Every finding on record at Lisner Louise Dickson Hurthome

Based on record review and staff interview, for one (1) of five (5) sampled residents, facility staff failed to report an incident of injury of unknown origin to the State Agency within 24 hours. Resident #5.The findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Repeated Falls, Difficulty Walking, and Seizures.Review of the resident's medical record revealed the following: A Modification Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 06, indicating severe cognitive impairment; no functional limitations in range of motion; used a walker and wheelchair mobility devices; required substantial/maximal assistance for toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene; and no falls since the prior MDS assessment.08/05/25 at 7:10 AM Nurses Note: Resident c/o (complained of) rt (right) hip pain, resident stated, 'I can't get OOB (out of bed), my rt hip hurts'. Upon assessment rt hip noted to be bigger than the left one, and it's warm to touch. PRN (as needed) Tylenol (pain medication) 500mg (milligrams) 2 tabs (tablets) given as ordered for pain with no relief.08/05/25 at 7:33 AM eInteract Situation Background Assessment Request (SBAR) Summary:- Situation: New or worsening edema and uncontrolled pain.- Primary care provider responded with the following feedback: X- ray of rt hip ordered.08/05/25 at 9:54 PM Radiology Results: - - Right Hip, Unilateral w/ Pelvis when performed, 1 View.- - Findings: There is an acute comminuted displaced intertrochanteric fracture involving the right femur with associated soft tissue swelling. A physician's order dated 08/05/25 directed, Transfer resident to hospital emergency department for evaluation of acute comminuted displaced intertrochanteric fracture involving the right femur with associated soft tissue swelling.08/06/25 at 6:31 AM Communication with Emergency Department: - - Call placed to [Hospital Name] emergency room (ER), spoke with the nurse at the ER who stated that the resident (Resident #5) has a femur fracture and is being admitted .A Facility Reported Incident (FRI), intake #2588424, submitted to the State Agency on 08/08/25 at 11:11 AM documented in part, On 8/5/2025 at approximately 7am resident c/o right hip pain and could not get out of bed. Hip site appeared swollen and warm to touch. X-ray was ordered and PRN pain medications were given. X-ray results returned with acute comminuted displaced intertrochanteric fx. (fracture) of right femur with associated soft tissue swelling.There has been no evidence or report of a fall.Full investigation is underway. The evidence showed that Resident #5 sustained an injury of unknown origin (right hip fracture) and that facility staff were aware of this on 08/05/25. However, this was not reported to the State Agency until 08/08/25, three (3) days later. During a face-to- face interview at 09/23/25 at 3:35 PM, Employee #2 (Director of Nursing/DON) acknowledged that facility staff failed to report of an injury of unknown origin to the State Agency within 24 hours and stated, I was having IT issues and couldn't send off the report. It was typed up and I had to wait until someone was able to help me to send it off.Cross Reference 22B DCMR Sec. 3232.4

Based on record review and staff interview, for one (1) of five (5) sampled residents, facility failed to ensure the physician signed and dated progress notes at the time of each visit. Resident #1. The findings included:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Depression, Anxiety Disorder, Sepsis, Hyperlipidemia and Intrahepatic Bile Duct Carcinoma.Review of the resident's medical record revealed the following:An admission Minimum Data Set (MDS) assessment date 07/09/25 showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15 indicating, intact cognitive status; Resident Mood Interview (PHQ-2 to 9 (C)) total severity score of 05 indicating mild depression; and received antianxiety and antidepressant medications.07/20/25 Initial Psych Consultation Note:- - Appetite decreased.- - Depression moderate.- - Gradual dose reduction: clinically contraindicated.- - Patient reports persistent feeling of low mood and lack of motivation. - - Recommendations and plan: continue antidepressant medication regimen; consider adjustment to address low motivation - Wellbutrin (type of antidepressant) 150 XL (extended-release) mg (milligrams) daily.- - Discussed risk and benefit of multiple antidepressants including serotine syndrome. 07/20/25 at 5:25 PM Nurses Note: Resident was seen by the Behavior MD (medical doctor) on unit, new order entered for Wellbutrin ER 24 hours 150 mg in am for depression. Resident (self RP) made aware of the new order.Review of the initial psych consultation note showed that the physician signed the note on 09/10/25 at 2:59 PM, 52 days later.The evidence showed that facility staff failed to ensure that the physician signed and dated Resident #1's progress note at the time of the visit.During a telephone interview on 09/19/25 at 10:52 AM, Employee #4 (Doctor of Nurse Practitioner - Psychiatric-Mental Health) acknowledged the findings and stated, This is a bad habit. I like to read over my notes and make sure I have everything documented and then I'll get pulled away and forget to sign.Cross Reference 22B DCMR Sec. 3207.10

Based on record reviews and staff interviews for one (1) of 26 sampled residents, the facility staff failed to show documented evidence that an allegation of resident-to-resident sexual abuse was reported to the state agency in the required time frame of 24 hours as evidenced by an allegation of possible sexual abuse first documented in Resident #27's medical record on 04/22/24 but not reported to the state agency until 04/24/24. Resident #27. The findings included: A review of the facility's policy titled Policy and Procedures for Abuse Prevention Program with an effective date of June 2023 documented the following: Sexual abuse-this refers to non-consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment, sexual coercion, inappropriate touching or sexual assault. Should an incident investigation lead to suspicion or allegation of resident abuse, the administrator, or his/her designee, will appoint an individual to investigate the incident. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia Severe with Anxiety, Unspecified Glaucoma, Repeated Falls, and Unsteadiness on Feet. A review of the medical record revealed the following: A nurse's general note dated 04/22/24 at 1:44 PM documented Resident continues to be confused with no evidence of pain or discomfort. A psychosocial progress note dated 04/22/24 at 3:06 PM documented in part, This SW (social worker) received report that the resident was observed hugging/kissing and being touched over her clothing by a male resident in the hallway outside her room around 10AM the prior day. It is unclear who initiated contact but resident was not upset by the physical touch. Residents separated by staff. This resident observed at the time/today for changes to behavior. None noted. Contact appeared reciprocal despite resident cognitive status. Guardian contacted. She stated that if the resident was not upset by the incident she has no immediate concerns but she wishes that they be kept separate in the future. She does not feel this is a case of sexual abuse even though the resident is severely demented. A review of the facility's investigative documents into this incident showed that there were 54 statements from the facility staff that dated the incident as occurring on 04/21/24. One (1) statement not of the 54 was blank except for a signature on the line marked for supervisor and one (1) form not of the 54 had a check mark no to the question Did you witness this incident? The facility's investigation also contained 2 intakes that were submitted to the State Agency. A review of a Facility Reported Incident (FRI) that was submitted to the State Agency on 04/24/24 documented the following: Staff observed this resident (Resident #27) and a male resident in the hallway. Residents were embracing. Male resident noted to kiss resident and touch resident's breasts. Resident is alert but not oriented. Resident was not tearful, did not become upset, did not push male resident away. Resident unable to give consent for physical contact due to severe dementia. Male resident (84) is alert and oriented x (times) 2-3 (to place and time) Residents separated. Male resident educated not to have physical contact with resident. Male resident denied additional occurrences. Male resident agreed to no future physical contact. Guardian of this female resident informed and did not wish to pursue this as abuse. Staff interviewed. No evidence of past occurrences noted other than what was observed. Residents have not had any physical contact for past several days. Investigation conducted and remains active at this time. It is noted that there is no documented evidence that the facility submitted the allegation of sexual abuse to the State Agency in the required 24-hour timeframe. During a face-to-face interview conducted on 06/20/25 at approximately 2:00 PM, Employee #2 (Director of Nursing) stated that the facility determined that this was not sexual abuse and acknowledged the findings.

Based on observations and interview, during a tour of the kitchen on June 16, 2025, at approximately 10:45 AM, facility staff failed to store and distribute food under sanitary conditions. The findings include: 1. One (1) of one (1) thirty-two-ounce container of Liquid Whole Eggs with Citric Acid stored in the walk-in refrigerator had a use-by date of April 24, 2025. 2. Three (3) of three (3) one and-one-half size pans, and four (4) of four (4) one-quarter size pans were stacked wet, on a shelf, ready for use. These findings were acknowledged by Employee #11 during a face-to-face interview on June 18, 2025, at approximately 10:00 AM.

Based on record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to implement its policies and procedures for investigating an allegation of abuse. Resident #41. The findings included: Review of the facility policy titled [Facility Name] Abuse Investigation Protocol, not dated, documented, .The individual conducting the investigation will, as a minimum . Conduct all interviews in the presence of a witness; Make every effort to interview staff members giving direct care to the resident for two days prior to the incident . Interview any staff members or others who may have knowledge of the incident . The following guidelines will be used when conducting interviews .Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports . Resident #41 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia, with Anxiety, Chronic Pain and Muscle Weakness. A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; no indicators of psychosis or behavior issues; required extensive assistance with one-person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #41's medical record revealed the following information: 03/21/22 at 2:47 PM [Psychosocial Note Late Entry] Care conference held on 3/17/2022 for quarterly review. Resident participated in assessment but did not wish to attend meeting. RP (representative) .notified of meeting but declined to attend. Care plan reviewed. Resident scored 4/15 on BIMS assessment. [Resident] was able to repeat 2/3 test words, could not recall test words with cueing, and was able to accurately state the month, but not day of the week or year. Resident is generally oriented to self, others, and place, although [resident] shows deficits in short-term memory as evidenced by repeating conversations and difficulty accurately recalling events . 03/23/22 at 4:42 AM [Nurses General Note] Resident continue c/o (complain of) throat discomfort. Throat culture collected, awaiting technician to pick it up. Resident remain afebrile. No coughing .Lung sounds clear on auscultation. 03/25/22 at 8:40 AM [Psychosocial Note] On 3/22/22, at Resident Council, resident reported concerns to include [resident] is treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports and RP . notified about concerns. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred on .Staff interviewed. No unusual incidents observed. Staff to monitor resident for additional reports. Investigation closed at this time. A Facility Reported Incident (FRI), DC00010646, received by the State Agency on 03/28/22 documented, On 3/22/22, at Resident Council, resident reported concerns to include [resident] treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred . Review of the facility's investigation documents provided to this surveyor on 04/06/23 showed a typed document dated March 22, 2022 that documented, Investigation of Claims of Rough Handling- Resident Council. DN (Director of Nursing) interviewed [Resident #41] following resident council . DN verbally interviewed the following staff who are usual caregivers. [Names of four (4) staff members]. No unusual incidents observed .There is no evidence of abuse. Investigation concluded. The 4 employee names who the Director of Nursing (DON) documented she verbally interviewed were cross-referenced to the facility's assignment sheets for dates 03/20/22 and 03/21/22 (the two days prior to the incident/allegation being reported) and it should be noted that two (2) of those employees did not provide direct care to Resident #41 in that time frame. The assignment sheets also revealed that there were six (6) employees who did provide direct care to Resident #41 during that time frame (03/20/22 to 03/22/22) for which there was no documented evidence of an interview or that they provided a signed and dated witness report/statement regarding Resident #41's allegation of being roughly handled. The evidence showed that the facility staff who conducted the investigation of Resident #41's allegation of abuse failed to follow the facility's policies and procedures as evidenced by failing to: 1. Provide documented evidence that the interviews (Resident #41 and the 4 staff members) were conducted in the presence of a witness; 2. Make every effort to interview all staff members giving direct care to the resident for two days prior to the incident being reported; 3. Obtain signed and dated written witness reports/statements from the employees. During a face-to-face interview conducted on 04/12/23 at 12:39 PM, Employee #2 (Director of Nursing), who conducted the investigation of this allegation of abuse stated, I interviewed [Resident #41]. [Resident #41] had a lot of paranoia and documented memory problems. When asked why none of the staff members interviewed provided a signed and dated written report/statement, Employee #2 stated, There weren't any witnesses; (Resident #41) couldn't tell us who did it or when. I just interviewed the regular staff who took care of [resident]. Employee #2 was then asked if any these interviews (resident and staff) were conducted in the presence of a witness, to which [Resident #41] stated, No. When asked why all the staff who cared for Resident #41 in the two days prior to the allegation being reported were not interviewed or provided a written report/statement, Employee #2 stated, [Resident #41] was not able to tell me when this occurred. That would've meant having to interview and get statements from almost all the staff. We didn't have time for that.

Based on record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to have documented evidence that an allegation of abuse was thoroughly investigated. Resident #41. The findings included: Review of the facility policy titled [Facility Name] Abuse Investigation Protocol, not dated, documented, .The individual conducting the investigation will, as a minimum . Conduct all interviews in the presence of a witness; Make every effort to interview staff members giving direct care to the resident for two days prior to the incident . Interview any staff members or others who may have knowledge of the incident . The following guidelines will be used when conducting interviews .Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports . Resident #41 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia, with Anxiety, Chronic Pain and Muscle Weakness. Review of Resident #41's medical record revealed: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 04, indicating severe cognitive impairment; no indicators of psychosis or behavior issues; required extensive assistance with one person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. 03/21/22 at 2:47 PM [Psychosocial Note Late Entry] Care conference held on 3/17/2022 for quarterly review. Resident participated in assessment but did not wish to attend meeting. RP (representative) .notified of meeting but declined to attend. Care plan reviewed. Resident scored 4/15 on BIMS assessment. [Resident] was able to repeat 2/3 test words, could not recall test words with cueing, and was able to accurately state the month, but not day of the week or year. Resident is generally oriented to self, others, and place, although she shows deficits in short-term memory as evidenced by repeating conversations and difficulty accurately recalling events . 03/23/22 at 4:42 AM [Nurses General Note] Resident continue c/o (complain of) throat discomfort. Throat culture collected, awaiting technician to pick it up. Resident remain afebrile. No coughing .Lung sounds clear on auscultation. 03/25/22 at 8:40 AM [Psychosocial Note] On 3/22/22, at Resident Council, resident reported concerns to include [resident] is treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports and RP . notified about concerns. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred on .Staff interviewed. No unusual incidents observed. Staff to monitor resident for additional reports. Investigation closed at this time. A Facility Reported Incident (FRI), DC00010646, received by the State Agency on 03/28/22 documented, On 3/22/22, at Resident Council, resident reported concerns to include [resident] is treated roughly by staff and had a sore throat that was not addressed by staff. Staff investigated reports. Resident interviewed. Unable to give details of staff treatment such as which staff, which day or which shift the treatment occurred . Review of the facility's investigation documents provided to this surveyor on 04/06/23 showed a typed document dated March 22, 2022 that documented, Investigation of Claims of Rough Handling- Resident Council. DN (Director of Nursing) interviewed [Resident #41] following resident council . DN verbally interviewed the following staff who are usual caregivers. [Names of four (4) staff members]. No unusual incidents observed .There is no evidence of abuse. Investigation concluded. The 4 employee names who the DN documented she verbally interviewed were cross-referenced to the facility's assignment sheets for dates 03/20/22 and 03/21/22 (the two days prior to the incident/allegation being reported) and it should be noted that two (2) of those employees did not provide direct care to Resident #41 in that time frame. The assignment sheets also revealed that there were six (6) employees who did provide direct care to Resident #41 during that time frame (03/20/22 to 03/22/22) for which there was no documented evidence of an interview or that they provided a signed and dated witness report/statement regarding Resident #41's allegation of being roughly handled. The evidence showed that the facility staff who conducted the investigation of Resident #41's allegation of abuse failed have documented evidence that an allegation of abuse was thoroughly investigated by failing to: 1. Make every effort to interview all staff members giving direct care to the resident for two days prior to the incident being reported; 2. Obtain signed and dated written witness reports/statements. During a face-to-face interview conducted on 04/12/23 at 12:39 PM, Employee #2 (Director of Nursing), who conducted the investigation of this allegation of abuse stated, I interviewed her [Resident #41]. Had a lot of paranoia and documented memory problems. When asked why none of the staff members interviewed provided a signed and dated written report/statement, Employee #2 stated, There weren't any witnesses; (Resident #41) couldn't tell us who did it or when. I just interviewed the regular staff who took care of [resident] . Employee #2 was then asked if any these interviews (resident and staff) were conducted in the presence of a witness, to which she stated, No. When asked why all the staff who cared for Resident #41 in the two days prior to the allegation being reported were not interviewed or provided a written report/statement, Employee #2 stated, [Resident #41] was not able to tell me when this occurred. That would've meant having to interview and get statements from almost all the staff. We didn't have time for that. Cross Reference: 22B DCMR sec. 3232.2

Based on observation, record review and staff interview, for one (1) of 29 sampled residents, facility staff failed to accurately code one resident's dental status in the Significant Change Minimum Data Set (MDS). Resident #21. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included: Mixed Hyperlipidemia, Vesicointestinal Fistula, and Long Term use of Anticoagulants. Review of Resident #21's medical record revealed: 12/31/22 at 11:33 [Nutrition Assessment] .Oral/Dental Condition: Dentures- full upper; Dentures- full lower. A Significant Change MDS dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 11, indicating moderate impaired cognition. Section L0200 (Dental), directed check all that apply, which included, No natural teeth or tooth fragments (edentulous). The MDS showed facility staff documented an X at the line None of the above were present. During a face-to-face interview conducted on 04/05/23 at 2:59 PM, Resident #21 was noted to have no upper or lower teeth. Resident #21 stated, I wear dentures. The resident's assigned Certified Nurse Aide (CNA) showed the surveyor a small, white container that contained a set of full upper and lower dentures. During a face-to-face interview conducted on 04/12/23 at 9:55 AM, Employee #6 (MDS Coordinator) reviewed the MDS and stated, You are correct. I was on vacation and someone else did this MDS. Cross Reference: 22B DCMR sec. 3231.12

Based on record reviews and staff interviews, for one (1) of 29 sampled residents, the facility staff failed to update a resident's care plan to include goals and approaches to address one resident's Sacral pressure ulcer. Residents' #50. Findings included: Resident #50 was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Hyperlipidemia, Osteoarthritis, Chronic Obstructive Pulmonary Disease, Anemia, Hypertensive Heart Disease, and Major Depressive Disease. A review of the medical record revealed the following: A review of care plans showed a focus area, [Resident Name] has potential for impairment to skin integrity related to frail/fragile skin, memory impairment, impaired mobility, use of hypertensive medications, initiated on 2/23/2023. The Admission Minimum Data Set (MDS) dated [DATE] showed in Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 15, indicating an intact cognitive response. Under Section G (Functional Status) - Bed Mobility and Personal Hygiene the resident was coded as requiring extensive assistance with one person's physical assistance from facility staff. In Section M (Skin Condition), M0210 indicated Does this resident have one or more unhealed pressure ulcers/injuries, the facility staff coded, yes. M0300 indicated, Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar coded as 1. The number of these unstageable pressure ulcers that were present upon admission/entry or reentry coded as 1. 2/22/2023 18:15 [6:15 PM] Medication Reconciliation Note: Resident admitted to this nursing facility this afternoon. Reviewed discharged orders with MD. New orders received . Use Dakin's solution to clean coccyx wound daily and PRN 2/22/2023 20:45 [8:45 PM] (Physician's Order) Dakin's (1/4 strength) external solution (sodium hypochlorite) Apply to coccyx topically as needed for dressing soiling /lifting. After cleansing with 1/4 strength Dakin's solution follow with gauze and cover with foam dressing. 4/5/2023 10:55 Skin/wound notes . [AGE] year-old A [patient] pt seen at bedside earlier today. sacral pressure injury . The sacrum is an unstageable pressure injury that is covered with 40% thin slough and 60% pale granulation around the wound edges. It is surrounded with intact tissue with scant s/s drainage continue the current treatment. 4/10/2023 16:31 Nurses Skilled Notes: . Wound still present and with scant slough in bed, no mal odor to the wound while observing for infection . wound care done and no bleeding observed . There was no documented evidence that facility staff updated Resident #50's care plan to reflect the open area found on 2/22/2023. During a face-to-face interview conducted on 4/12/2023, at approximately 9:00 AM with Employee #3 (ADON/Educator), she acknowledged the finding. Cross Refrence: 22B DCMR sec.3210.4

Based on observations, record reviews and staff interviews, for two (2) of 29 sampled residents, facility staff failed to account for the dispensing of a controlled medications. Residents' #6 and #23. The findings included: 1. Facility staff failed to account for the dispensing of Resident #6's ordered Tramadol (narcotic pain reliever). Resident #6 was admitted to the facility on [DATE] with diagnoses that included: Polyosteoarthritis, Idiopathic Peripheral Autonomic Neuropathy and Dementia. Review of Resident #6's medical record revealed: A physician's order dated 08/25/22 that directed, Tramadol HCl (hydrochloride) Tablet 50 MG Give 0.5 tablet by mouth everyday shift for pain control . During a narcotic count conducted on 04/06/23 at 10:16 AM of the Team A medication cart with Employee #7 (Licensed Practical Nurse), it was noted that Resident #6's inventory sheet for Tramadol (narcotic pain reliever) 50 mg (milligrams) 1/2 (half) tablets documented 21 remaining, however, the blister packet was observed to have 20 half tablets remaining. Review of the Medication Administration Record (MAR) for April 2023 showed that Employee #7 initialed to indicate that Resident #6 was administered Tramadol 25 MG on 04/06/23 for day shift. During a face-to-face interview conducted at the time of the observation, Employee #7 acknowledged the findings and stated, I gave it to [resident] this morning and forgot to sign it out. 2. Facility staff failed to account for the dispensing of Resident #23's ordered Lorazepam (anti-anxiety medication). Resident #23 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia with Anxiety, Hallucinations and Hypertensive Heart Disease. A physician's order dated 07/20/21 that directed, Ativan tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours for anxiety. Review of the Medication Administration Record (MAR) for April 2023 showed that Employee #8 initialed to indicate that Resident #23 was administered Lorazepam 0.5 mg tablet at 1:00 PM. During a narcotic count on 04/11/23 at 1:08 PM of the Team A medication cart with Employee #8 (Licensed Practical Nurse), it was noted that Resident #23's inventory sheet for Lorazepam 0.5 mg tablets documented 6 remaining, however, the blister packet was observed with 5 tablets remaining. During a face-to-face interview conducted at the time of the observation, Employee #8 acknowledged the findings and stated, I know to sign out the narcotic medications when I give it. I don't know what happened. Cross Reference: 22B DCMR sec 3224.3

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by final rinse temperatures from one (1) of two (2) dishwashers that were consistently below 180 degrees Fahrenheit (F) in high heat disinfect mode. The findings included: During observations in dietary services on April 5, 2023, at approximately 12: 45 PM, one (1) of one (1) dishwasher in the main kitchen failed to reach a minimum of 180 degrees Fahrenheit on numerous consecutive occasions. Two (2) of two (2) trays of dishes and utensils that had been washed were rewashed in the chemical disinfect dishwasher located in the resident's small kitchen, on the Long-Term Care unit. When tested , the chemical disinfect solution from that dish machine was at 200 PPM. Employee #10 confirmed the findings on April 10, 2023, at approximately 11:00 AM. Cross Refrence: 22 DCMR sec.3219.1

Based on record review and staff interview for one (1) of 29 sampled residents, facility staff failed to maintain medical records on each resident that were complete. Residents' #105. The findings included: Resident #105 was admitted to the facility on [DATE], with diagnoses that included Peripheral vascular Disease, Gastroesophageal Reflux Disease, Chronic Kidney Disease, and Major Depression. The facility submitted a facility reported incident (FRI) on 2/1/2023 to the State Agency, that documented, Resident reported to Guardian during routine monthly visit that he had been slapped by a staff member at 3 AM [morning] on the day of the visit. Guardian reported to social worker staff. Investigation initiated. Resident interviewed by [registered nurse] RN on day of report. Resident interviewed by Dir of SW [Director of Social Work] on day after report and two days after report. Resident did not repeat report in theses interviews. No bruising, or abraisions noted. Alert and oriented to person only, Hx of Vascular dementia, with paranoid ideation. Hx of recent GDR [gradual drug reduction] of antipsychotic and tx [treatment]of UTI [urinary tract infection]. Staff interviewed by DN [director of nursing] with written statement taken. No unusual incident reported, Investigation concluded as not substantiated for abuse. Resident to be tx [treated] by behavioral health and followed by SW services for possible f/u report. Review of the medical record showed progress notes dated 1/27- 2/2023 documentation was not complete as there was no mention in the progress note of resident #105's reported allegation of abuse information . The evidence showed that facility staff failed to maintain resident #105's medical records which were not complete with the resident's allegation of abuse information in the progress note when it was reported on 1/28/2023. During a face-to-face interview conducted on 4/11/2023 at 11:00 AM, Employee #4 (Director of Social Service) acknowledged the findings and stated, I made a mistake of not documenting it in the resident record.

Based on observation, record review, and staff interviews, facility staff failed to maintain infection prevention and control practices during a wound care dressing change observation for one resident. Resident #50. The findings included: According to the National Library of Medicine, when performing wound care, staff should, Wash your hands Clean the trolley using soap and water, or disinfectant, and a cloth. Start at the top of the trolley and work down to the bottom legs of the trolley using single strokes with your damp cloth. Place the sterile dressing/procedure pack on the top of the trolley. Open the sterile dressing pack on top of the trolley. Open the sterile field using the corners of the paper. Open any other sterile items needed onto the sterile field without touching them. Wash your hands and put on non-sterile gloves (to protect yourself) before removing an old dressing. Dispose of this dressing in a separate dirty clinical waste bag. Fold up the dressing/procedure pack and place all contaminated material in a bag designated for clinical waste, making sure all sharps are removed and disposed of in a sharp's container.Remove gloves and place them in a waste bag. Wash your hands. (www.ncbi.nlm.nih.gov/pmc/articles/PMC4579997/) During wound care observation for Resident #50's pressure ulcer on 04/06/23 at 11:27 AM Employee #7 was observed cleaning the sacral wound with gauze covered with Dakin solution. He then placed the used unclean gauze on the bedside table with the clean gauze and foam dressing he needed to complete the dressing change. Physician orders dated 02/22/23 at 8:45 PM showed, Dakin's (1/4 strength) external solution (sodium hypochlorite) Apply to coccyx topically as needed for dressing soiling /lifting. After cleansing with 1/4 strength Dakin's solution follows with gauze and cover with foam dressing. During wound care observation on resident #50 4/6/2023 at 11:27 AM Employee #7 was observed cleaning the sacral wound with gauze covered with Dakin solution. He then placed the used unclean gauze on the bedside table with the clean gauze and foam dressing he needed to complete the dressing change. In a face-to-face interview conducted on 4/6/2023 at approximately 11:28 AM, Employee #7 stated, I did not have a red bag to put it (used soiled gauzed) in. He was able to verbalize the procedure for completing the dressing change. A face-to-face interview was conducted on 4/12/2023, at approximately 9:00 AM with Employee #5 (Infection Control), she acknowledged the finding and stated, Staff will be trained. Cross Reference: 22B DCMR sec 3217.6 43776

Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by final rinse temperatures that were below 180 degrees Fahrenheit (F) on April 4, 2023, at approximately 12:45 PM. The findings include: During observation in dietary services on April 5, 2023, at approximately 12:45 PM, final rinse temperatures from one (1) of one (1) dishwasher in the main kitchen did not reach a minimum of 180 degrees Fahrenheit as required. Facility staff attempted to use the dishwasher in chemical disinfect mode. However, when tested , the chlorine disinfect solution failed to reach the minimum requirement of 50 Parts per Million (PPM). Employee #10 confirmed the findings on April 10, 2023, at approximately 11:00 AM Cross Refrence: 22B DCMR sec. 3258.13

Based on observations and interviews, the facility's staff failed to follow Standard of Practices for Infection Control to prevent or contain the spread of COVID-19 by touching the front of his used N95 facemask after providing care for residents in the COVID-19 unit. The findings included: According to San Francisco Department of Health, Avoid touching the front of the mask. The front of the mask is contaminated. Only touch the ear loops/ties/band. https://www.sfcdcp.org/communicable-disease/healthy-habits/how-to-put-on-and-remove-a-face-mask/ During an observation the facility's COVID-19 unit on 09/30/22 at approximately 11:00 AM, Employee #4 was observed walking out of a room with two (2) residents. The employee was wearing his face shield and a N95 mask. After walking into the hallway, the employee walked to the opposite side of the hallway, touched the front of his N95 mask with his bare hands to readjust the nose piece, touched his face shield, touched the top of Personal Protective Equipment (PPE) storage cart, put on a gown and gloves, knocked on the door of another resident, and announced his self to enter the room. Employee #4 was stopped by the surveyor before he entered the other resident's room. During a face-to-face interview on 09/30/22 at approximately 11:15 AM, Employee #4 was asked if it was the facility's practice or protocol for him to enter a resident's room wearing a face shield and N95 mask that he wore while providing care to COVID positive residents? He said he was supposed to discard the used N95 mask and face shield and replace them with brand-new ones before entering another resident's room. Employee #4 then said that he forgot to discard the used PPEs (the face shield and N95 mask). Lastly, the employee proceeded to remove all PPE. During a face-to-face interview 9/30/22 at approximately 11:30 AM, Employee #3 (Infection Preventionist) stated that it was the facility's protocol and practices for employees to discard face shields and N95 masks when leaving a room after providing care to residents with COVID-19. The employee then said that she would ensure that the PPE equipment storage cart was removed from the floor and decontaminated. Additionally, Employee #3 stated that she would re-educate all employees regarding the facility's practice and protocol for disposing of personal protective equipment.

Based on record review, and staff interview, for one (1) of 16 sampled residents, facility staff failed to implement the interventions specified in the care plan for monitoring a resident on antidepressant and antipsychotic medications. Resident #5. Findings included . Resident #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record showed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 8/24/2020 at 17:00 (5:00 PM) [MEDICATION(S)] Tablet 25 MG (milligrams) . Give 0.5 tablet by mouth in the evening for Delusions 0.5tab (tablet) 12.5mg 8/25/2020 at 09:00 (AM) [MEDICATION(S)] Tablet 25 MG . Give 1 tablet by mouth one time a day for Delusions 8/25/2020 at 09:00 (AM) [MEDICATION(S)] Tablet 25 MG . Give 1 tablet by mouth one time a day for Anxiety Review of the care plans dated 02/22/2021, showed the following focus area: [Resident #5] is at risk for adverse reaction related to . use of antidepressant medication, use of antipsychotic medication with the following interventions: Administer medications per orders. Monitor/document for effectiveness and any side effects. Administer [CONDITION(S)] medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-shift. A review of the nursing progress notes, behavior tab, treatment administration record, and the paper chart dated from 08/24/2020, to 03/10/2021, showed that there was no documented evidence that the facility staff monitored Resident # 5 for effectiveness or side effects of the antidepressant and antipsychotic medication as outlined in the care plan. During a face-to-face interview conducted with Employee #5 on 03/10/2021, at approximately 2:20 PM, she stated, I have not been documenting any behavior assessments on Resident #5. Employee #5 then proceeded to show the surveyor the blank Behavior section in the electronic health record. Continued interview revealed that the facility also uses a paper copy of the checklist for monitoring behaviors and side effects however, Employee #5 stated, Resident #5 has not had one. During a face-to-face interview on 03/10/2021, at approximately 2:30 PM with Employee #6 (Unit Manager), acknowledged the finding and stated, I am not sure why she [Resident #5] hasn't been getting monitored but she needs to be and needs a behavior sheet. Facility staff failed to implement the interventions (monitor/document for effectiveness and any side effects) specified in the care plan for monitoring Resident #5 who receives antidepressant and antipsychotic medications.

Based on record review and staff interview for one (1) of 16 sampled residents, facility staff failed to follow the professional standards of practice for completing the assessment on Resident #24 prior to leaving the facility for [CONDITION(S)] treatment. Findings included . Resident #24 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .every day shift every Tue [Tuesday], Thu [Thursday] and Sat [Saturday]. A review of Resident #24's [CONDITION(S)] Communication Record [A form used to facilitate communication between the nursing facility and the [CONDITION(S)] center] showed the following: On 01/30/2021, facility staff failed to complete the resident assessment (resident status, intake by mouth, graft site function, vital signs, mobility, and [CONDITION(S)] transportation) on the form prior to the resident leaving the facility for [CONDITION(S)] treatment. On 02/27/2021, facility staff failed to record the vital signs obtained from the resident on the [CONDITION(S)] communication form prior to leaving the facility for [CONDITION(S)] treatment. During a face-to-face interview on 03/11/2021, at 12:30 PM with Employee # 9, she stated, The information from the facility to the [CONDITION(S)] center is from the Resident's morning assessment that includes resident status, intake by mouth, graft site function, vital signs, mobility and [CONDITION(S)] transportation to [CONDITION(S)]. At the time of the interview, Employee #9 acknowledged the findings. Facility staff failed to follow the professional standards of practice for completing the assessment on a resident going out for [CONDITION(S)] treatment.

Based on record review, and staff interview, for one (1) of 16 sampled residents, facility staff failed to adequate monitoring a resident who is on antipsychotic medication. Resident #5. Findings included . Resident #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record showed the following orders: 8/24/2020 17:00 (5:00 PM) [MEDICATION(S)] Tablet 25 MG (milligrams) . Give 0.5 tablet by mouth in the evening for Delusions 0.5tab (tablet) 12.5mg 8/25/2020 09:00 (AM) [MEDICATION(S)] Tablet 25 MG . Give 1 tablet by mouth one time a day for delusions Review of the care plan dated 02/22/2021, showed the following focus area: [Resident #5] is at risk for adverse reaction related to . use of antipsychotic medication with the following interventions: Administer medications per orders. Monitor/document for effectiveness and any side effects. Administer [CONDITION(S)] medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-shift. A review of the nursing progress notes, behavior tab, treatment administration record, and the paper chart dated 08/24/2020 to 03/10/2021, showed that there was no documented evidence that the facility staff monitored Resident #5 for effectiveness or side effects of the antidepressant and antipsychotic medication as outlined in the care plan. During a face-to-face interview conducted with Employee #5 on 03/10/2021, at approximately 2:20 PM, she stated, I have not been documenting any behavior assessments on Resident #5. Employee #5 then proceeded to show the surveyor the blank Behavior section in the electronic health record. Continued interview revealed that the facility also uses a paper copy of the checklist for monitoring behaviors and side effects however, Employee #5 stated, Resident #5 has not had one. During a face-to-face interview on 03/10/2021, at approximately 2:30 PM with Employee #6 (Unit Manager), acknowledged the finding. Facility staff failed to adequately monitor a resident who is on antipsychotic medication.

Based on observation and staff interview, facility staff failed to store biologicals in safe condition as evidenced by nine (9) of 54 containers of sterile water, that were stored past their expiration date of November 2019, in the oxygen storage room located on the [NAME] Drive unit. Findings included . During a walkthrough of the facility on March 11, 2021, at approximately 1:10 PM, nine (9) of 54, 3.4 ounces containers of sterile water were stored past their expiration date of November 2019, in the oxygen room located on the [NAME] Drive unit. Employee #3 acknowledged the findings during a face-to-face interview on March 11, 2021, at approximately 1:15 PM.

Based on observations made on March 8, 2021, at approximately 12:30 PM, it was determined that dietary staff failed to store and prepare food in accordance with professional standards for food service safety, as evidenced by one (1) of one (1) open pack of parmesan cheese and one (1) of one (1) open container of mustard that were stored beyond their use-by-date of March 4, 2021, one (1) of one (1) grease fryer that was soiled with cooked food residue, and four (4) of seven (7) sheet pans that were dented throughout. Findings included . 1. One (1) of one (1) open pack of parmesan cheese and one (1) of one (1) container of mustard were stored in one (1) of one (1) walk-in refrigerator beyond their use-by-date of March 4, 2021. 2. One (1) of one (1) grease fryer was soiled with leftover fried food residue. 3. Four (4) of seven (7) sheet pans, stored in the ready-for-use area, were dented throughout. These observations were acknowledged by Employee #7 during a face-to-face interview on March 12, 2021, at approximately 11:00 AM.

Based on observation and interview, facility staff failed to maintain building equipment in good working condition as evidenced by one (1) of one (1) hopper that did not function as intended. Findings included . One (1) of one (1) hopper, located in the soiled utility room on the [NAME] Drive unit failed to flush when tested . During a face-to-face interview on March 11, 2021, at approximately 1:45 PM, Employee #8 acknowledged that the hopper was no longer functioning and needed to be removed from the soiled utility room.

Based on observation, record review and staff interview for one (1) of 26 sampled residents, it was determined that facility staff failed to accurately assess and implement interventions with timeliness to care for a facility acquired pressure sore for Resident #9. The findings include: A review of the clinical record for Resident #9 revealed an alteration in skin integrity was identified on April 15, 2011. A period of approximately 3 days lapsed before the physician was notified and treatment initiated to care for the alteration in skin integrity. The wound worsened during the period of April 15, 2011 through April 18, 2011. The facility acquired wound was assessed as an " unstageable pressure sore of the left buttocks on April 18, 2011. According to the history and physical examination Brittle IDDM (insulin dependent diabetes mellitus) , diabetic [MEDICAL CONDITION], [MEDICAL CONDITION], PAD (peripheral artery disease), CAD ([MEDICAL CONDITION]), S/P CABG (coronary artery bypass graft), lumber spinal stenosis with [DIAGNOSES REDACTED], and rectal fissure". According to the quarterly Minimum Data Set signed and dated March 9, 2011, Resident #9 was coded as totally dependent for transfer, bathing and personal hygiene and required extensive assistance for bed mobility, locomotion and dressing in Section G, Functional Status. According to Section H, Urinary/Bowel, the resident was incontinent of bowel and bladder. Section M, Skin, revealed the resident had a history of [REDACTED]. A review of Resident #9 ' s care plan revealed the interdisciplinary team identified " Skin breakdown " related to immobility, incontinence, diabetes and decreased sensation as a problem on April 18, 2011. A review of nurse ' s notes dated April 15, 2011 at 3:00 PM, revealed: " ...CNA (certified nursing assistant) brought to my attention that while changing resident, noticed a non pressure ulcer on resident ' s Lt (left) buttocks ... non-pressure ulcer 2 cm width x 1? cm length. " The successive nurse ' s entry dated April 18, 2011 at 8:20 AM read, " MD (Medical doctor) gave new order for the open area on the (left) buttocks. Cleanse area with wound cleanser, pat dry, apply [MEDICATION NAME] ointment, cover with Allevyn dressing Q (every) 3 hours and prn (as needed). " The subsequent nurse ' s entry on April 18, 2011 at 3:30 PM read, " Buttocks wound assessed by wound clinician. Recommended Santyl ointment with dressing change daily, cleared by MD. Daughter (named) notified. " The record revealed licensed staff initiated a document entitled "Skin Condition Record for Non-Pressure Ulcer Skin Conditions " that read: "Date of onset -April 15, 2011; comments - wound on Lt buttocks is pink with red lining on the outside of wound; size - length 1? cm by 2cm width; " 0 " depth; exudate type - none; exudate amount - none; odor - none; wound bed - pink/beefy red; surrounding skin color - bright red; surrounding tissue/wound edges - normal for skin. " The record revealed a document entitled "Weekly Pressure Ulcer Healing Record " that included the following: "Date of onset - April 18, 2011; site - (Left) buttocks; comments - covered with 100% yellow slough and no surrounding redness; stage - unstageable; size - 1x1x0; exudate type - serous; exudate amount - scant; odor - none; wound bed - slough 100%; surrounding skin color - normal; surrounding tissue/wound edges - normal; progress - new; treatment - changed. " The record lacked evidence that interventions were implemented during the period of April 15 - 18, 2011 to care for the left buttocks facility-acquired wound sustained by the resident. The worsening of the site is evidenced by the progression of the wound, as documented in the nursing assessments; from a " beefy red " wound bed to a 100% slough covered wound bed as follows: " Skin Condition Record for Non-Pressure Skin Conditions " dated April 15, 2011 - wound bed (left buttocks) " pink/beefy red. " " Weekly Pressure Ulcer Healing Record " dated April 18, 2011 - wound bed " slough 100%. " Further review of the clinical record revealed the resident had a history of [REDACTED]. According to Weekly Pressure Ulcer Healing Records, the resident was treated for [REDACTED]. During the period of January 2 - 25, 2011, treatment was implemented for a Stage 2 ulcer of the left buttocks. A review of the facility ' s pressure ulcer risk tool, the Braden Scale, revealed licensed staff assessed Resident #9 as a " mild risk " for the development of pressure ulcers. The scoring of the scale depicts high risk: 10-12; moderate risk: 13-14 and mild risk 15-18. The assessment dates and correlating scores for Resident #9 are as follows: September 1, 2010 - total score: 15; December 8, 2010 - total score: 15; March 10, 2011 - total score: 18 and April 17, 2011 - total score 16. The risk factor identified as " sensory perception, " was assessed as " 4 " no impairment. However, the score lacked evidence that the assessor considered " decreased sensation " (noted in care plan) and the medical [DIAGNOSES REDACTED]. Licensed staff failed to accurately assess the alteration in skin integrity at the time of initial identification on April 15, 2011. The wound was assessed as a " non-pressure ulcer " of the left buttocks. The location of the wound, in a pressure-bearing area (the buttocks) and the resident ' s history of pressure ulcer(s) in the same and/or similar site would have lead the assessor to consider the wound to be of pressure in origin. The assessment conducted by the facility ' s wound specialist on April 18, 2011 identified the wound as a pressure ulcer. The record revealed the most recent dietary assessment was documented March 9, 2011 and the resident ' s skin was intact. There was no evidence that the dietician was notified regarding the resident ' s alteration in skin integrity. The nutrition care plan was not updated with goals and approaches to address the resident's skin impairment from a nutritional perspective. A review of physician's order [REDACTED]. The pressure-relieving device was implemented approximately 3 weeks post identification of the facility acquired pressure ulcer. A face-to-face interview was conducted with Employees #1, 2 and 3 on May 13, 2011 at approximately 2:00 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 #9 ' s facility acquired wound. Facility staff failed to accurately assess and implement interventions with timeliness to care for a facility acquired pressure ulcer. The record was reviewed May 13, 2011.