively intact and able to participate in care planning. The resident was assessed for mood symptoms, include: little interest or pleasure in doing things, feeling down, depressed, or hopeless, feeling tired or having little energy. The resident had impairment of both lower extremities and used a wheelchair for mobility.Self-care performance was coded as: Eating and Oral Hygiene - setup or clean-up assistance; Upper Body Dressing - supervision or touching assistance; Toileting Hygiene, Shower/Bathe Self, Lower Body Dressing, Putting On/Taking Off Footwear, Personal Hygiene - dependentThe resident was coded as always incontinent with bladder and bowel.A review of the resident's medical diagnosis list confirmed Bipolar Disorder was documented at the time of admission.A review of the care plan initiated 04/14/2025 documented: Focus: [Resident #50] has diagnosis of Bipolar Disorder, Goal: Resident will demonstrate more mood stability with fewer episodes of mania/depression, Intervention: Staff will encourage the resident to maintain treatment and medication compliance to establish stable and consistent mood.On 03/02/2026 at approximately 2:30 PM, Resident #50 was observed lying in bed with no acute signs of distress but stated, I am too young to be like this, to be a resident here.On 03/11/2026 at approximately 1:05 PM, the resident was observed lying in bed watching television after finishing lunch with no acute distress. The resident stated, It is very boring here. I have watched more TV in here than my entire past life. The resident expressed unhappiness about staying in the facility.A review of the PASARR Level I screening dated 04/14/2025 documented in part: .beneficiary has negative screen for ID or related conditions, and no further action is necessary.However, a review of ePASARR submissions dated 05/21/2025 and 03/11/2026 documented in part: .beneficiary has a positive screen for serious mental. and indicated a possible positive screen for serious mental illness that was submitted to the Department of Health Care Facilities (DHCF).There was no evidence in the resident's medical record that a PASARR Level II evaluation was completed despite the documented diagnosis of Bipolar Disorder.During a face-to-face interview on 03/12/2026 at approximately 1:30 PM, Employee #6 (Social Services Director) stated that he does not complete PASARR screenings and that Employee #9 (Business Office Manager) handles the process. He further stated that a psychiatric company evaluates residents and based on that evaluation he believed the PASARR process is completed. Employee #6 also stated that Resident #50 often expresses anger about life.During a face-to-face interview on 03/12/2026 at approximately 2:05 PM, Employee #10 (Business Office Manager) explained that when a resident is admitted , a psychiatric doctor evaluates the resident within 30 days, and Employee #10 reviews the psychiatric note for mental illness diagnoses. If a mental illness diagnosis is present, Employee #9 then files an ePASARR with Teligent (psych. evaluation company name) for further screening. Employee #10 stated further that Teligen determines whether the resident requires a PASARR Level II evaluation. She added she received training from the Department of Behavioral Health on filing ePASARR.

Based on observations, record reviews and staff interviews, facility staff failed to maintain an effective pest control program so that the facility is free of pests.The findings included:During the follow-up kitchen survey on 03/10/ 2026 approximately at 12:50 PM, it was observed a dead cockroach on floor in the dry storage room. Employee #14, Food service manager, and Employee #16, Maintenance Staff, were immediately made aware of these findings and proceeded to implement measures to address the issue.Record review of the pest control reports from Bay City pest management Co. Inc dated 2.28.2026 and 2.7.2026 documented in part that there was no cockroach activity noted in the kitchen.During a face-to-face interview on 03/10/2026, approximately at 12:50 PM, the above observations were acknowledged by Employee #14, Food Service Manager and Employee #16, Maintenance Staff.During a face-to-face interview on 03/10/2026 approximately at 1:10 PM, Employee #1, Administrator, stated the contracted professional pest exterminator services the facility biweekly and as needed.

Based on observations and staff interviews, facility staff failed to maintain equipment in safe operating condition.The findings included:During the initial kitchen survey on 03/02/ 2026 approximately at 11:15 AM, it was observed that:1. The automatic dish washer pressure gauge was not functional2. The back flow preventer valve next to the pressure gauge at the automatic dishwashing machine was leaking water.3. Water was spraying out of the dishwashing machine when the dish mashing machine was operating. Plastic bags were put atop the machine in an effort to stop the water from spraying out of it.4. The spray hose was placed on the garbage scrap board, below the floor rim level and there wasn't a hook or a hanger provided to store it above flood rim level when it is not in use. 5. Condensate water drainpipe originating from air conditioning unit installed above ceiling was extended through the ceiling tile and drained into the garbage disposer sink. Employee # 14, Food Service Manager, and Employee #17, Maintenance Director, were immediately made aware of these findings and proceeded to implement measures to address the issues.During a face-to-face interview on 03/02/2026, approximately at 11:15 AM, the above observations were acknowledged by Employee #14, Food Service Manager and Employee #17, Maintenance Director.

Based on observations, record review and staff interviews for eight (8) of 49 sampled residents, it was determined that the facility staff failed to: (a.) implement appropriate infection control measures to manage the transmission of a Norovirus outbreak when five (5) residents-four (4) residents on one floor and one (1) resident on another floor-became ill within a five-day period with nausea and vomiting. Subsequently, during this period, one (1) of the five (5) residents became ill after he was allowed to cohort in the same room with his roommate who had exhibited symptoms of the Norovirus (b.) perform hand hygiene when providing services to three (3) residents during meal time; and (c.) conduct an annual review of two (2) infection control policies. Residents' #144, #194, #162, #130, #99, #180, #33, #12. The findings included: A facility policy titled 'Infection Prevention and Control Policy' with a review date of 1/2026 [January 2026] documented, in part: Purpose: The facility will maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and To provide an ongoing surveillance for infection control that is actively involved in detecting trends in facility infections, early detection of outbreaks, and to evaluate the efficacy of infection control practices. (a.) Facility staff failed to implement appropriate infection control measures to address the transmission of a Norovirus outbreak when five (5) residents-four (4) residents on one floor and one (1) resident on another floor-became ill within a five-day period with nausea and vomiting. Subsequently, during this period, one (1) of the five (5) residents became ill after he was allowed to cohort in the same room with his roommate who had exhibited symptoms of the Norovirus just one day earlier. 1. Resident #144 was admitted to the facility on [DATE] with multiple diagnoses that included: Heart Failure, Hypertension, Stroke, Peripheral Vascular Disease and Altered Mental Status. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '09,' that indicated the resident was moderately impaired. Functional goals and abilities that indicated the resident was dependent on staff for Activities of Daily Living (ADL) care and required substantial to maximal assistance from staff with meals. The facility's census dated 12/26/25 revealed that Resident #144 had a roommate. A Situation, Background, Assessment, Request (SBAR) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool dated 12/26/25 at 13:50 [1:50 PM] documented, in part: Vomiting. Resident vomited during his Lunch when the CNA (Certified Nursing Assistant) was feeding him. [Nurse Practitioner's name] was made notified with NNO (no new orders). Refused his Lunch after he vomited. 2. Resident #194 was admitted to the facility on [DATE] with multiple diagnoses that included: Acute Osteomyelitis of Right Ankle and Foot, Malignant Melanoma of Skin, Anemia and Dementia. An admission Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '05,' that indicated the resident was severely impaired. Functional goals and abilities that indicated the resident was dependent on staff for all ADL care. The facility's census dated 12/27/25 revealed that Resident #194 had a roommate. A Situation, Background, Assessment, Request (SBAR) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool dated 12/27/25 at 11:45 [AM]documented, in part: Vomiting x 2 [twice] . Gastrointestinal (vomiting) . New orders: Senna Oral Tablet 8.6 MG (Sennosides) 1 tablet PO (by mouth) Q (every) 12 hours for bowel regimen hold for loose stool . Vomited x 2 about 100cc of some food particles . MD (medical doctor) made aware, new order given. A physician's order dated 12/29/25 at 13:19 [1:19 PM] documented, Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth every 12 hours for bowel regimen old [sic] [hold] for loose stool. A review of Resident #194's Medication and Administration Record dated 12/1/2025 - 12/31/25 revealed that facility staff administered Senna oral tablet 8.6 MG every 12 hours as ordered by the physician. It should be noted that Resident #194 had a planned discharge to home with home health services on 01/30/26. 3. Resident #162 was admitted to the facility on [DATE] with multiple diagnoses that included: Stroke, Hemiplegia, Dementia, Anemia and Hypertension. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the facility coded a Brief Interview for Mental Status (BIMS) summary score of '05,' indicating that the resident was severely impaired. Functional goals and abilities that indicated the resident required Supervision from staff with toileting and showers, tub/shower transfer, toilet transfer and to walk 10 feet; set-up only from staff with eating, oral hygiene, dressing, personal hygiene, sit-to-stand and chair/bed-to-chair transfers. The facility's census dated 12/28/25 revealed that Resident #162 had a roommate. His roommate was Resident #99. A Situation, Background, Assessment, Request (SBAR) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool dated 12/28/25 at 22:24 [10:24 PM] documented, in part: vomited x 1 [once] with undigested food particles.Around 10:15pm resident had one episode of vomiting with presence of food particles.Encouraged oral fluids. [Doctor's name] notified and order obtained Zofran 4 mg (milligram) q (every) 8 hours for nausea/vomiting. A physician's order dated 12/28/25 documented, Zofran Oral Tablet 4 MG (Ondansetron HCl (hydrochloride)) Give 1 tablet by mouth every 8 hours as needed for Nausea/vomiting. A nursing progress note dated 12/28/25 at 23:41 [11:41 PM] documented, in part: Zofran 4mg given for vomiting. 4. Resident #130 was admitted to the facility on [DATE] with multiple diagnoses that included: Stroke, Dementia, Depression and Hypertension. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '04,' that indicated the resident was severely impaired. Functional goals and abilities that indicated the resident was dependent with toileting hygiene/shower-bath/dressing/personal hygiene/transfers/bed mobility; and required setup assistance with eating and oral hygiene. The facility's census dated 12/29/25 revealed that Resident #130 had a roommate.A Situation, Background, Assessment, Request (SBAR) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool dated 12/29/25 at 02:23 [10:24 PM] documented, in part: vomited x3 [three times] with undigested food particles . Resident was noted with vomit of undigested food particles at 11:15pm. After cleaning her up, she had another episode of vomiting and large BM (bowel movement) . [Doctor's name] made aware and order to administer PRN (as needed) Zofran 4mg q 8 hours for nausea/vomiting.At 5:30AM resident noted vomiting again, Doctor was called and gave the order to send the resident to the nearest ER (emergency room) for evaluation. A physician's order dated 12/29/25 documented, Ondansetron HCl Oral Tablet 4 MG (Ondansetron HCl) Give 1 tablet by mouth every 8 hours as needed for Nausea and vomiting. A review of Resident #130's Medication Administration Record dated 12/1/2025 - 12/31/25 documented that facility staff administered Ondansetron HCl Oral Tablet 4 mg for nausea and vomiting on 12/29/25 at 01:45 AM. A physician's order dated 12/29/25 at 05:31 [5:31 AM] documented, Transfer to the ER for evaluation and treatment. A nursing progress note dated 12/29/25 at 05:47 [5:47 AM] documented, Ondansetron HCl Oral Tablet 4 MG Give 1 tablet by mouth every 8 hours as needed for Nausea and vomiting PRN Administration was: Ineffective indicating the medication was ineffective in relieving her episodes nausea and vomiting. A nursing progress note dated 12/29/25 at 07:30 [7:30 AM] documented, in part: This writer was notified again by the unit nurse that resident continues to vomit food particles. Upon assessment resident appeared weak, had vomited multiples times .Foul smelling bowelmovement was noted. This nurse called and notified the physician again, new order to sendresident to the ER to evaluate and treat obtained. Resident initially declined going to the hospital when EMS (emergency medical services) arrived, but RP (responsible party) was contacted again who spoke with resident over the phone and resident agreed to go to the hospital. Resident left facility at about 6:40am to [hospital name]. A nursing progress noted dated 12/29/25 at 20:18 [8:18 PM] documented, in part: Writer called [hospital name] to f/u (follow up) with resident status, ER personnel who stated that resident is evaluated, and she is discharging. The ER personnel stated she is in stable condition, waiting for transportation. A nursing progress note dated 12/30/25 at 13:11 [1:11 PM] documented, in part: [Resident #130], a resident of this facility who is readmitted after a short stay hospitalization for nausea and vomiting. Resident returned via stretcher to [room number] . no N/V (nausea/vomiting) noted or voiced by the resident. It should be noted that Resident #130 returned to the same semi-private room prior to her hospitalization for nausea and vomiting and she had a roommate. A social work progress note dated 12/31/25 at 08:54 [8:54 AM] documented, in part: Resident transferred to [hospital name] emergency room related to multiple episode[s] of emesis, 6-108 (notice of discharge or relocation form), Bed Hold Policy, sent to resident's responsible party/LTC (long term care) Ombudsman. 5. Resident #99 was admitted to the facility on [DATE] with multiple diagnoses that included: Alzheimer's Disease, Renal Disease, Arthritis and Anemia. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '04,' that indicated the resident was severely impaired. Functional goals and abilities that documented the resident required supervision with showers and bathing and was independent with all other activities of daily living care. The facility's census dated 12/29/25 revealed that Resident #99 had a roommate. Resident #162 was his roommate. A Situation, Background, Assessment, Request (SBAR) Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool dated 12/29/25 at 19:18 [7:18 PM] documented, in part: vomited x1 (one time) with undigested food particles . Around 18:00 [6:00 PM] Resident had one episode of vomiting with presence of food particles . Encouraged oral fluids . [Doctor's name] notified and order obtained Zofran 4 mgs (milligrams) PO (by mouth) Q (every) 8HRS (eight hours) prn (as needed) for vomiting. A physician's order dated 12/29/25 at 19:52 [7:52 PM] documented, Zofran Oral Tablet 4 MG (Ondansetron HCl) Give 1 tablet by mouth every 8 hours as needed for vomiting. A review of Resident #99's Medication Administration Record dated 12/1/2025 - 12/31/25 documented that facility staff administered Zofran oral tablet 4 MG ON 12/29/25 at 8:12 PM as ordered by the physician. A nursing progress note dated 12/29/25 at 22:37 [10:37 PM] documented, in part: Resident verbalized feeling much better after PRN zofran [Zofran] administered for vomiting. He was encouraged and offred [offered] to take fluids. It should be noted that Resident #99 became ill while cohorting with his roommate, Resident #162, who first became ill with symptoms of nausea and vomiting. It should also be noted that there is no documented evidence that Residents' #144, #194, #162, #130 and #99 were moved to another room when they became ill with the symptoms of the Norovirus, or away from their roommates, who were initially unaffected, to prevent the spread of the virus. A review of the facility's daily census from 12/25/25 to 01/02/26 revealed that the facility had available beds and unoccupied resident rooms. During a face-to-face interview conducted on 03/4/26 at approximately 10:00 AM with Employee #12 (Infection Prevention and Control) he stated, We thought it was an isolated incident, so we didn't think that we needed to move affected residents to other rooms. During a face-to-face interview conducted on 03/06/26 at approximately 3:34 PM with Employee #2 (Director of Nursing) she acknowledged the findings. (b.) Facility staff failed to conduct hand hygiene in between providing services to three (3) residents while handling meal trays, offering set-up and feeding assistance as to prevent the spread of infections. A facility policy titled 'Hand Hygiene' with a review date of 01/2026 [January 2026] documented, in part: 1. All personnel are provided with hand hygiene training upon hire and annually thereafter. 2. All personnel are required to adhere to hand hygiene policies and practices. Staff adherence to hand hygiene is incorporated into infection prevention and control process surveillance and monitored by the infection preventionist as part of the facility infection prevention and control program. 1. Hand hygiene is indicated: a. before touching a resident; b. before preparing or handling food; f. after touching a resident; g. after touching a resident's environment or belongings (e.g., bedrails, etc.) . 1. Use an alcohol-based hand rub (ABHR) for most clinical situations. a. Unless hands are visibly soiled, ABHR is the preferred method of hand hygiene in clinical situations because it is more effective at killing germs, faster to use, and less irritating to the skin than soap and water. Resident #180 was admitted to the facility on [DATE] with multiple diagnoses that included: Stroke, Dementia, Hemiplegia, Seizure Disorder and Acquired Absence of Right Leg Above Knee. A care plan dated 04/05/19 documented, in part: Focus: [Resident's name] has Self Care performance Deficit. Interventions: Feed/assist resident during meals. A care plan dated 10/17/25 documented, in part: Focus: [Resident's name] has an ADL self-care performance deficit r/t Disease Process . Interventions: BED MOBILITY: The resident is totally dependent on (2) staff for repositioning and turning in bed. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' that indicated the resident was cognitively intact. Functional goals and abilities that documented the resident required Substantial to Maximal assistance from staff with bed mobility and Partial to Moderate assistance from staff with eating meals. A physician's order dated 02/10/26 documented, Regular diet Mechanical Soft texture, Thin Liquids consistency. 2. Resident #33 was admitted to the facility on [DATE] with multiple diagnoses that included: Heart Failure, Hypertension, Stroke and Fracture of Left Side Rib. A care plan dated 06/16/25 documented, in part: [Resident's name] has ADL Self-care deficit related to generalized weakness and impaired mobility due to Right MCA Stroke . Interventions: Assist with daily hygiene, grooming, dressing, oral care and eating as needed. EATING: Ms. [NAME] can eat independently after tray setting up. A physician's order dated 08/21/25 documented, Regular diet, Mechanical Soft texture, Thin Liquids consistency. A care plan dated 02/16/26 documented, in part: Focus: [Resident's name] has an ADL self-care performance deficit r/t Disease Process . Interventions: EATING: The resident is set up meals by (1) staff for eating. EATING: The resident requires (setup assistance) by (1) staff to eat. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '12,' that indicated the resident was moderately impaired. Functional goals and abilities that documented the resident required Substantial to Maximal assistance from staff with bed mobility, lying to sitting, and transfers; and required Setup assistance with eating. A review of the facility's census on 03/04/26 revealed that Resident #33 had a roommate. Her roommate was Resident #12. 3. Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included: Aphasia, Dementia, Stroke and Hemiplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score that indicated the resident was 'Severely Impaired.' Functional goals and abilities that documented the resident was Dependent with all Activities of Daily Living and required Substantial to Maximal assistance from staff with eating. A care plan dated 01/30/26 documented, in part: [Resident's name] has an ADL self-care performance deficit r/t (related to) Hemiplegia/Hemiparesis of cerebral infarction. Interventions: BED MOBILITY: The resident requires extensive assistance by (1) staff to turn and reposition in bed . EATING: The resident requires extensive assistance by (1) staff to eat. A care plan dated 01/30/26 documented, in part: The resident has limited physical mobility r/t right sided weakness . Interventions: Provide supportive care, dependent with ADL's: locomotion, bed mobility, transfer, bathing, personal hygiene, eating as needed. A physician's order dated 02/02/26 documented, NAS (no added salt)/LCS (low concentrated sweets) diet Mechanical Soft texture, Thin Liquids consistency. During a dining observation conducted on 03/04/26 at approximately 8:38 AM to 9:00 AM, a facility staff was observed passing breakfast trays to the residents. It was noted that Employee #22 (assigned Certified Nursing Assistant, CNA) removed a breakfast tray from the food cart and delivered the meal tray to Resident #180, placed the tray on the bedside table, raised the head of the bed, assisted the resident up in bed, removed the dome covering the hot plate, repositioned the bedside table in front of the resident, removed silverware and straw from the packaging, opened a carton of milk and placed the straw into the milk carton. After completing these tasks, Employee #22 left the resident's room. She then retrieved another meal tray from the food cart and delivered the tray to Resident #33 where she placed the tray on the bedside table, assisted the resident to a sitting position at the side of the bed, repositioned the bedside table in front of the resident, removed the dome covering the hot plate, removed the silverware and straw from the packaging, opened a carton of milk and placed the straw into the milk carton, and cut the resident's pancakes into small pieces. After she completed those tasks, she left the semi-private room and retrieved another meal tray. Employee #22 delivered that tray to Resident #12, Resident #33's roommate, then repositioned the bedside table in front of the resident, removed the dome covering the hot plate, removed the silverware and straw from the packaging, opened a carton of milk and placed the straw into the milk carton, then sat down next to the resident to provide feeding assistance. It should be noted that, while Employee #22 (CNA) was being observed, she did not perform any hand hygiene using an alcohol-based hand rub (ABHR), or soap and water, before and after touching a resident and the resident's environment (e.g., bed and bedside table) and before and after providing setup and feeding assistance to Residents' #180, #33, and #12. During a face-to-face interview conducted on 03/04/26 with Employee #22 (CNA) she stated, I must have forgot. During a face-to-face interview conducted on 03/04/26 at approximately 9:05 AM with Employees' #23 (Unit Manager) and Employee #2 (Director of Nursing), they both acknowledged the findings. (c.) Facility staff failed to conduct an annual review for two (2) of its infection control policies. A review of the facility's Infection Control policies revealed a policy titled 'Policy - COVID-19 Resident Vaccination Policy that documented, Revised 06/1/2022 and a policy titled 'Policy: COVID-19 PPE, source control for Healthcare personnel' that documented, Rev (revised) Date: 6/2023. During a face-to-face interview conducted on 03/12/26 at approximately 3:30 PM with Employee #12 he acknowledged the findings and stated, We wait to get the updates from our regional office. Cross reference: DCMR S 3206.3

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, for three (4) of 49 sampled residents, the facility staff failed to ensure that binding arbitration agreements made between the facility and the resident and or their representative provided for the selection of a neutral arbitrator agreed upon by both parties; and provided for the selection of a venue that is convenient to both parties. Residents # 125, #27, #33, and #127.The findings included:A review of the facility's most recent admission packet included the following binding arbitration agreement for residents and the facility that documented: Resident-Facility Binding Arbitration Agreement [Name of Facility] and [Resident's Name](Resident, or :Resident Legally Authorized Representative (hereinafter, collectively, Resident) understand and agree that any dispute, disagreement, controversy, demand or claim, including but not limited to, legal claims, arising between them regarding any service or health care provided to the Resident by the Facility, even if such dispute arises after the Resident's stay at the Facility has ended, shall be submitted to binding arbitration and exclusively resolved by arbitration, except as otherwise set forth below. This Agreement does not apply to (a) collection actions instituted by the Facility, (b) Resident's due process rights before state or federal regulatory or administrative agencies.The parties understand and agree that by signing this arbitration agreement, they are giving up and waiving their statutory and constitutional rights to have any claim, including malpractice and wrongful death claims, decided in a court of law before a judge and jury.The parties acknowledge that this Agreement binds the Facility, the Facility's Agents, the Facility's Employees, the Resident, the Resident's legally authorized appointed representative (including without limitation a Guardian, Attorney in Fact, or holder of Power of Attorney), the Resident's spouse, children, and heirs(once determined), the Resident's Estate (once extant), The Resident's Estate executor (upon naming), the Resident's successors and assigns, and all persons whose claim(s) derives through or on behalf of the Resident. Of note, there was no language in the agreement stating that if the Resident and facility go to arbitration, a neutral arbitrator agreed upon by both parties will be selected, along with an arbitration venue convenient to both parties.1.Resident was admitted to the facility on [DATE] with diagnoses that included: Multiple Sclerosis, Other Muscle Spasms, Vitamin D Deficiency, Contracture, Left Hand; Vitamin B-12 Deficiency Anemia, and Weakness.A review of Resident #125's medical record revealed:A face sheet which documented that Resident #125 represented himself and was his own responsible party.An admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.A binding arbitration agreement between Resident #125 and the facility dated 08/27/25 that was -e-signed (electronically signed) by Resident #125 as his own representative and by Employee #21 (Admissions Director) as the Facility's representative.During a face-to-face interview on 03/10/26, at 10:57AM, with Resident #125, when asked if Employee #21 explained that if the Resident and the facility go to arbitration a neutral arbitrator and a neutral location for the arbitration to take place would be selected by both parties, Resident #125 stated, No, I don't recall the Admissions person explaining that to me. 2.Resident #27 was admitted to the facility on [DATE] with diagnoses that included: Dysphagia; Hemiplegia and Hemiparesis following Cerebral Infarction; Encounter for Attention to Gastrostomy; Type 2 Diabetes Mellitus; Cognitive Communication; Muscle Weakness (Generalized) and Gout. A review of Resident #27's medical record revealed: A face sheet showing that Resident #27 had two family members documented as Emergency Contact #1 and Emergency Contact #2, respectively.A binding arbitration agreement between Resident #27 and the facility, dated 05/29/25, signed by Resident #27. Emergency Contact #1 as the Resident's representative and by Employee # (Admissions Director) as the Facility's representative.An admission Minimum Data Set (MDS) assessment dated [DATE] showed the Resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition.A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.During a telephone interview on 03/10/26 at 10:27 AM, with Emergency Contact #1 and #2 for Resident #27, Emergency Contact #1 stated, I don't remember the admission staff person ever explaining that we could select a neutral arbitrator and a neutral location for arbitration that was convenient for us and the facility. 3.Resident #33 was admitted to the facility on [DATE] with diagnoses that included: Fracture of Rib, Left Side; Protein calorie Malnutrition; Atrial Fibrillation; Systolic (Congestive) Heart Failure; Muscle Weakness (Generalized) and Cognitive Communication Deficit. A review of Resident #33's medical record revealed:A face sheet showing that Resident #33 was her own responsible party, and that the Resident had four family members documented as Emergency Contact #1-#4, respectively.A binding arbitration agreement between Resident #33 and the facility dated 06/20/25 that was e-signed (electronically signed) by Resident #33's Emergency Contact #1 as the Resident's representative and by Employee # (Admissions Director) as the Facility's representative.An admission Minimum Data Set (MDS) assessment dated [DATE] showed the Resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.During a face-to-face interview on 03/11/26 at 9:08 AM, with Resident #33 when asked if the facility staff explained that if the Resident and the facility go to arbitration, both parties could choose a neutral arbitrator and a neutral location for the arbitration, the Resident stated, No. 4.Resident #127 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia, Affecting Right Dominant Side; Displaced Fracture of Lateral End of Right Clavicle; Hematuria; Muscle Weakness (Generalized); Adjustment Disorder with Mixed Disturbance of Emotions and Conduct and Cognitive Communication Deficit.A review of Resident #127's medical record revealed:A face sheet which showed that Resident #127 had a Power of Attorney as her representative/responsible party.A binding arbitration agreement between Resident #127 and the facility dated 02/10/26 that was e-signed (electronically signed) by Resident #33's Emergency Contact #1 as the Resident's representative and by Employee # (Admissions Director) as the Facility's representative.An admission Minimum Data Set (MDS) assessment dated [DATE], which showed the Resident had a Brief Interview for Mental Status (BIMS) of 14, indicating that the Resident had intact cognition.During a telephone interview on 03/12/26 at 11:50 AM with Resident #127's representative/Power of Attorney, when asked if facility staff explained that should the Resident and staff have to go to arbitration, a neutral arbitrator and a neutral location for the arbitration would be selected by both parties, she stated No , I don't recall anyone from Admissions explaining that to me.Interviews with Residents, Resident representatives, and residents' emergency contacts who had signed binding arbitration agreements with the facility showed no evidence that facility staff explained that if arbitration occurs between the Resident, the representative, or Emergency contact, a neutral arbitrator and a neutral location for the arbitration would be selected by both parties.During a face-to-face interview on 03/12/26 at 3:23 PM, Employee #21, Director of Admissions, stated that Language regarding the selection of the arbitrator and the location for arbitration is not included in the agreement. I believe Residents and their reps do have a say in the arbitrator. In cases of arbitration, I am accustomed to letting them know who their arbitrator is. I will have to check with my regional office to see if the arbitrator and the location can be selected by both parties.

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, for three (4) of 49 sampled residents, the facility staff failed to ensure that residents and or their representatives understood the binding arbitration agreements made between the residents and /or their representatives and the facility. Residents #125, ##27, #33, and #127.The findings included:A review of the facility's most recent admission packet included the following binding arbitration agreement for residents and the facility that documented: Resident-Facility Binding Arbitration Agreement[Name of Facility] and [Resident's Name](Resident, or :Resident Legally Authorized Representative (hereinafter, collectively, Resident) understand and agree that any dispute, disagreement, controversy, demand or claim, including but not limited to, legal claims, arising between them regarding any service or health care provided to the Resident by the Facility, even if such dispute arises after the Resident's stay at the Facility has ended, shall be submitted to binding arbitration and exclusively resolved by arbitration, except as otherwise set forth below. This Agreement does not apply to (a) collection actions instituted by the Facility, (b) the Resident's due process rights before state or federal regulatory or administrative agencies.The parties understand and agree that by signing this arbitration agreement, they are giving up and waiving their statutory and constitutional rights to have any claim, including malpractice and wrongful death claims, decided in a court of law before a judge and jury.The parties acknowledge that this Agreement binds the Facility, the Facility's Agents, the Facility's Employees, the Resident, the Resident's legally authorized appointed representative (including without limitation a Guardian, Attorney in Fact, or holder of Power of Attorney), the Resident's spouse, children, and heirs(once determined), the Resident's Estate (once extant), The Resident's Estate executor (upon naming), te Resident's successors and assigns, and all persons whose claim(s) derives through or on behalf of the Resident.The Resident understands that (1) the Resident should seek legal counsel concerning this Agreement, (2) the Resident does not have to sign this Agreement as a precondition to the Facility providing services to the Resident, and (3) this Agreement may be rescinded by written notice sent to the other party by Certified Mail, return receipt requested, within thirty (3) days of the date upon which it is signed.Rescission or waiver of this Agreement can only be affected in writing. 1.Resident was admitted to the facility on [DATE] with diagnoses that included: Multiple Sclerosis, Other Muscle Spasms, Vitamin D Deficiency, Contracture, Left Hand; Vitamin B-12 Deficiency Anemia, and Weakness.A review of Resident #125's medical record revealed:A face sheet which documented that Resident #125 represented himself and was his own responsible party.An admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.A binding arbitration agreement between Resident #125 and the facility dated 08/27/25 that was -e-signed (electronically signed) by Resident #125 as his own representative and by Employee # (Admissions Director) as the Facility's representative.During a face-to-face interview on 03/10/26, at 10:57AM, Resident #125 stated, I understand what arbitration is, and the process of arbitrating when an issue or concern arises, but I don't remember signing an arbitration agreement with the facility. If I signed the agreement, I was not clear on what I was signing. I may have signed it just to get through the admission packet. I don't recall the Admissions person clearly explaining to me that that I should seek legal counsel before signing the agreement, or that if signed the agreement, I was giving up certain legal rights, otherwise, I would never have signed it. 2.Resident #27 was admitted to the facility on [DATE] with diagnoses that included: Dysphagia; Hemiplegia and Hemiparesis following Cerebral Infarction; Encounter for Attention to Gastrostomy; Type 2 Diabetes Mellitus; Cognitive Communication; Muscle Weakness (Generalized) and Gout. A review of Resident #27's medical record revealed:A face sheet showing that Resident #27 had two family members documented as Emergency Contact #1 and Emergency Contact #2, respectively.A binding arbitration agreement between Resident #27 and the facility, dated 05/29/25, signed by Resident #27. Emergency Contact #1 as the Resident's representative and by Employee # (Admissions Director) as the Facility's representative.An admission Minimum Data Set (MDS) assessment dated [DATE], which showed the Resident had a Brief Interview for Mental Status (BIMS) of 00, indicating that the Resident had severely impaired cognition.A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.During a telephone interview on 03/10/26 at 10:27 AM, with Emergency Contact #1 and #2 for Resident #27, Emergency Contact #1 stated, We don't remember signing anything that would have prevented [Name of Resident #3] or our family from ever taking the facility to court. We currently have several concerns with the facility and will be filing grievances. The arbitration process nor the agreement with the facility were made clear with us, before signing because we would not have signed anything like that. 3.Resident #33 was admitted to the facility on [DATE] with diagnoses that included: Fracture of Rib, Left Side; Protein-calorie Malnutrition; Atrial Fibrillation; Systolic (Congestive) Heart Failure; Muscle Weakness (Generalized) and Cognitive Communication Deficit. A review of Resident #33's medical record revealed: A face sheet showing that Resident #33 was her own responsible party and that the Resident had four family members documented as Emergency Contact #1-#4, respectively.A binding arbitration agreement between Resident #33 and the facility dated 06/20/25 that was e-signed (electronically signed) by Resident #33's Emergency Contact #1 as the Resident's representative and by Employee # (Admissions Director) as the Facility's representative.An admission Minimum Data Set (MDS) assessment dated [DATE], which showed the Resident had a Brief Interview for Mental Status (BIMS) of 15, indicating that the Resident had intact cognition.During a face-to-face interview on 03/11/26 at 9:08 AM, Resident #33 stated, I don't remember signing any legal papers like that. There were a lot of papers to sign when I first got here. [Emergency Contact #2] was with me when I first got here, and he wouldn't allow me to sign something like that. Call him. Of note Emergency Contacts #1 and #2 for Resident #33 could not be reached by phone and were unavailable for interview during the survey. 4.Resident #127 was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia, Affecting Right Dominant Side; Displaced Fracture of Lateral End of Right Clavicle; Hematuria; Muscle Weakness (Generalized); Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, and Cognitive Communication Deficit.A review of Resident #127's medical record revealed:A face sheet which showed that Resident #127 had a Power of Attorney as her representative/responsible party.A binding arbitration agreement between Resident #127 and the facility dated 02/10/26 that was e-signed (electronically signed) by Resident #33's Emergency Contact #1 as the Resident's representative and by Employee # (Admissions Director) as the Facility's representative.An admission Minimum Data Set (MDS) assessment dated [DATE] showed the Resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.During a telephone interview on 03/12/26 at 11:50 AM with Resident #127's representative/Power of Attorney, she stated, I did not understand what I was signing at that time at all. I am not even sure if I understand how arbitration works. Given the need to quickly find a long-term care facility for the Resident, I was more concerned with the Resident's current state of health and welfare. I do not remember the admissions staff suggesting that I seek legal counsel before signing the agreement, and the admission staff person did make it clear that by signing the document, I or the Resident would be giving up the right to ever seek legal action against the facility in court.Interviews with Residents, Resident representatives, and residents' emergency contacts who had signed binding arbitration agreements with the facility showed no evidence that facility staff explained the agreements clearly to ensure that the Residents' representatives or residents' emergency contacts understood what they were signing. During a face-to-face interview on 03/12/26 at 3:23 PM, Employee #21, Director of Admissions, stated: The binding arbitration agreements are included in our admission packet. Before going over the binding arbitration agreements with the Resident, I always wait until the facility has determined the Resident's Brief Interview for Mental Status (BIMS) summary score. For residents with a BIMS score of 12 or higher, I schedule a meeting with the Resident and/or their representative or emergency contacts to review the admissions packet and the binding arbitration agreement. I also schedule meetings with the resident representative of residents who have a BIMS score of 12 or lower and want to sign an arbitration agreement. Before the Resident/representative or emergency contact signs the binding arbitration agreement, I ask whether they have ever heard of a binding arbitration agreement. If they haven't, I will explain what it is. I explain that by signing the agreement, they agree to use our arbitrator, rather than their own legal counsel, for any unresolved grievance, dispute, or legal matter between the Resident and the facility. I let them know that signing is voluntary and is not required for the Resident's admission to the facility. I then let the Resident, their representative, or emergency contact know that they have 30 days from the date that they signed the binding arbitration agreements to change their minds. When asked if that process for rescinding the binding arbitration agreement between the Resident, representative or emergency contact and the facility was outlined anywhere in the document itself, Employee started , No, I just let the Resident or representative know that can contact me by calling my office extension or come to my office and I let our regional office know so it can be rescinded.When asked how she determines that the Resident or representative understood all of the information she provided about the binding arbitration agreements, the Employee stated, I ask them if they understand.

Based on observations and staff interviews, facility staff failed to prepare and distribute food under sanitary conditions, and store food at the appropriate temperatures as evidenced by the following observations. The findings include:During an initial kitchen survey in the kitchen on 03/02/2026 approximately at 11:15 AM, the following observations were made: Interior surfaces of the ice making machines were not cleaned.There was no hand-washing soap provided in the dispenser mounted on wall above hand washing sink at the food preparation area in the kitchen.Food service manager, Employee #13 and Employee #14, Nutritionist, were immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 03/02/2026, approximately at 11:45 AM, the above observations were acknowledged by Employee #13, Food Service Manager and Employee #14, Nutritionist.During follow-up kitchen survey on 03/11/2026 approximately at 12:50 PM, the following observations were made: Cooked chicken was not held at proper hot holding temperature on the steam table. Employee #13 (Kitchen Manager) used digital probe thermometer to check the cooked chicken temperature and observed it was held at 122 degrees F.Melted commercially packaged chocolate ice cream in small cup in bin with ice observed melted.The automatic dish washing machine was supplied with sodium hypochlorite (commonly known as bleach) sanitizing chemical. However, there was no proper test strips provided to measure the appropriate concentration of the sodium hypochlorite (bleach) solution.Employee belongings such jackets, backpacks, etc were placed haphazardly on top of cases of bottled water stored for emergency purposes. During a face-to-face interview on 3/11/2026, approximately at 12:50 PM, the above observations were acknowledged by Employee #13, Food Service Manager and Employee #15, Maintenance Staff.

Based on observations and staff interviews, facility staff failed to employ staff with the appropriate competencies. The findings include:During the initial kitchen survey on 03/02/2026 approximately at 11:15 AM, it was observed that the kitchen food service manager has not obtained a valid certified food protection manager identification card issued by the DC Department of Health.During a face-to-face interview on 03/02/2026, approximately at 11:15 AM, the above observation was acknowledged by Employee #14, Food Service Manager and Employe #15, Nutritionist.

Based on record review and staff interviews, the facility failed to ensure that irregularities identified during the consultant pharmacist's Medication Regimen Review (MRR) were reported, acted upon, and/or implemented in a timely manner for four (4) of 49 sampled residents. (Residents #4, #5, #19 and #7) Resident #4 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Hypertension, Diabetes Mellitus, Hyperlipidemia, Osteoarthritis, Dementia with psychotic disturbance, Paranoia Schizophrenia, Depression, and Anxiety. A review of the Physician Medication orders showed Resident #4 is currently taking the following medication. Clonazepam 0.5mg for Anxiety Mirtazapine 15 mg for Depression Olanzapine 20mg for Paranoid Schizophrenia Amlodipine 10mg for HTN Donepezil 10mg for Dementia Metoprolol 25mg for HTN Hydralazine 100mg for HTN Gabapentin 300mg for Neuroleptic pain Eliquis 5mg for Chronic embolism and Thrombolysis in right leg Ezetimibe 10mg for Hyperlipidemia Toujeo Solostar 300-unit pen injector for DM Voltaren Arthritis topical Gel for pain A review of the Pharmacist drug regimen review (DRR) documentation in e-chart showed reviews were conducted on the following dates [1/26/26, 1/25/26, 3/14/26, 3/9/26, 9/3/25, 6/25/25 2/5/25, 2/4/25, 2/1/25]. the pharmacist recorded three (3) irregularities, dated [9/3/25 ,1/25/2026, and 3/4/2026] and the physician/advanced practice nurse response was recorded as I agree, however the response did not include what action was to be taken for the irregularities. Additionally, there was no documented evidence that the Pharmacist drug regimen review was conducted monthly. A face-to-face interview conducted on 03/11/2026 with Employee# 2 [Director of Nursing] reviewed Resident #4's records and acknowledged the lack of monthly reviews and complete responses to the DRR. 2. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia with Psychotic Disturbance, Seizure Disorder and Colostomy. A physician's order dated 6/10/25 documented, Memantine HCl (Hydrochloride) Oral Tablet 10 MG (milligram) (Memantine HCl) Give 1 [one] tablet by mouth two times a day for Dementia. A physician's order dated 6/10/25 documented, QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Agitation. A physician's order dated 6/26/25 documented, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule[s] by mouth three times a day for Dementia w/(with) behavioral disturbances give with food. A care plan dated 06/25/25 documented, in part: Focus: [Resident #5's name] uses psychotropic medications r/t (related to) Disease process (DEMENTIA WITH PSYCHOTIC DISTURBANCE) . Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Discuss with MD, family re[[NAME]] ongoing need for use of medication. Educate his family about risks, benefits and the side effects and/or toxic symptoms of psychoactive medication drugs being given. Monitor/record/report to MD (medical doctor) prn (as needed) side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Modified Independence,' the resident had a history of Dementia and was prescribed antipsychotic medications. A review of Resident #5's medical record conducted on 03/11/26 at approximately 9:30 AM revealed that there was no documented evidence of monthly drug regimen reviews conducted for the following months: March 2025, April 2025, May 2025, August2025 and September 2025. 3. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia with Psychotic Disorder. A physician's order dated 11/25/25 documented, Abilify Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth one time a day for schizophrenia. A care plan dated 11/26/25 documented, in part: Focus: [Resident #19's name] uses psychotropic medications r/t (related to) schizophrenia . Interventions: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (psychotropic medication drugs being given). Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. A care plan dated 12/16/25 documented, in part: Focus: [Resident #19's name] is at risk for adverse reaction r/t POLYPHARMACY . Interventions: Discuss with resident and family the number and type of medications resident is taking and the potential for drug interactions and side effects from over-medication. Monitor for possible signs and symptoms of adverse drug reaction: falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, gastric upset. Request physician to review and evaluate medications. Review Pharmacy consult recommendations, and follow up as indicated. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' indicating the resident was cognitively intact, had a history of Schizophrenia with psychotic disturbance and was prescribed antipsychotic medications. A review of Resident #19's medical record conducted on 03/11/26 at approximately 9:30 AM revealed that there was no documented evidence of monthly drug regimen reviews conducted for the following months: August 2025 and September 2025. During a face-to-face interview conducted on 03/11/26 at approximately 10:20 AM with Employee #2 (Director of Nursing) she acknowledged the findings and stated, in part that If it's medication changes, then it's the Unit Managers and the Charge Nurse who updates the order if the provider agrees and then the reviewed pharmacy recommendation is placed back into the binder to be uploaded in the miscellaneous tab under pharmacy recommendation within one week. The Unit Managers don't keep hard copies because they're all uploaded. 4. Resident #7 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Type 2 Diabetes Mellitus, Protein Energy Malnutrition, Major Depressive Disorder, Atrial Fibrillation, Hydronephrosis, Urinary Retention, and Urinary Calculus. A review of the Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicated the resident had some level of impaired cognition. The resident utilized a wheelchair for mobility and had an indwelling urinary catheter. A review of the resident's care plan, initiated 04/07/2025, indicated the resident had actual skin impairments including a left great toe diabetic wound, and included interventions to follow wound care orders as directed. A review of the Consultant Pharmacist Medication Regimen Review (MRR) dated 12/23/2025 documented in part: The resident has an order for DICLOFENAC (Voltaren) gel. Please provide a dose. Please note the suggested dosing: For upper extremities: Apply 2 grams every 6 hours – not to exceed 8 grams/day to any single joint. For lower extremities: Apply 4 grams every 6 hours – not to exceed 16 grams/day to any single joint. Please also consider updating the order to include 'Maximum total body dose (all joints combined) is 32 grams/day,' if applicable. The pharmacist recommendation was signed by the consultant pharmacist and also signed and dated by Employee #7, RN, 1st Floor Unit Manager. Further review of a Consultant Pharmacist MRR dated 02/27/2026 documented the same recommendation requesting that the Voltaren gel order include a defined dose and dosing limits. This document was signed by the consultant pharmacist and Employee #7, RN, 1st Floor Unit Manager. A review of the Medication Administration Record (MAR) dated 02/01/2026 through 02/28/2026 revealed Resident #7 received Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium topical) twice daily at 0900 hours (9:00 AM) and 1700 hours (5:00 PM). The MAR did not reflect the dosing parameters recommended by the consultant pharmacist. A review of the physician order dated 03/02/2026, ordered by Employee #11, documented: Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium topical) – Apply to left hand topically two times a day for left hand pain. This order did not include the dosing parameters recommended in the pharmacist's DRRs dated 12/23/2025 and 02/27/2026. Further review revealed a subsequent physician order dated 03/06/2026, ordered by Employee #13, Medical Director, documented: Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium topical). Apply to bilateral knee topically four times a day for bilateral knee pain. Apply 4 grams every 6 hours – not to exceed 16 grams/day to any single joint. This order reflected the dosing guidance previously recommended by the consultant pharmacist. During a face-to-face interview on 03/11/2026 at approximately 11:30 AM, Employee #2 (Director of Nursing) stated that the DON, ADON, and QA/IP staff receive Medication Regimen Review reports through the SCCG portal, and these reports are distributed to unit managers for physician review and implementation. The DON further stated that once providers agree with recommendations, they should be implemented and uploaded to the resident's PointClickCare electronic medical record within approximately one week. The DON acknowledged that the pharmacy recommendations referenced above were not uploaded into the PointClickCare system at the time of the interview, and stated they would be uploaded as soon as possible. During a phone interview on 03/11/2026 at approximately 11:50 AM, Employee #11, Nurse Practitioner, stated that it is his responsibility to review medications and consider pharmacy recommendations when prescribing medications. He stated he inadvertently missed the pharmacist's recommendations dated 12/23/2025 and 02/27/2026 to include dosing parameters for Diclofenac (Voltaren) gel when prescribing the medication on 03/02/2026. Based on the above findings, the facility failed to ensure that pharmacist-identified medication regimen irregularities were acted upon and implemented in a timely manner for Resident #7.

Based on observations, record review and staff interviews for two (2) of 49 sampled residents, it was determined that the facility staff failed to follow physician orders for splint placement for one resident with a contracture and failed to consistently assist one resident with the application of dentures. (Residents #5 and #199) The findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia with Psychotic Disturbance, Seizure Disorder and Colostomy. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Modified Independence,' had a history of Dementia and had impairment on both sides to upper and lower extremities. A physician's order dated 12/31/25 documented, in part: FMP (functional maintenance program); Splint; Patient will wear the left elbow extension splint in LUE (left upper extremity) for 3 hours. A care plan dated 01/16/26 documented, in part: Focus: [Resident #5's name] Requires to wear the left elbow extension splint in LUE (left upper extremity) for 3 . INTERVENTIONS: check extremities with splints/prosthesis/brace every shift to ensure adequate circulation. report abnormalities to MD (medical doctor); Check skin beneath and adjacent to splint for pressure or irritation q (every) day. During an initial observation conducted on 03/02/26 at approximately 9:30 AM, the resident was noted to be lying in bed with a splint in place to his left arm. During a follow-up observation conducted on 03/02/26 at approximately 3:20 PM, the resident was noted with the left arm splint still in place. During a face-to-face interview conducted on 03/12/26 at 11:54 AM with Employee #4 (Restorative Aide/Certified Nursing Assistant) she stated that, We remove it [the splint] but it's not documented that we remov[ed] it. We put [the splint] on between 7 to 8 (7:00 AM and 8:00 am) then go back to remove it between 1-2pm (1:00 PM and 2:00 PM) every day except Sundays. We get the order from Rehab, with the order of how long to wear it. Rehab put the splint on first then we follow the order. It should be noted that Employee #4 was unaware of the length of time that splint for Resident #5 should be in place as ordered by the physician. 2. Resident #199 was admitted to the facility on [DATE] with diagnoses that included: Dysphagia Following Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Autonomic (Poly)Neuropathy, Heart Failure, Primary Open-Angle Glaucoma, Major Depressive Disorder, Morbid (Severe) Obesity, and Generalized Muscle Weakness. During an initial tour observation and face-to-face interview on 03/03/26 at 11:00 AM Resident #199 was observed awake, lying in her bed watching television. Next to the head of the bed on the right side was a night table that had the Resident's belongings and a denture cup sitting on top of it. When asked if the Resident required staff assistance during oral care, the Resident stated, Yes, they help me rinse my mouth, and help me put my dentures, but I have not been wearing them lately. They don't fit right, and when I try to wear them, they hurt. I want to get new dentures so I can eat other foods. When asked if the facility was aware of the Resident's concern with the dentures, the Resident stated, Yes, I just saw the dentist a few months ago and got these new dentures. I lost my old ones, but these new dentures don't fit right. During an observation on 03/05/26 at 3:22 PM Resident #199 was observed awake, lying in her bed watching television. The resident was not wearing dentures. When asked if any staff had assisted her with her dentures, she said, No, as I said before they hurt. During an observation at 03/11/26 at 9:46 AM, Resident #199 was observed awake, lying in her bed watching television. The resident was not wearing dentures. When asked whether any of the nursing staff offered to schedule an appointment with the dentist to get the dentures fixed, the Resident stated, No. A review of Resident #199's medical record revealed the following: Three (3) physician's order dated 11/11/24 at 3:00 PM that directed: Dentures- Assist/encourage resident to place full upper& lower dentures on during AM care 7-3 shift and off during PM care 3-11 shift, Check dentures for fitness while the resident is awake, and Check linens, waste basket, meal trays, and dishes for dentures before discarding if missing. A physician's order dated 11/11/24 at 8:00 PM that directed: Assist/encourage resident to wash dentures and place in denture and place in denture tablet at bedtime. A care plan initiated on 09/17/24 that documented: [Name of Resident #199] has impaired dentition r/t (related to) using denture(s). Goal: [Name of Resident #199] has clean teeth, healthy gums, and mouth until the next review date. Interventions: Assess and document resident's ability to perform dental care, assist if needed; Dental consult per facility policy and prn; Modify diet for ease/comfort of oral intake prn (as needed), Monitor oral intake; Assist/encourage resident to place full upper and lower dentures on during AM care 7-3 shift and off during PM care 3-11 shift;. Assist/encourage resident to wash dentures; place dentures in denture tablet at bedtime; check dentures for fit while resident is awake; check linens, wastebasket, meal trays, and dishes for dentures before discarding if missing. A quarterly Minimum Data Set (MDS) assessment dated 12/22//25 which documented that the Resident had a Brief Interview for Mental Status (BIMS) summary score of 15, indicating that the resident had intact cognition, hand upper extremity impairments on both sides, and required substantial maximal assistance with oral hygiene which included the ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. A review of Resident #199's Treatment Administration Records (TAR) from 03/01/26 to 03/11/26, showed that facility staff documented that per physician orders, they were: assisting/encouraging the resident to place full upper and lower dentures on during AM care [7-3 shift]; assisting the Resident to remove during PM care [3-11 shift]; checking dentures for fitness while resident was awake, and assisting/encouraging the Resident to wash the dentures and place them the denture cup at bedtime. Of note on: 03/03/26 at 11:00 AM, 03/05/26 at 3:22 PM, and 03/11/26 at 9:46 AM, Resident #199 was observed not wearing her dentures. During a face-to-face interview on 03/10/26 at 3:31 PM Employee #20 /Evening shift Certified Nurse Assistant, when asked if she had ever assisted Resident #199 with removing and rinsing her dentures, she stated, That might be something the nurses or day shift CNA does, because I didn't even know she had dentures. I have never seen her with dentures. Observations of Resident #199 and resident and staff interviews, showed no evidence that nursing staff implemented Resident #199's care plan, which included assisting the Resident with applying and removing her dentures. During a face-to-face interview on 03/11/26 at 1:58 PM, Employee #19 (Registered Nurse/Unit Manager), stated there were physician orders for the Resident #199's dentures and a dental care plan with interventions for the Resident's dentures. When asked if she was aware of any of issues or concerns that Resident #199 had with wearing her dentures, the Employee replied, No. Employee #19 then went to Resident#199's room. Employee #19 observed Resident #199 awake, lying in bed, watching her television. The resident was not wearing dentures. Employee #19 asked the Resident why she was not wearing her dentures. The Resident replied that they did not fit right and hurt, so she had not been wearing them for a few months. Employee #199 stated that no other nursing staff reported that Resident #199's dentures were not fitting properly. When asked how that was possible if the nurses had been following the physician's orders and the Resident's dental care plan interventions, The Employee then acknowledged the findings and made no further comment.

Based on observation, record review, and staff and resident interviews, the facility staff failed to implement and document individualized one-to-one (1:1) activity sessions for a bed-bound resident in accordance with the resident's care plan and assessed needs for one (1) of 49 sampled residents. (Resident #34). Findings include:Resident #34 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Osteomyelitis of Vertebra Sacral and Sacrococcygeal Region, Stage 4 Sacral Pressure Ulcer, Generalized Muscle Weakness, Oropharyngeal Dysphagia, Moderate Protein-Calorie Malnutrition, Cognitive Communication Deficit, and Monoclonal Gammopathy.Review of the Minimum Data Set (MDS) dated [DATE] indicated the resident had minimal hearing difficulty with hearing aid use, BIMS score of 14 indicated the resident was cognitively intact, was dependent on staff for toileting hygiene, shower/bathe self, upper body and lower body dressing and putting on/taking off footwear, used wheelchair for mobility, and reported little interest or pleasure in doing things, indwelling catheter and frequently incontinent bowel.Review of the care plan, revised on 03/05/2025, documented in part:Focus: The resident is dependent on staff for activities, cognitive stimulation, and social interaction related to physical limitations.Goal: The resident will attend or participate in activities of her choice weekly by the next review date.Interventions: Invite the resident to scheduled activities. Provide 1:1 bedside or in-room activities if unable to attend group activities. Provide an activities calendar and notify the resident of any changes. Staff to converse with the resident during care and encourage engagement in activities.During an observation on 03/04/2026 approximately at 1:00 PM, Resident #34 was observed lying in bed with no signs of distress. The activities calendar was posted on the wall behind the head of the resident's bed.During an observation on 03/09/2026 approximately at 10:55 AM, Resident #34 was observed sitting in her wheelchair while being wheeled out of her room by the unit manager for a doctor's appointment. No signs of distress were noted.Review of the activities task documentation from 02/05/2026 through 03/05/2026 revealed that the resident received only two documented 1:1 activity sessions, on 02/19/2026 and 03/02/2026, despite the care plan indicating weekly participation.Review of progress notes from 02/02/2026 through 03/06/2026 revealed limited documentation from activities department and did not demonstrate consistent provision of 1:1 activity session. Documentation included:02/25/2026 at 12:32 PM: Resident was greeted for social daily visits.02/20/2026 at 10:39 AM: Resident had mail dropped off and daily morning social visit.02/19/2026 at 11:03 AM: Resident brother paid her a visit.These entries did not reflect provision of structured 1:1 activity sessions as included in the resident's care plan and assessed needs.During a face-to-face interview on 03/04/2026 at 1:00 PM, Resident #34 stated she was not aware the activities calendar was posted in the room. Additionally, the resident said, I really don't know the activities process. I am bedridden. For example, I didn't know about the Thanksgiving party until a Certified Nursing Aide (CNA) told me.During a face-to-face interview on 03/06/2026 at 10:00 AM, Employee #18 (Activities Director) stated that residents with physical limitations who cannot attend group activities receive 1:1 activities, such as painting or watching movies. The Activities Director stated that 1:1 activities should be conducted weekly for residents with physical limitations and that documentation of activities had not been consistently done prior to their starting work at the facility two months ago, but that they now document activities in progress notes.During a face-to-face interview on 03/06/2026 at 11:10 AM, Employee #2 (Director of Nursing) stated residents are provided with an activities calendar and nursing staff remind residents about activities as part of the morning routine. The DON further stated that residents unable to attend group activities should receive bedside activities such as coloring or other engagement from staff and activities personnel.Despite these statements, the facility failed to consistently provide and document weekly 1:1 activity sessions for Resident #34 in accordance with the resident's care plan and assessed needs.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, for 49 of 49 sampled residents/and or their representatives, the facility staff failed to: 1) post the results of its most recent survey in a place readily accessible to residents, family members, and resident representatives and 2) have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect with respect to the facility available upon request for any individual to review. The findings included: During an observation and interview on 03/09/26, at approximately 10:10 AM with Employee #3 (Front Desk Receptionist), the surveyor observed the Employee behind the front desk of the facility's front entrance. When asked where the facility kept the most recent State Agency survey results, the employee responded, while looking around on top of her desk and on top of the black cabinets behind her chair, she stated, I am not sure where they keep them, but I can call the Administrator to find out. During a second observation on 03/09/26 at 10:19 AM, the surveyor observed a binder placed in a plastic binder holder attached to a wall across from the front entrance reception desk. On the outside of the binder was a sign on the Facility's letterhead that read, Entrance Survey Results Book. Please Do Not Remove. The binder had four subject tabs labeled for four surveys. Under the first tab was the survey results and a page that read, CMS 2567 & State Form Recertification, and Annual Licensure Survey Conducted 08/05/22. Under the second tab labeled, State, were the survey results for the licensure survey conducted on 08/05/22. Under the third tab labeled Emergency Preparedness and Life Safety Code Survey, were the emergency preparedness and life safety survey results conducted on 08/09/22, and under the fourth tab labeled Federal Comparative Life Safety Code Survey, were the results of the comparative federal life safety code survey conducted on 09/27/22. There were no recent state or federal surveys in the binder. During a face-to-face interview on 03/09/25 at 10:35 AM, Employee #1 (Administrator) stated that all current survey reports should be kept in a binder across from the front desk. At approximately 11:00 AM, Employee #1 returned and acknowledged that the facility did not have the most recent survey reports available in the binder at the front desk but stated that the binder would be updated as soon as possible.During a Resident Council meeting on 03/09/25 at 2:00 PM, when asked whether the results of the State inspections were available to read without having to ask, the Residents did not know that they were available or where to find them. During the time of the observations and resident and staff interviews, there was no evidence that the facility had posted the results of its most recent survey in a place readily accessible to residents, family members, and resident representatives. In addition, the facility failed to have available, upon request, its survey reports, including certification surveys, complaint investigations, and any plan of correction in effect for the three preceding years, for review by any individual, and failed to have the reports in areas easily accessible to the public. On 03/10/25 at approximately 1:30 PM, Employee #1 stated that the binder had been updated to include the most recent surveys and all surveys conducted in the prior three years.

Based on record review, observation, and staff interviews, the facility failed to develop and/or implement a comprehensive care plan interventions to address one resident's documented allergies and the application of dentures for another resident in two (2) of 49 sampled residents. (Resident #49 and #199).Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Convulsions, Todd's Paralysis (Postepileptic), Dysphagia, Hypertension, Acute Kidney Failure, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side, Acute Embolism and Thrombosis of Deep Veins of Lower Extremity, Muscle Weakness, Altered Mental Status, Morbid Obesity, and Age Related Nuclear Cataract. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had a BIMS score of 14, indicating the resident was cognitively able to participate in the care decisions. A review of the Physician History and Physical dated 02/25/2026 revealed Resident #49 had documented allergies to Motrin and Tuna. A review of the resident's comprehensive care plan revealed there was no care plan developed to address the resident's allergies (Tuna and Motrin). During an observation on 03/02/2026 at approximately 11:25 AM, Resident #49 was observed lying in bed and stated she was allergic to Tuna. Resident #49 stated she believed the facility was providing her food that had tuna in it and because of that she was experiencing some allergic reaction on her face, a rash on her face. The resident showed no signs of distress at the time of observation. During a face-to-face interview on 03/10/2026 at 11:55 AM, Employee #7 (RN, 1st Floor Unit Manager) stated she believed that the Tuna allergy for Resident #49 was listed on the resident's meal ticket, but she needed to verify this information with the food operation department. During a face-to-face interview on 03/10/2026 at approximately 2:50 PM, Employee #8 (Dietician) stated that residents' food preferences are entered into the facility's dining manager electronic system, which generates information that appears on residents' meal tickets. Employee #8 further stated that food preferences are obtained during the initial assessment and baseline care plan development and are reviewed every three (3) months and revised as needed based on health conditions, physician orders, and resident preferences, with documentation in care plan and dietician progress notes. During a face-to-face interview on 03/09/2026 at approximately 3:10 PM, Employee #9 (RN Charge Nurse, 1st Floor) stated she had never heard Resident #49 complain about food allergies, but she knew the resident was allergic to Tuna because she completed the admission assessment. Employee #8 also stated that the resident's granddaughter visited the day prior, and when asked if there were any unmet needs for her grandmother, she did not express any concerns. During a face-to-face interview on 03/09/2026 at approximately 3:30 PM, Employee #2 (Director of Nursing) stated that medication and food allergies should be assessed and documented in the resident's record during admission. Employee #2 further stated she was not aware of any complaint from Resident #49 related to allergies. During a face-to-face interview on 03/10/2026 at 3:00 PM, Employee #2 stated that the resident should have a care plan addressing her allergies. Employee #2 further stated that the care plan for allergies was developed and added to the resident's comprehensive care plan on the same day (03/10/2026). The facility failed to ensure Resident #49's documented allergies were addressed in the comprehensive care plan until after the surveyor inquiry. 2. Resident #199 was admitted to the facility on [DATE] with diagnoses that included: Dysphagia Following Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Autonomic (Poly)Neuropathy, Heart Failure, Primary Open-Angle Glaucoma, Major Depressive Disorder, Morbid (Severe) Obesity and Generalized Muscle Weakness. During an initial tour observation and face-to-face interview on 03/03/26 at 11:00 AM, Resident #199 was observed awake, lying in her bed, watching television. Next to the head of the bed on the right side was a night table with the Resident's belongings and a denture cup. When asked if the Resident required staff assistance during oral care, the Resident stated, Yes, they help me rinse my mouth and put my dentures in, but I have not been wearing them lately. They don't fit right, and when I try to wear them, they hurt. I need to get new ones. When asked if the facility was aware, the Resident stated, Yes, I just saw the dentist a few months ago and got these dentures because I lost my old ones, but they don't fit right. Resident #199 was admitted to the facility on [DATE] with diagnoses that included: Dysphagia Following Cerebral Infarction, Type 2 Diabetes Mellitus with Diabetic Autonomic (Poly)Neuropathy, Heart Failure, Primary Open-Angle Glaucoma, Major Depressive Disorder, Morbid (Severe) Obesity, and Generalized Muscle Weakness. During an initial tour observation and face-to-face interview on 03/03/26 at 11:00 AM, Resident #199 was observed awake, lying in her bed, watching television. Next to the head of the bed on the right side was a night table that had the Resident's belongings and a denture cup sitting on top of it. When asked if the Resident required staff assistance during oral care, the Resident stated, Yes the help me rinse my mouth, and help me put my dentures, but I have not been wearing them lately. They don't fit right, and when I try to wear them, they hurt. I want to get new dentures so I can eat other foods. When asked if the facility was aware of the Resident's concern with the dentures, the Resident stated, Yes, I just saw the dentist a few months ago and got these new dentures. I lost my old ones, but these new dentures don't fit right. During an observation on 03/05/26 at 3:22 PM Resident #199 was observed awake, lying in her bed watching television. The resident was not wearing dentures. When asked if any staff had assisted her with her dentures, she said, No, as I said before they hurt.During an observation on 03/11/26 at 9:46 AM, Resident #199 was observed awake, lying in her bed, watching television. The resident was not wearing dentures. When asked if any of the nursing staff offered to schedule an appointment with the dentist to get the dentures fixed, the Resident stated, No. A review of Resident #199's medical record revealed the following: A physician's order dated 12/17/19 at 6:39 PM that directed: Consults: Dental consult and treat as needed. A physician's order dated 11/09/20 at 4:33 PM that directed: Schedule resident for General Dental for dentures [Name of Local Hospital] after teeth extraction. A physician's order dated 12/11/23 10:45 AM that directed: Dentures -Every day shift for dentures rinse and apply every morning and every evening shift for denture, remove denture, rinse and place in denture cup.Three (3) physician's order dated 11/11/24 at 3:00 PM that directed: Dentures- Assist/encourage resident to place full upper& lower dentures on during AM care 7-3 shift and off during PM care 3-11 shift, Check dentures for fitness while the resident is awake, and Check linens, waste basket, meal trays, and dishes for dentures before discarding if missing.A physician's order dated 11/11/24 at 8:00 PM that directed: Assist/encourage resident to wash dentures and place in denture and place in denture tablet at bedtime. A care plan initiated on 09/17/24 that documented: [Name of Resident #199] has impaired dentition r/t (related to) using denture(s). Goal: [Name of Resident #199] has clean teeth, healthy gums, and a mouth until the next review date. Interventions: Assess and document resident's ability to perform dental care, assist if needed; Dental consult per facility policy and prn; Modify diet for ease/comfort of oral intake prn (as needed), Monitor oral intake; Assist/encourage resident to place full upper and lower dentures on during AM care 7-3 shift and off during PM care 3-11 shift;. Assist/encourage resident to wash dentures and place in denture tablet at bedtime; Check dentures for fitness while resident is awake; Check linens, wastebasket, meal trays, and dishes for dentures before discarding if missing. A quarterly Minimum Data Set (MDS) assessment dated 12/22//25 which documented that the Resident had a Brief Interview for Mental Status (BIMS) summary score of 15, indicating that the resident had intact cognition, hand upper extremity impairments on both sides, and required substantial maximal assistance with oral hygiene which included the ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment. A review of Resident #199's Treatment Administration Records (TAR) from 03/01/26 to 03/11/26, showed that facility staff documented that per physician orders, they were: assisting/encouraging the resident to place full upper and lower dentures on during AM care [7-3 shift]; assisting the Resident to remove during PM care [3-11 shift]; checking dentures for fitness while resident was awake, and assisting/encouraging the Resident to wash the dentures and place them the denture cup at bedtime. Of note on: 03/03/26 at 11:00 AM, 03/05/26 at 3:22 PM, and 03/11/26 at 9:46 AM, Resident #199 was observed not wearing her dentures. During a face-to-face interview on 03/10/26 at 3:31 PM, Employee #20 /Evening shift Certified Nurse Assistant, when asked if she had ever assisted Resident #199 with removing and rinsing her dentures, she stated, That might be something the nurses or day shift CNA does, because I didn't even know she had dentures. I have never seen her wearing dentures. Based on observations, record reviews, and interviews, the facility staff showed no evidence that they implemented Resident #199's dental care plan interventions. During a face-to-face interview on 03/11/26 at 1:58 PM, Employee #19 (Registered Nurse/Unit Manager), stated that Resident #199 had a dental care plan with interventions that included assisting the Resident with her dentures. When asked if she was aware of any issues or concerns that Resident ##199 had with her dentures fitting properly, the Employee stated, No. Employee #19 then went to Resident#199's room and observed the Resident with no dentures in her mouth. Employee #19 asked Resident#199 why she was not wearing her dentures. The Resident replied that they did not fit right and hurt, so she had not been wearing them for a few months.Employee #19 commented further that no one, including the Resident, made her aware that the Resident's dentures were not fitting properly. When asked if the nursing staff had: assisted/encouraged the Resident to place full upper and lower dentures on during AM care [7-3 shift]; assisted the Resident to remove during PM care [3-11 shift]; checked the Resident's dentures for fitness while the Resident was awake, and assisted/encouraged the Resident to wash the dentures and place them in the denture cup at bedtime, or helped the Resident to obtain a dental consult per the Resident's dental care plan interventions, Employee #19 stated, I will put in for a dental consultation now. The Employee then acknowledged the findings and made no further comment.

Number of residents sampled: Number of residents cited: Based on record review and staff interview for one (1) of 49 sampled residents, the facility staff failed to accurately code a Resident as receiving opioids on a quarterly MDS assessment. Resident #185The findings included:Resident #185 was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Cerebral Vascular Accident with Left- sided Residual Deficit, Atrial defibrillation, Parainfluenza, Epilepsy, Type 2 Diabetes Mellitus, Vascular Dementia, and Schizophrenia. A review of Resident #185's medical record revealed the following: A physician's order dated 11/17/25 at 2:00 PM that directed: Tramadol HCl Oral Tablet 50 mg (milligrams) (Tramadol HCl). Give 1 tablet by mouth every 8 hours for pain. The physician's order was discontinued on 01/29/26.A physician's order dated 01/30/26 at 12:00 AM, that directed Tramadol HCl Oral Tablet 50 mg (milligrams) (Tramadol HCl). Give 1 tablet by mouth every 8 hours for pain. The physician's order was discontinued on 03/10/26.A physician's order dated 03/11/26 at 9:00 AM that directed: Tramadol HCl Oral Tablet 50 mg (milligrams) (Tramadol HCl). Give 1 tablet by mouth every 8 hours for pain.A quarterly minimum data set (MDS) dated [DATE] MDS showed that Resident #185 was taking the following medications: an antidepressant, an anticoagulant, a hypoglycemic, and an anticonvulsant. Of note, the MDS assessment did not show that the resident was taking opioids for pain.A review of Resident #185's medication administration (MAR) records from November 17, 2025, to March 10, 2026, showed that facility staff administered Tramadol HCl Oral Tablet 50 mg one tablet by mouth every 8 hours for low back pain.During a face-to-face interview on 03/04/26 at 2:42 PM, Employee #5, MDS Coordinator, acknowledged the finding and stated, It was overlooked. I will correct it now.

Based on observations, record reviews and staff interviews, the facility staff failed to develop effective discharge planning for one (1) of 49 sampled residents whose record showed discharge upon hospitalization. (Resident #188) Resident#188 was admitted on [DATE] 22:28 with diagnosis of fluid overload, hypertension, Skin ulcer of right heel and with Necrosis of muscles, Dementia, Heart failure with reduced ejection fraction, and iron deficiency Anemia. A review of her medical record on 3/6/2026 showed the following progress notes: Date: 01/23/2026 07:24 Type: Nurses Notes: Resident received in bed awake with hypotensive, high fever, altered mental status, lethargy but alert, no SOB or distress noted, V/S- 90/58, HR-102, RR-18, Temp- 101.5, SPO2-97%RA. MD made aware new order given, Transfer to nearest ER [emergency room] for further evaluation. 911 called and resident RP [name] notified of the situation and the plan of care. Further review of progress notes dated 01/23/2026 16:18 showed Hospitalization listing the hospital as the resident's discharge location. A review of Care plan on 03/10/2026 showed Resident #188's care plan was closed on 02/10/2026, the reason listed read discharged . It should be noted there was no documented evidence of discharge planning in the resident's medical record and no additional information related to discharge planning subsequent to the resident's hospitalization. A face-to-face interview conducted on 03/11/2026 with Employee#2 [Director of Nursing] stated that the patient was discharged . The findings were acknowledged when there was no documented discharged reason with location for the resident discharge.

Based on observations and staff interviews, facility staff failed to maintain a safe environment for the residents.The findings included:During the initial kitchen walkthrough on 03/02/ 2026 approximately at 11:15 AM, a damaged dry wall and missing base board were observed in the dry storage room.During a face-to-face interview on 03/02/2026, approximately at 11:15 AM, the above observation was acknowledged by Employee #14, Food Service Manager.

Based on record review and staff interviews for one (1) of 12 sampled residents, facility staff failed to ensure that one resident was free of a significant medication error as evidenced by ordering. transcribing and dispensing a medication that included an incorrect route for the Resident's medication. Resident #4 The findings included: Resident # 4 was admitted to the facility on [DATE] with diagnoses that included: Seizure Disorder, Adrenal Insufficiency, resolved COVID-19, Bowel dysfunction, Diabetes Mellitus DM, Intellectual Delay, Ogilvie syndrome, Gastrostomy Status, Dependence on Supplemental Oxygen, Aspiration Pneumonia. A review of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is under the control of a healthcare professional, patient, or consumer.Medication errors occur at any stage of the medication management process, not just administration. This includes prescribing, transcribing, dispensing, and administering. The potential for harm exists even if an error was caught before administration. The incorrect order and transcription created a risk for the resident .Long-term care facilities have a responsibility to prevent medication errors. This includes ensuring accurate prescribing, transcribing, and administration of medications. Any deviation from established protocols or physician's orders can be considered a medication error and could have serious consequences for residents (https://www.nccmerp.org). A review of the facility's Medication Transcription policy (reviewed 01/2025) documented: 1. Medication Transcription: All medication orders, including new, changed, or discontinued prescriptions, must be transcribed promptly and accurately into the MAR by licensed nursing staff. All transcriptions must match the prescriber's written or electronic order .4. Medications from external sources: Medications may be ordered or provided by other healthcare facilities (hospitals or external specialty pharmacies) and must be reviewed for accurate dosage, must be packaged and approved by the resident's physician before administration. A review of Resident #4's medical record revealed the following: An admission minimum data set (MDS) assessment dated [DATE] that showed that the resident was severely cognitively impaired, had a gastrostomy tube and was in hospice. A physician's order dated 03/19/24 at 9:45 PM that directed: Lorazepam Oral Concentrate 2 mg/ml (milligrams per milliliter) (Lorazepam) Give 0.5 ml by mouth every 15 minutes as needed for seizure until 04/16/2024. A physician's order dated 03/19/24 at 10:00 PM, Morphine Sulfate (Concentrate) oral solution 20 mg/ml (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain until 04/02/2024. Of note, Resident #4 had a gastrostomy tube that was clogged and was not functioning properly, and the resident could not take medications orally due to his diagnoses. A physician's order dated 03/19/24 at 10:00 PM that directed: Lorazepam Oral Concentrate 2 mg/ml (Lorazepam) Give 0.5 ml sublingually every 15 minutes as needed for seizure until 04/16/2024. An admission Progress Note dated 03/19/24 at 11:35 PM that documented: Resident .admitted to the facility from [Name of Local Hospital]. He is non-verbal with visual and hearing impairment. His admitting diagnoses are resolved COVID-19, Bowel dysfunction, Diabetes Mellitus (DM,) imbalanced nutrition, intellectual delay and Seizure disorder. Lungs are clear on auscultation. Abdomen is soft and non-distended and positive bowel sounds in all 4 quadrants. He has G-Tube in place which is not used for feeding due to him being on comfort care . A physician's order dated 03/20/24 that documented: NPO (nothing by mouth) Diet NPO Texture, at risk for malnutrition/comfort care measure only- no GT (gastrostomy tube) related to Unspecified Adrenocortical Insufficiency; Severe Intellectual Disabilities. A Physician History and Physical dated 03/20/24 at 1:04 PM that documented: .Assessment and Plan: The resident had an advanced intellectual disability, bilateral flexion, and malfunctioning G-tube. Per transfer summary, there was massive distention of the [abdomen] with the use of the G-tube. The summary stated the stomach had collapsed. The resident was transferred to palliative care. P (Plan): refer to current orders and plan of care. The patient will be placed on comfort care pending further social evaluation. An SBAR (Situation, Background, Assessment (Registered Nurse/RN) or Appearance (Licensed Practical Nurse/LPN) and Request) - Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool dated 03/26/24 at 4: 18 AM, that documented: Situation: Unresponsiveness; Background: Adrenocortical Insufficiency; Assessment: . Resident was unresponsive .PN (Progress Note): At the beginning of shift, Resident was received in bed sleeping, chest moving up and down, ADL (activities of daily living) care provided, at 3:25 am, Resident was observed unresponsive in bed, no pulse, nor respiration, Resident is DNR, (Do Not Resuscitate), DNI (Do Not Incubate), [Name of Medical Director] notified, pronounced Resident dead. A medication administration record (MAR) for March 2024 showed that from 03/19/24 to 03/26/24, the facility staff did not administer Morphine Sulfate (Concentrate) oral solution 20 mg/ml (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain. The order on the Resident's MAR had an incorrect route for the medication (morphine). Of note, the Resident per physician's order could not receive anything by mouth. An Interim Medication Regimen Review (MMR) report from the consultant pharmacist dated 03/20/24 at 10:27 PM documented: Based on the information for this review. I have no recommendations at this time .Should there be any questions regarding the resident's medication regimen, please contact the consulting pharmacist of record. Of note, the consultant pharmacist was not available for interview. In addition, the dispensing pharmacist, Medical Director, and the nurse who transcribed Resident #4's medication order when the Resident was admitted to the facility, were not available during the survey for interview. A review of Resident#4's medical record showed that although facility staff never administered the Resident's Morphine, there was no documented evidence to show that the dispensing pharmacist, Medical Director, transcription nurse, or the consultant pharmacist corrected the medication order by changing the route from oral to another route, the Resident's medication. During a face-to-face interview on 06/27/25 at 10:34 AM, Employee #2 (Director of Nursing/DON) stated, When a resident is admitted from the hospital, the nurse assigned to the resident (admitting nurse), reviews the medication lists from the hospital discharge summary. The nurse then calls the physician, and the nurse and physician review the resident's medication orders. Once the physician approves the orders, the admitting nurse then transcribes (enters) the orders in the resident's electronic health record. After the admitting nurse enters the orders in the computer in the resident's electronic health record, the unit manager completes a 24-hour chart check to ensure that transcribed orders for the residents were entered into the Resident's electronic medical record accurately. In addition, when asked if there was any documentation from the dispensing pharmacy to show that the order for the resident's morphine was incorrect, she stated that she could not provide documentation. Of note, the dispensing pharmacist, the Medical Director, and the nurse who transcribed Resident #4's medication order when the Resident was admitted to the facility, were not available during the survey for interview. During a face-to-face interview on 06/27/25 at 11:14 AM, , Employee #4 (Licensed Practical Nurse/1st Floor Resident Clinical Coordinator), stated: When Resident #4 was admitted to the facility, I completed a 24-hour chart check. I printed the medication orders that the transcription nurse entered and reviewed them for accuracy. I then documented that the 24-hour chart check was completed in the reports section of the Resident's electronic health record. When I reviewed Resident #4's medication orders, I didn't consider the route for morphine, because it was such a small dose. The medication could have been given by another route besides orally. The medication was never given, but I understand it was a near miss and was an error and the Employee acknowledged the finding.

Based on observations, record reviews and staff interviews, for two (2) of 12 sampled residents, facility staff failed to follow infection control policies and procedures for residents on Enhanced Barrier Precautions (EBP). Residents' #9 and #12The findings included:A facility policy Infection Prevention and Control Policy dated January 2025 documented:- Standard and transmission-based precautions are to be followed to prevent the spread of infections.1. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Gastrostomy Status, and Aphasia. Review of the resident's medical record showed the following:A care plan focus area: [Resident #9] is on Enhance Barrier Precautions (EBP) last reviewed on 04/11/25 that had interventions that included, use Enhanced Barrier Precautions: use of gown and gloves only for high-contact resident care activities due to G (gastrostomy) tube, Foley [Catheter] and wounds.A physician's order dated 05/29/25 directed, Use Enhanced Barrier Precautions: Use of gown and gloves only for high-contact resident care activities due to G (gastrostomy) tube, Foley [Catheter] and wounds, every day shift.During an observation on 06/23/25 at 10:33 AM, there was a Enhanced Barrier Precautions sign posted at the door of Resident #9's room that documented, Providers and staff must wear, gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use - urinary catheter, feeding tube . Upon entering the resident's room, Employee #8 (Certified Nursing Assistant/CNA) was observed bathing the resident and not wearing a gown. It should be noted the employee was wearing a face mask and gloves. When asked if she was aware that Resident #9 is on Enhanced Barrier Precautions, she stated, Yes. When asked why she is not wearing a gown while bathing Resident #9, she stated, I forgot.The evidence showed that Employee #8 failed to follow infection control policies and procedures for Resident #9 who was on Enhanced Barrier Precautions.During a face-to-face interview on 06/25/25 at 1:50 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated that education will be provided. 2. Resident #12 was admitted to the facility on [DATE] with diagnoses that included: Bilateral above the knee amputations, Chronic Obstructive Pulmonary Disease COPD, Gout, Osteoarthritis, Hypertension, Benign Prostatic Hyperplasia (BPH), Urinary retention, and Dysphagia.During an initial tour on 06/23/25 at 10:25 AM, on the outside of Resident #12 room beside the door entrance was a sign that read: Enhanced Barrier Precautions Everyone must: Clean their hands; including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following high-contact resident care activities: dressing; bathing/showering, transferring; changing linens, providing hygiene, changing briefs or assisting with toileting . Inside of the room Employee # 5 (Certified Nurse's Aide/CNA) was observed at Resident #12's bedside. The Resident was laying supine with the bed raised. Beside the bed on the bedside table was a basin of soapy water with a washcloth. Employee #5 was wearing gloves and was drying Resident#12 with a towel. The Employee then put a clean gown on the Resident. She then poured out the dirty water in the Resident's sink, removed her gloves, washed her hands, placed the dirty towel and wash cloth in a dirty linen bag that was in the resident's room. The Employee then exited the Resident's room carrying the dirty linen bag and placed the bag in the soiled linen room. From 06/16/25 to 06/25/25, the facility was in a COVID-19 outbreak status and all staff and visitors were instructed to wear face masks in residential care areas during this time period.A review of Resident #12's medical record showed:A significant change minimal data (MDS) set assessment dated [DATE] that documented that the Resident had upper and lower extremity impairments on both sides, was dependent on staff for bathing and personal hygiene and had one Stage IV pressure ulcer that was present upon admission.During a face-to-face interview on 06/23/25 at 10:53 AM, Employee #5 (Certified Nurse Assistant/CNA) when asked what the proper PPE was for bathing a resident on enhanced barrier precautions (EBP), responded that staff should wear a gown and gloves. When asked when she had been educated on proper PPE for staff caring for residents on EBP the Employee responded that she could not remember and provided no explanation for not wearing a gown when bathing Resident #12. During a face-to-face interview on 06/23/25 at 10:31 AM, Employee #4 (Licensed Practical Nurse/1st Floor Resident Clinical Coordinator), stated that all the CNAs had been educated during orientation and at least annually via the Shared Nursing Leadership (a computer -based education/ training program). She then acknowledged that Employee #5 should have been wearing gloves, a gown while bathing Resident #12 and stated that she would immediately provide a reminder/in-service for all staff to wear proper PPE for all residents on any type of precaution on the unit.Cross Reference 22B DCMR Sec. 3217.6

Based on observation, record review and staff interview, for one (1) of 12 sampled residents, facility staff failed to develop a comprehensive care plan with goals and interventions to address one resident's use of a Foley Catheter. Resident #9. The findings included: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Gastrostomy Status, and Aphasia. Review of the resident's medical record showed the following: 04/10/25 at 10:43 PM admission Note: - The resident arrived from [hospital name] around 9:00 PM on a stretcher accompanied by 2 paramedic staff. - Resident has Foley Catheter draining yellow urine. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded that the resident had an indwelling catheter. A Physician's orders dated 05/29/25 directed, Foley Catheter due to Obstructive Uropathy. During an observation on 06/23/25 at 10:33 AM, Resident #9 was observed in bed with a Foley Catheter to bedside drainage. Further review of the resident's medical record showed no documented evidence that a comprehensive care plan with goals and interventions was developed to address her use of a Foley Catheter. During a face-to-face interview on 06/25/25 at 1:50 PM, Employee #2 (Director of Nursing/DON) stated, The resident's last care plan meeting was 04/11/25 and acknowledged that facility staff failed to develop a comprehensive care plan with goals and interventions to address Resident #9's use of a Foley Catheter. Cross Reference 22B DCMR Sec. 3210.4

Based on observation, record review, review of video footage, staff interviews, and resident interviews, for one (1) of six (6) sampled residents, the facility staff failed to adequately supervise Resident #1 while the resident sat in the secured courtyard on the evening of 07/27/23. Subsequently, a pizza delivery person who was leaving the facility held open the secured gate to allow Resident #1 to pass through. These failures resulted in an immediate jeopardy situation. The immediate jeopardy was identified on August 4, 2023, at 3:04 PM. The facility provided a plan of action to address the immediacy on August 4, 2023, at 10:02 PM and it was accepted. After the plan was verified the IJ was removed on August 7, 2023, at 2:21 PM while the survey team was onsite. After the removal of immediacy, the deficient practice remained for the potential for minimal harm, with the scope and severity of D. The findings included: A review of the facility's Elopement (Pink Alert) Policy with a revision date of 05/17/18 documented, 1. Elopement Prevention- section C- In the event of elopement Pink Alert a search is conducted immediately, If the resident is not located within 1/2 hour of sustained search, the Administrator and Director of Nursing are to be called regardless of the day or hour . 2. Elopement Drill Procedures. Section A. Schedule - the elopement drill schedule is reasonable intervals as scenario determines. The schedule is carried out by the Safety Committee. Section B. Staffing - search party participants search rooms, boiler room, beneath beds, storage, equipment, laundry, staff development rooms, trash bins, parking areas, beneath stairways, parking areas, parked vehicles and surrounding shrubbery. Section D. Documentation - Elopement Checklist -SCC (Safety Committee Chair) completes the checklist .checklist is maintained by the SCC. Review of a document titled, Elopement Drill Check List documented, The front desk (alert Code Pine (sp)) and Safety Officer are to be notified within 5 minutes, the DON and Administrator are to be notified within 15 minutes, the physician is to be notified within and half hour. If the resident is not found within one hour the police department is to be notified .If resident is not found in less than two hours (DOH) is to be notified. Next the Ombudsman followed by the Adult Protective Services. A review of a policy titled, Wandering & Wander Guard Policy dated 07/30/18 documented, .Section 5. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement /missing resident emergency procedure will be initiated .If the resident is not located, notify the Administrator and Director of Nursing services, the Legal Representative, the Attending Physician, Law Enforcement Officials, and Required Government Agencies. Review of an untitled policy dated 01/01/23 documented, Policy Statement: Inspire Rehabilitation and Wellness Center is committed to the safety of our residents, staff, visitors, and property; while respecting the privacy, rights of our residents, staff, and visitors. The courtyard is fenced and can be used for outdoor visitation and outdoor activities. This area is monitored by surveillance camera and screen is at the receptionist area for monitoring by the receptionist. The receptionist is present in the lobby 24 (hours) X 7 (days-a-week) .The exit gate is secured by wander alert and every person entering or leaving needs to be buzzed in or out to prevent any resident from leaving without authorization. The document included an Elopement Drill Check List that lacked documented evidence of who conducted the outlined task and times the task was done, including: the time front desk staff announced the Pink Alert, the time the Administrator, DON, and physician were notified of the drill, and documented evidence of communication that staff checked on all non-nursing units (basement , kitchen, administrative offices, elevators, roof access if there [applicable], dining area, building premises, parking lot, smoking area, patio [and] lobby) for [Resident #3] . Review of a policy titled, Elopement/Missing Resident dated 05/2023 documented, The facility will identify residents who are risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision if necessary, would be considered an elopement section 3. If a resident is missing, initiate the elopement /missing resident emergency procedure .if the resident was not authorized to leave, call a code for the missing resident [Code Pink] .follow search protocol . The facility's assessment dated [DATE] documented, Inspire has a surveillance camera system, nurse call system, door alarm system .wanderalert complaint entry/exit ways . Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Dementia with Agitation, Cognitive Communication Deficit, and Muscle Weakness. A review of an admission nursing note dated 07/05/23 at 9:28 PM documented, .Alert oriented X 2 (name and time) .Medical history of the following: Acute Encephalopathy, 2/2 Delirium and Toxic Encephalopathy, Dementia with Agitation .Discharge diagnosis Living alone and unable to care for self .He was transferred to [Nursing Home Name], a skill [skilled] nursing facility for further therapy . Review of a document titled, Elopement Risk Evaluation, dated 07/05/23, revealed staff failed to complete sections D - Mobility and E - Diagnosis. Resident #1, however, had an Elopement Risk Score of 0 and was documented as not at risk for elopement. A review of progress notes dated from 07/05/23 to 07/11/23 lacked documented evidence of staff noting elopement attempts or elopement concerns for Resident #1. An Admission Minimum Data Set, dated dated dated [DATE] documented Resident #1 had a Brief Interview for Mental Status summary score 04, Resident #1 was coded for wandering that occurred 1 to 3 days during this assessment period. Additionally, under section Functional Status - the resident was coded for requiring supervision and support by the physical assistance of one staff person when off the unit. A review of Resident #1's care plan revealed it did not outline how staff would supervise Resident #1's locomotion while off the unit. Progress notes dated from 07/12/23 to 07/26/23 lacked documented evidence of staff noting elopement attempts or elopement concerns for Resident #1. The Medication Administration Record (MAR) revealed the resident was administered Xarelto 20 mg po for Atrial Flutter and Valproic Acid 250 mg for Mood Disorder at 5 PM on 07/27/23. An observation of the facility's surveillance video showed a pizza delivery person entering the lobby at 6:16 PM on 07/27/23. It was then observed that the pizza delivery person held the secured exit gate open so Resident #1 could pass through. Resident #1 was then seen self-propelling in a wheelchair and exiting the facility courtyard at 6:17 PM on 07/27/23 unsupervised and without the knowledge of facility staff. The resident was noted to be wearing a long sleeve shirt, long-leg pants, and socks. The resident, however, was not wearing shoes. Per World Weather, the following temperatures were listed for 07/27/23. Morning- 77 degrees Day - 93 degrees Evening - 91 degrees Night - 79 degrees https://world-weather.info/forecast/usa/washington_1/27-July/ Review of the State Agency Facility Reported Incident Form #DC-12139, documented, Date of Alleged Event - 07/27/23- Approximately around 7:30 [PM] after receiving [pronoun] dinner during routine rounds, [Resident #1] was not observed on the unit or the dinning facility, after the looking in the facility the resident was not located and an elopement was called. Family and police notified, neighborhood search was initiated, and the facility staff went to the resident home .Update from provider dated 07/28/23 [Resident #1] has not been located. We discovered [pronoun] was let out [secured gate] by the Pizza delivery driver . 2nd Update 07/28/23 at 12:52 PM .Administrator, Social Worker and Administrator in Training went to [local hospital] to confirm the identity of [Resident #1]. Resident located at [local hospital] resident is alert, oriented X4 (name, place, time, and situation) .per the hospital, they are ready to discharge [pronoun] back to the facility . A review of a social worker's progress note dated 07/27/23 at 10:30 PM documented, The following hospitals were called to inquire if the resident was located at their hospital to which they indicated [Resident #1] was not. [Local hospital #1] was contacted at 10:20 PM, [Local hospital #2] was contacted at 10:30 PM, [Local hospital #3] was contacted at 10:40 PM, [Local hospital #4] was contacted at 11:00 PM, [Local hospital #5] was contacted at 11:00 PM, [Local hospital #6] was contacted at 11:20 PM, and [Local hospital #7] was contacted at 11:30 PM. A review of a nursing supervisor's progress note dated 07/27/23 at 10:32 PM documented, Resident had [pronoun] dinner and [pronoun] plate was taken around 5:40 PM by the CNA. [Resident #1] was last seen by the CNA [a] few minutes before 6 PM in the hallways and wheeling [pronoun] around. [Resident #1] usually goes downstairs and comes back to [pronoun] room. Later on, Employee #4 (Receptionist) reported that [Resident #2] saw [Resident #1] leaving the facility. Code Pink (missing person) was called by the receptionist. A review of a social worker's progress note dated 07/27/23 at 11:30 PM, documented, Writer contacted DC Adult Protective Services . to file a report on [Resident #1] eloping from the facility . A review of a nursing progress note dated 07/28/23 at 12:30 PM documented, At around 11 AM, during continued search attempts [Resident #1] was located at [local hospital #4] 2 staff members went to [local hospital #4] name] to identify [Resident #1] in-person. Identity confirmed for [resident's name] and [pronoun] is in stable condition .Per [local hospital #4] resident is alert, oriented X4 and was picked up from Massachusetts Avenue. Per the nurse at the ER, the resident was at the side walk and reported that [pronoun] just felt weak and a passerby to call 911 . [Resident #1] was registered in their system at 11:07 PM last night. Per labs done at the hospital, there are no critical findings and are within normal limits. Per the hospital . They are ready to discharge [Resident #1] back to the facility .Physician and family notified . A review of a hospital discharge summary dated 07/28/23 documented, patient discharge instruction for [Resident #1]. Patient Information arrival date and time 07/28/22 at 00:22 (12:22 AM). discharge date and time 07/28/23 at 12:14 [PM] In addition, the discharge instructions documented, No concerning findings on labs or imaging of XR (x-ray) of the hip. Please return if you have any concerning symptoms. According to the hospital's discharge summary, the resident was evaluated for Weakness. It should be noted the resident check in time in the ER approximately 6 hours after [pronoun] left the facility. A review of an Elopement Risk assessment dated [DATE] indicated Resident #1 was at risk for elopement with a score of 4. A second Elopement Risk Assessment was conducted on 07/31/23, in which Resident #1 received a score of 8 and was categorized as at risk for elopement. A review of the facility's investigative notes and progress notes dated from 07/27/23 to 08/01/23 lacked documented evidence of the specific times when investigation activities occurred, such as when Code Pink was called, when the Administrator was informed of Resident #1's elopement, when the police were notified of Resident #1's elopement, and when the family and physician were informed of Resident #1's elopement. During an observation on 08/01/23 at approximately 2:30 PM, the surveyor had to identify herself before staff buzzed her into the secure gate. Also, observed was signage posted outside/inside the gate located near the intercom system that documented, Do not let any resident follow behind you when you leave. The door will be buzzed out for you individually. The resident needs to sign out before leaving the facility. During an initial observation of Resident #1's room on 08/01/23 at approximately 3:00 PM showed Resident #1 sleeping, wander guard on left ankle, bed in low position, fall mat on left side, and wheelchair at the foot of the bed on the right side. During face-to-face interview starting at 6:19 PM on 08/01/23 to 4:18 PM on 08/02/23 with Employee #6 (Unit Manager), Employee #2 (DON), Employee #3 (QA/Educator) Employee #1 (Administrator), and Employee #5 (the nursing supervisor who completed the Elopement Assessment) revealed they could not provide the surveyor with a key code to delineate what the different scores meant for the facility. However, they admitted to using assessments and residents' behavior to determine elopement risk. During a face-to-face interview on 08/01/23 at 4:48 PM, Employee #3 (Staff Educator/ Quality Assurance/ Infection Preventionist) stated that after Resident #1 eloped on 7/27/23, she began educating staff, including Employee #4 (Receptionist), on Elopement Prevention, Reaction, Ensure Resident Safety. Additionally, a review of the post-test provided to staff revealed that the tests had not been graded. There were no teaching tools available. Also, Employee #3 stated that she didn't grade all tests, and during teaching, she engaged with employees to make sure they understood and that her test served as a teaching tool as well. During a face-to-face interview on 08/01/23 at approximately 6:00 PM, Employee #10 (assigned CNA) she stated that she picked up Resident #1's dinner tray between 5:30 PM and 5:45 PM. The employee reported that she heard an announcement for Code Pink around 6:30 p.m. to 7:00 p.m. and was instructed to check all residents on the unit. Having searched the unit and being unable to locate Resident #1, Employee #7 (RN) went to the courtyard to look for the resident. In addition, Employee #10 reported that Resident #1 has gone to the courtyard independently and returned to the unit in the past. During a face-to-face interview on 08/01/23 at 6:07 PM, Employee #11 (CNA) stated that she gave Resident #1 [pronoun] dinner tray around 5:00 PM on 07/27/23 and last saw the resident sitting in [pronoun] wheelchair in the hall of the unit around 6:00 PM. In addition, the employee said a nurse told her to check all residents. When she checked Resident #1's room, the resident was not in the room. The employee also said she then went to the courtyard to look for the resident, but she could not locate the resident. Furthermore, Employee #11 reported that Resident #1 has gone to the courtyard independently and returned to the unit in the past. During a face-to-face interview on 08/01/23 at 6:19 PM, Employee #6 (2nd Floor Unit Manager) he stated that the DON (Employee #2) called him on 07/27/23 between 6:15 PM and 6:30 PM informing him that Resident #1 eloped. The employee stated that he was very surprised because of the resident's cognitive impairment and the resident had no issues prior with elopement concerns. Furthermore, the employee said that he called and spoke with staff to include Employee #5 (assigned nurse/Supervisor), Employee #10 (assigned CNA) and Employee #7 (RN who worked on the floor) who reported they were informed by Employee #4 (Receptionist) who made them aware that Resident #1 was outside the gate. In addition, the employee said that he spoke with Employee #4 (Receptionist) who reported that Resident #2 made him aware that he observed Resident #1 rolling past the gate in a wheelchair. During a second observation of Resident #1's room on 08/01/23 at 6:30 PM, Resident #1 was observed sleeping, wander guard on left ankle, bed in low position, fall mat on left side, and wheelchair at the foot of the bed on the right side. During a face-to-face interview on 08/01/23 at 6:50 PM, Employee #2 (DON) stated that staff called her and informed her that Resident #1 had been observed outside the gate by another resident. Her and the administrative staff went to the facility and continued the elopement protocol including searching for the resident, educating staff, and reassessing elopement residents. During a face-to-face interview on 08/01/23 at 7:12 PM, Resident #2 stated that [pronoun] saw [Resident #1] outside the locked gate rolling down the street in a wheelchair between 6:15 PM and 6:30 PM on 07/27/23. Resident #2 said [pronoun] told Employee #4 (Receptionist) that a resident was outside the gate rolling down the street in a wheelchair. Then Resident #2 said, [Employee #4] saw on camera that [Resident #1] got out with the pizza man when he [Resident #4] buzzed the pizza man out. During a face-to-face interview on 08/02/23 at 8:31 AM, Employee #4 (Receptionist) stated that he had multiple responsibilities including monitoring residents sitting in the courtyard via the surveillance camera, buzzing individuals in and out of the secured gate surrounding the courtyard, and making announcements on the loudspeaker. When asked what happened on 07/27/23, Employee #4 reported that Resident #2 informed him that another resident was outside the secured gate. Because he had no idea what resident was outside the gate, he notified all five units that a resident had been observed outside by Resident #2, and staff should verify residents on each unit. After a few minutes, the staff on Unit One informed him that Resident #1 wasn't on the unit, so he announced, Code Pink (missing person) over the loudspeaker. The employee was asked how Resident #1 got out of the secured gate since he controls who enters and exits the gate and monitors residents in the courtyard. Employee #4 said, I don't know. I looked at the monitor screen to buzz the pizza delivery guy out, but I didn't see [Resident #1]. I took my eyes off the screen to call staff to pick up the pizza. I assume the resident left out the gate with the pizza guy. In addition, the employee stated, I saw Resident #1 in the courtyard on 07/27/23 but [pronoun] went back to [pronoun] floor before 3:00 PM. I don't recall [pronoun] coming back downstairs. Employee #4 was asked if he left his post after 3:00 PM on 07/27/23. Employee #4 said, I worked 12 hours that day and someone covered me earlier in the day when I went to the bathroom, but not around that time. The employee could not remember who covered him when he went to the bathroom. It should be noted that the job description for Employee #4 (dated 03/02/23) did not specify what the employee was expected to do when monitoring (supervising) residents in the courtyard. During an observation of the receptionist area including the surveillance screen on 08/02/23 at approximately 9:00 AM, the entire courtyard including the secured gate could be observed. Additionally, the screen showed people entering and exiting the gate. During a third observation of Resident #1's room on 08/02/23 at 11:20 AM revealed Resident #1 was lying in bed, awake, and oriented. According to Resident #1, [pronoun] left the facility recently to go to Marymount, Florida. During a face-to-face interview on 08/02/23 at 12:30 PM, Employee #13 (Receptionist) stated that [pronoun] was responsible for monitoring residents while in the courtyard. It should be noted the employee signed job description (dated 05/20/22) did not specify what the employee was expected to do when monitoring (supervising) residents in the courtyard. During a face-to-face interview on 08/02/23 at 2:37 PM, Employee #1 (Administrator) stated that staff called and informed him of Resident #1's elopement. Upon arrival at the facility, he continued elopement interventions, which included notifying public officials of Resident #1's elopement, searching in the community for the resident until 3:00 a.m. on 7/28/23, calling hospitals, checking an electronic health system for local hospital admissions, evaluating the wander guard system, and educating staff about elopement and the new entry and exit process at the secured gate. When determining if a resident is at risk for elopement, the clinical team meets and discusses risk factors, behaviors, medications, and diagnoses. During a face-to-face interview on 08/02/23 at 3:56 PM, Employee #7 (RN) stated that he last observed Resident #1 on 07/27/23 when he administered the resident's routine 5:00 PM medications. Also, Employee #7 didn't realize Resident #1 wasn't on the Unit until Employee #4 (Receptionist) called and told him Resident #2 saw Resident #1 outside the gate. Furthermore, Employee #7 reported that he searched the unit, courtyard, outside the gate, and down the street, but could not find Resident #1. During a face-to-face interview on 08/02/23 at 4:18 PM, Employee #5 (Assigned Nurse/Nursing Supervisor) stated that he arrived late (7:00 PM) to work on 07/27/23 due to an emergency. Upon entering the unit, he heard Employee #4 (Receptionist) announce Code Pink. He instructed nursing staff to check on all residents. Then he walked downstairs to talk with Employee #4, who told him that Resident #2 observed Resident #1 outside the locked gate rolling down the street in [pronoun] wheelchair. Afterwards, Employee #5 walked outside the gate and up the street looking for the resident but failed to locate Resident #1. After approximately 15 minutes, he returned to the facility and called the DON (Employee #2) to notify her of Resident #1's elopement. According to Employee #5's timesheet, he punched in at 7:00 PM on 07/27/23. During a face-to-face interview on 08/03/23 at 10:10 AM, Employee #8 (CNA) stated that Code Pink meant shooter. During a face-to-face interview on 08/03/23 at 10:15 AM, Employee #9 (CNA) could not articulate the meaning of a Code Pink. However, a review of the emergency codes badge noted intermittently on employee badges, revealed a list of codes. On the badge, code pink was defined as missing person. During a face-to-face interview on 08/03/23 at 11:17 AM, Employee #12 (HR Director) reviewed the job description for all Receptionists and commented, I don't see that they [receptionists] are responsible for supervising residents while in the courtyard. Additionally, Employee #12 said, During orientation they [receptionists] are paired with a partner and the partner tells them about supervision, monitoring, what to look for, and who to call in anything that is off-putting (altercation). However, Employee #12 did not have documented evidence of Employee #4's orientation related to resident courtyard supervision. Based on these findings, on August 4, 2023, at 3:04 PM, an Immediate Jeopardy (IJ)-J situation was identified. On August 4, 2023, at 10:02 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: 1. CORRECTIVE ACTION FOR THE AFFECTED RESIDENTS -Resident #1 was located at [local hospital #4] on 7.27.23. Resident #1 returned to the facility on 7.28.23. Resident #1 was assessed head to toe by the charge nurse. The were not negative findings. This is consistent with the discharge notes from the hospital including having no pertinent findings with labs and Xray. Resident #1's elopement risk assessment was -updated by the charge nurse on 7/28/2023 to ensure the resident receives proper interventions and prevent future incidences. Resident #1 was added in the elopement binder in all locations to ensure that staff are aware of his elopement risk and ensure his safety. The resident was given a Wanderguard and placed on 1:1 immediately. Resident #1's care plan was modified for elopement on 7.31.23 to ensure that resident's care plan outlines how staff have interventions for elopement in place and ensure residents safety to prevent further elopement incidences. The care plan continues to be updated and the most recent update was done on 8.4.23 outlining supervision and level of assistance for the resident. Due to the wanderguard, the exit gates will not open unless a staff punches in a code to specifically let the resident out. 2. IDENTIFICATION OF OTHERS WITH THE POTENTIAL TO BE AFFECTED -All residents have the ability to be affected by this deficient practice. A head count was done for all residents on 7.27.23 and all residents were accounted for within the facility. A house wide elopement evaluation was done for all residents on 7.28.23 and no other resident was found to be at risk for elopement. The elopement drill conducted on 2.17.23 with Check List had the Administrator and Director of Nursing's signature who conducted and coordinated the elopement drill with the date. The police was not called as that part is not done during the drills. The time of events during the drill will be incorporated in the next elopement drill. This deficient practice, however, cannot be retroactively corrected. Upon notification by DOH about the responses by the CNA about Code Pink a check was done by the Nurse Educator on 8.4.23 for all CNAs in house to reinforce the meaning of Code Pink. The rest of the CNAs will have reinforcement of the education upon the start of their shift. This will be on-going to ensure house-wide reinforcement is complete. 3. MEASURE TO PREVENT REOCCURRENCE -A robo-call was made to all staff and to all family members on 7.28.23 to educate them that they should not hold the door open for anyone else, everyone will be buzzed out individually. A notice was posted at all exits effective 7.27.23 to state DO NOT LET ANY RESIDENT FOLLOW BEHIND YOU WHEN YOU LEAVE. The door will be buzzed out for you individually. RESIDENTS NEED TO SIGN OUT BEFORE LEAVING THE FACILITY. Education for elopement was done for all staff on 7/27/23 by the QA nurse on 3-11 and 11-7 shift. The facility ensured 100% of staff present in the facility at the time were educated and ensured education thereafter for all staff at the start of their shift. The ADON educated all department heads on 7.28.23 during the Ad-HOC QAPI meeting and the department heads educated all their staff on elopement protocols. Education continued by the Staff Educator, QA Nurse and ADON for all employees as they resumed duty effective 7.28.23 onward. All residents who have orders for Wander Guard had their devices checked for function and proper placement on 7/27/2023 by the nursing staff. Maintenance checked all WanderGuard Door alarms and locks to ensure proper functionality on 7/28/2023. There were no negative findings from this audit. Nursing Staff continues to supervise all residents under their care with ensuring they round on the residents at least every 4 hours. Residents with behaviors or cognitive impairment that need additional supervision will be rounded on at least every 2 hours. Nursing staff will ensure hourly rounding is done for elopement risk residents to ensure safety. Supervisors/designee are responsible for rounding in social areas like dining rooms to ensure residents are monitored in common areas of the facility. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition (appears or acts differently than baseline), identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting, any assistance, etc. If any abnormality is noted, appropriate steps of complete assessment, notifications and documentation are required. In those cases, rounding may need to be more frequent as applicable to the change in condition. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse for any changes in the resident's condition and medical need. Additionally, the receptionist will notify the nursing supervisor when a resident is in the courtyard unattended for more than an hour. The receptionist will use a sign in/out log with time for residents in the courtyard going forward. -Receptionists were additionally educated on 7.27.23 by the Staff Educator and HR on their job description to elaborate Monitor visitor access area by emphasizing the importance of using camera surveillance to supervise resident activity in the courtyard and ensuring the gate is monitored while buzzing people out with special emphasis on a heightened level of supervision while food delivery personnel or visitors enter and exit the gate. Any person entering or exiting the courtyard is now required to identify themselves via intercom. In addition, they are instructed to ensure the gate is closed behind them and to not allow anyone access to get in or out of the courtyard besides themselves. The gate will then be unlocked if all the conditions are met. The receptionist/designee monitors this activity through camera surveillance. If any resident is leaving unauthorized at this time, the receptionist will not buzz them out. A resident council meeting was held on 7.28.23 by the Administrator reviewed and discussed safety policy for resident elopement. Administrator expressed the importance to always keep everyone safe by being aware of our surroundings. Provided residents with letters for continued educated about entry and exit from the premises safely when being buzzed in and out once being cleared to leave. 4. MONITORING CORRECTIVE ACTION -Nursing Director or designee will conduct a weekly audit of Wanderguard residents to ensure it is properly functioning and all WanderGuard are properly in place. This audit was started on 7.28.23 will be done weekly x 4 and monthly x 2. Negative findings, if any, will be corrected upon discovery. Maintenance manager or designee will audit Wanderguard doors, and locks to ensure proper functioning and that the receptionists are following procedures to secure the courtyard, including following entry and exit protocols, and monitoring surveillance cameras. This audit will be done weekly x 4 and monthly x 2. Negative findings, if any, will be corrected upon discovery. Elopement Binders will be audited by the Unit Managers to ensure that the list of residents at risk of elopement is accurate and consistent with the elopement assessment. These audits will be completed weekly times four and monthly times three. Negative findings will be corrected upon discovery. An audit will be done by the Administrator/Designee to ensure the courtyard is being supervised by the receptionist using the surveillance monitoring camera and there is use of the intercom to ensure each person is buzzed out is reminded to close the door behind them and not let others outside. This audit was started on 7.27.23 for 11-7 shift and scheduled to be done q shift x 3 days, daily x 3 days and weekly thereafter x 4 weeks, monthly x 2 months. Negative findings, if any, will be corrected upon discovery. All the above-mentioned audits will be tracked and reported to the QAPI committee monthly and audits will be completed weekly times four and monthly times three. Negative findings will be corrected upon discovery. All Findings to be reported to the monthly QAPI for further recommendations. Verification of the removal of the immediacy was performed by the survey team onsite on August 7, 2023, at 2:21 PM. Cross reference 22B DCMR sect. 3211.1 (d)

Based on record review and staff interview, for one (1) of 50 sampled residents (#146), facility staff failed to provide a resident with services consistent with the professional standards of practice to prevent pressure ulcer/injury development. Subsequently, when the resident's pressure ulcer was first observed, it was at an advanced stage (Unstageable). The findings included: Resident #146 was admitted to the facility on [DATE] with multiple diagnoses that included: Fluid Overload, Chronic Kidney Disease and Dysphagia. Review of Resident #146's medical record revealed: 04/20/22 at 8:35 PM [Admission/Readmission Screener] . Bilateral dry lower extremities (Skin Not open) . 4/20/2022 at 9:42 PM [Admission Note] .admitted from [Hospital Name] . Head-to-toe assessment was conducted . [Resident] has bilateral very dry lower extremities. Resident does not have open skin issue . 04/20/22 [Physician's Order] Head-to-toe assessment and document in nurses note, notify MD (medical doctor)/RP (representative) of changes every evening shift every Wed (Wednesday). 04/20/22 [Physician's Order] Braden Scale: weekly x 4 wks (weeks) post-admission, then quarterly [and] PRN (as needed). Braden Scale for Predicting Pressure Ulcers dated 4/20/22 showed, Admission .Low Risk [for developing pressure ulcers]. Admission Minimum Data Set (MDS) assessment dated [DATE] showed facility coded: required extensive assistance with two plus persons physical assistance for bed mobility, toilet use, and personal hygiene; had an indwelling catheter; always incontinent of bowel; at risk for developing pressure ulcers and had no pressure ulcers, lesions, skin tears or moisture associated skin damage (MASD). The Treatment Administration Record (TAR) for 05/05/22 [Thursday] showed that facility staff initialed in the designated location that they conducted a head-to-toe assessment of Resident #146 per the physician's order. The staff also recorded that the head-to-toe assessment was completed in the nursing notes on the same day. From 05/05/22 evening shift (3:00 PM - 11:00 PM) to 05/07/22 night shift (11:00 PM- 7: 00 AM), a total of eight (8) shifts, the Certified Nurse Aide (CNA) documentation showed that Resident #146 did not receive a bed bath or shower. The Bath and Shower Sheet dated 05/07/22 showed .bath/shower days: Wed (Wednesday), Sat (Saturday), 3 PM-11 PM .[recorded Resident #146's skin as:] Normal- yes, redness/rash- no, peeling- no, open area- no, bruise-no . This form was signed by the assigned CNA and a licensed nurse. 05/08/22 at 3:40 PM [Daily Skilled Note] .ADLs (activities of daily living) care done, assisted with feeding. TURP (turning and repositioning) done q (every) 2 hrs (hours) for comfort and pressure relief . skin is dry and warm to touch . 05/09/22 at 12:06 PM [Tissue Analytics] Wound .Location: Sacrum. Length: 2.17 cm .Width: 6.07 cm .Observations: % (percent) granulation-10.00, % slough/eschar 90%. Wound Status- new. Acquired in House? Yes . [unstageable pressure ulcer]. 05/09/22 at 12:18 PM Situation Background Assessment Request (SBAR) . Communication Tool .Situation: open blister on right buttock . Resident observed with open blister on right buttock, NP (Nurse Practitioner) . notified . Wound team in house and assessed the wound. Responsible party . made aware . However, the Skin/Wound Noted dated 05/09/22 at 9:03 PM documented, .Sacral Ulcer/Sacral/Unstgble (unstageable) . Procedures: Ulcer debridement site . location: sacrum .Post-debridement [the removal of damaged tissue or foreign objects from a wound] length (cm- centimeter): 2.17 . width (cm): 6.07 . depth (cm): 0.2 . Percent debrided: 100% .Surgical debridement done to ulcer site .New unstageable pressure ulcer noted to sacrum. Area debrided at visit today Care Plan initiated on 05/09/22 [Resident #146] has open blister on right buttock . There was no documented evidence that from 05/01/22 to 05/08/22 (8 days), the facility staff observed any new skin issues/impairment on Resident #146. Subsequently, on 05/09/22, Resident #146 was observed with an unstageable pressure ulcer to the right sacrum/buttocks area that required surgical debridement. During a face-to-face interview on 08/03/22 at 1:51 PM, Employee #5 (1st Floor Unit Manager) acknowledged the finding and made no further comment.

Based on record review and staff interview of two (2) of 42 sampled residents, it was determined that facility staff failed ensure that one (1) resident who entered the facility without pressure sores did not develop pressure sores and one (1) resident who entered the facility having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident ' s #39 and #174. The findings include: 1. Facility staff failed to accurately assess and implement interventions with timeliness to care for a facility acquired pressure sore for Resident #39. The "Admission Order Sheet and Physician Plan of Care" form revealed that Resident #39 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. A review of the "Resident Assessment - Data Collection Form" revealed the skin condition section identified that the resident was admitted with a " blister " to the right heel, (no measurements identified) + (plus) two (2) [MEDICAL CONDITION]; the comments section indicated " No open areas " . The "Nurse ' s Notes" dated October 18, 2011, 11:00 PM indicated skin generally warm to touch and dry, blister on the Rat (right heel) noted, [MEDICAL CONDITION] +2 pitting, on both lower extremities. The Braden Scale-For Predicting Pressure Sore Risk was scored 15 which indicates " Mild Risk " The "History and Physical" dated October 19, 2011 revealed under physical examination that the resident ' s skin " reddish tender area, lateral left malleolous. According to the "Admissions MDS (Minimum Data Set)" with an ARD (Assessment Reference Date) of October 25, 2011 indicated that the resident was coded in Section M: Skin conditions: M0100 Determination of Pressure Ulcer risk: A: Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device ... M0300 Current number of Unhealed (non-[MEDICATION NAME] zed) Pressure Ulcers at Each Stage: B stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister 1. Number of stage 2 pressure ulcers.. coded 1; Number of these stage 2 pressure ulcers that were present upon admission/reentry ...coded 1. M0700 Most Severe Tissue for Any Pressure Ulcer coded 2: Granulation tissue (pink or red tissue with shiny, moist, granular appearance). A review of Resident ' s #39 "Interdisciplinary Team Care Plan" identified on October 18, 2011 " Skin concerns/wounds " related to Other, however there was nothing identified. A second care plan identified " Skin Breakdown " related to Incontinence, Impaired bed mobility, Fragile skin, cognitive Impairment, Other: noted blister to rt (right) heel intact noted skin discoloration. A review of the clinical record for Resident #39 revealed an alteration in skin integrity was first recognized on October 29, 2011, however documentation of the alteration in skin integrity did not occur until October 31, 2011. According to the "Daily Skilled Nurse ' s Note" signed and dated October 31, 2011 " at 8:00 AM writer called to observe resident in (his/her) room on (his/her/) bed with bruises: 1. BLE (Bilateral Lower Extremities) weak ..., 2. Red Bruise 2x2 rt (right) heel 3. Red bruise 3x2.5 on lt (left) leg, 4. Red bruise on lt (left) heel 3.5x2.5 5. Red bruises x 2 on the lt (left) hip 24x6.5x0 6. Behind both ears lobe open area from oxygen tubing .... The writer was told by one of the CNA (Certified Nursing Assistant) (the one that works on the west wing M-F (Monday-Friday) 7-3) that this (opened on 10/29/11 and the CNA that worked with that resident told the Charge Nurse Team I and she said it was from the diaper ...MD (Medical Doctor) made aware new orders given for: cleanse both behind ears lobes with NS (Normal Saline) pat dry leave open to air and apply [MEDICATION NAME] QS (Every Shift) until healed ...The MD orders failed to address measures to address the alteration in skin integrity of the bilateral lower extremities. A period of approximately 12 days lapsed before the physician was notified and treatment initiated to care for the alteration in skin integrity to the bilateral lower extremities. According the "Interim Order Form" dated November 10, 2011 6:15 PM: 1. Cleanse rt (right) malleolus ulcer with NSS (Normal Saline Solution), pat dry apply santyl then wrap with bulky gauze QD (every day)/ prn (as needed) until healed. 2. D/C tx (treatment) to lt (left) malleolus with Santyl, 3. Cleanse lt malleolus ulcer with NSS, pat dry apply Santyl then wrap with bulky gauze qd/prn until healed; 4. Apply skin prep to lt (left) medial heel blister q shift until healed, 5. Apply skin prep to rt (right) medial heel q shift until healed, apply skin prep to lt medial leg bruise area q shift until healed. According the "Interim Order Form" dated November 10, 2011 no time indicated: 1. Zinc Sulfate 220mg po (by mouth) daily x 21 days for wound healing; 2. Vitamin C 500mg po bid (twice a day) for wound healing; 3. Santyl apply to lateral malleolus after cleaning with Normal Saline, cover with 4x4 bid x 7 (seven) days; 4. Clean ulcers of the ear with normal saline then apply [MEDICATION NAME] ointment bid, leave to air x 7 days; 5. Clinitron or substitute for pressure sores. Turn and reposition every 2 hours and a s needed; 6. CMP (Complete Metabolic Panel), [MEDICATION NAME]. Review of the "Daily Skilled Nurse ' s Notes" from October 18, 2011 to November 10, 2011 failed to consistently identify alterations in skin integrity for Resident #39. October 18, 2011 identified the resident with a blister to the right heel and no open areas; October 19, 2011 at 2:00 PM identifies blister to bil (bilateral) leg ...;October 20, 2011 at 8:00 AM identifies the resident with blisters on both heels intact; October 27, 2011 identifies blister to right heel on the front side of the form, however there is mention of a left heel blister intact in the narrative on the back side of the form; October 28, 2011 identifies blister to right heel intact; October 29, 2011 at 7:30 AM identifies that blister to the right heel as intact; October 31, 2011 " at 8:00 AM writer called to observe resident in (his/her) room on (his/her/) bed with bruises: 1. BLE (Bilateral Lower Extremities) weak ..., 2. Red Bruise 2x2 rt (right) heel 3. Red bruise 3x2.5 on lt (left) leg, 4. Red bruise on lt (left) heel 3.5x2.5 5. Red bruises x 2 on the lt (left) hip 24x6.5x0 6. Behind both ears lobe open area from oxygen tubing .... The entries lacked consistent identification of each wound, lacked measurements and appropriate treatment. November 7, 2011 2:00 PM identifies left posterior leg noted with bruise of 6cmx3.5cm ...bilateral ankle wound persist ...November 9, 2011 at 2:00 PM identifies open are to behind both ears..continue treatment, bruise to lt (left) leg ...November 10, 2011 7:00 AM Tx (treatment) done to bilateral ear, no bleeding noted, November 10, 2011 7:45 AM, noted open area to left ankle measures 2x2x0.1cm and rt (right) ankle open area measures 2x2x0.1cm no drainage noted ...November 10, 2011 10:48 PM identifies 2 (at) 4:00 PM MD mad award of resident ' s changes in skin condition ...pressure ulcer noted to bilateral malleolus, bilateral heel blister, and pressure sore in bilateral ear area, MD gave new orders: mattress changed, lab orders received, @ 6:00 PM wound nurse checked resident, assessed and provided new orders, 02 (oxygen) continuous d/c ... According to the "Data Collection/Evaluation Nutritional" form dated October 26, 2011 indicated weight on second day of admission 183.4 # (pounds). Resident assisted with feeding, diet texture changed to puree, potential concern for poor po intake, spoke to resident and suggested supp (supplement). Resident stated " I want to eat real food and I never been a big eater, will monitor po (by mouth) meal intake. Skin remains intact no current lab to review will follow-up with resident. Entry dated November 10, 2011 revealed ...Resident reported to have open area on the ankle, pressure ulcer. Will [MEDICATION NAME] 1 pk (packet) TID (three times a day) for wound healing, will follow up. November 16, 2011 identifies ...po meal intake remains poor 26-50%, resident getting diet supplement. Ensure Plus provided 750 calorie and 27 grams protein, will recommend diet supplement Med Pass 240ml TID to provide extra 1200 calorie and 60gm protein. Resident seen by wound round interdisciplinary team, PU (Pressure Ulcer) rt (right) heel, blister size 5x5.3x0.1 tx Santyl [MEDICATION NAME]. Blister on lt (left) medial leg 2.4x2x0.1 tx skin prep. PU on rt lateral malleolus unstageable, 2.3x1.3x0.1 tx Santyl/[MEDICATION NAME]. Bruises on left medial leg, size 1.8x1.4x0.1 tx Santyl/[MEDICATION NAME]. PU on left ear and right ear resolved. Resident [MEDICATION NAME] 1 pk tid for wound healing. According to the facility Initial Skin Condition Progress Report dated November 10, 2011 identifies the following: Wound #1: right malleolus 2.0cm x 2.5cm 0.1cm serous drainage, stage III ... Wound #1: right lateral malleolus 1.8cm x 1.4cm x 0.1cm unstageable serous drainage ... Wound #2: left medial blister heel 5.0cm x 5.3cm x 0.1cm unstageable no drainage ... Wound #3: Left lateral malleolus 2.3cm x 1.3cm x 0.1cm unstageable serous drainage ... Wound #3: right medial blister 2.4cm x 20cm x 0.1cm no stage indicated no drainage ... Wound #5: left medial leg, bruise, 5.5cm x 2.0cm x 0.0cm no drainage ... The record lacked evidence of wound identification and measurements for the period of October 18, 2011 until November 10, 2011. The forms reviewed lacked consistent identification and treatment and monitoring. An observation of the wound was made on February 7, 2012 at 9:43 AM with the Interdisciplinary Wound Team with included the Wound Nurse, the Dietician and the Wound Doctor, the following observation was made: Left Foot: 2.8cm x 2.2cm x 0.1cm 90 % (percent) granulation, 5% slough, 5% necrosis, 5% debridement; Right Foot: 3.6cm x 4.5cm x 0.3cm 70% granulation, 20% yellow necrosis, 10% slough debridement; Right Foot: 2.4cm x 2.5cm x 0.1cm, 100 % granulation. A face-to-face interview was conducted with Employees #2, 3, and 11 on February 8, 2012 at approximately 6:00 PM. Employee #2 acknowledged the findings and stated that a corrective action plan had been implemented once the administration identified concerns with the management of Resident #39 ' s facility acquired wound. Facility staff failed to accurately assess and implement interventions with timeliness to care for facility acquired pressure ulcers. The record was reviewed on February 6, 2012 2. Facility staff failed to consistently assess the status of Resident #174's skin integrity for the left heel. A review of resident #174 ' s clinical record revealed the followings: The October 25, 2011, the noted day of admission, the " Resident Assessment-Data Collection Form " under " Skin Condition " Comment for skin condition indicated that the resident had intact skin while the resident assessment data dated 10/25/11 revealed left heel marking on the anatomical depiction. A " Daily Skilled Nurse ' s Note " dated October 25, 2011 under " Physical Functioning " revealed that the resident is totally dependence for bed mobility and transfer, with extensive assistance for locomotion. A " Progress Notes " dated November 18, 2011 that noted that the resident was seen in the facility by the Nurse Practitioner for an acute visit. The Nurse Practitioner documented: " left heel stage 1 " (positive) [DIAGNOSES REDACTED] noted on left heel. Skin prep to left heel and elevation of bilateral heels. " An " Interim Order Form " dated November 18, 1011 that directed " 1. Skin Prep to (L) (Left) heel. (2) Elevate B/L (Bilateral) heels. " An undated " Initial Skin Condition Progress Report " that identified left heel pressure wound as " admitted with. " An October 25, 2011 " Interdisciplinary Care Plan for Skin concerns / Wound " that failed to include and or address the left heel pressure wound. Resident #174's clinical record including the admission notes: nursing progress notes and daily skilled notes failed to reflect that the resident had a skin problem. The admission notes do not reveal that the resident entered the facility with skin impairment. A further review of the resident ' s clinical record lacked documented evidence that facility staff consistently assessed the status of Resident #174's skin integrity for the left heel. A face-to-face interview was conducted with Employees #2 and #18 on February 8, 2012 at approximately 4:30 PM. They both acknowledged the aforementioned findings. The record was reviewed February 8, 2012.