Every finding on record at Serenity Rehabilitation and Health Center LLC

Based on observations, record review and staff interviews, for one (1) of four (4) sampled residents, facility staff failed to provide the necessary podiatry consult, treatment and foot care to Resident #2, who is a diabetic with increased risk to developing foot problems.The findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Hyperlipidemia, Cerebral Infarction and Schizophrenia. Review of the resident's medical record revealed the following: A physician's order dated 10/13/25 that directed, Dental/Ophthalmology/Podiatry/Psychiatry/Dietary consult PRN (as needed) 10/14/25 at 1:07 PM Skin and Wound Note: Date of Service: 10/14/25Reason for visit: new admission to the facility, skin/wound assessment.The patient is recommended for routine in house Podiatry evaluation for management of nail trimming and thickened nails. Care plan focus area initiated 10/15/25: [Resident #2] has unstable blood glucose r/t (related to) Diabetes Mellitus.Interventions: Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. A physician's order dated 10/19/25 that directed, Weekly skin assessment by Licensed nurse every day shift every Tue (Tuesday] for weekly skin assessment; Shower twice a week and as needed every day shift every Tue, Fri (Friday). A physician's order dated 10/20/25 directed, Offload bilateral heels while in bed and as tolerated, every shift for heel pressure relied (sp). 10/21/25 at 11:39 AM Skin and Wound Note:- Date of Service: 10/21/25.- The patient is recommended for routine in house Podiatry evaluation for management of nail trimming and thickened nails. 10/28/25 at 2:26 PM Skin and Wound Note:- Date of Service: 10/28/25.- The patient is recommended for routine in house Podiatry evaluation for management of nail trimming and thickened nails. Care plan focus area, last revised on 10/28/25: [Resident #2] has an ADL (activities of daily living) self-care performance deficit related to (r/t) generalized weakness.Interventions: [Resident #2] Requires skin inspection. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Care plan focus area, last revised on 10/28/25: [Resident #2] has an ADL Self-care deficit related to generalized muscle weakness.Interventions: Assist with daily hygiene, grooming, dressing, oral care and eating as needed. Care plan focus area, last revises on 10/28/25 [Resident #2] is at risk for pressure ulcer development r/t fragile skin, incontinence, decreased mobility, and other comorbidities.Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Offload heels/pressure areas while in bed, as tolerated. Weekly skin assessment by licensed nurse. 11/07/25 at 9:06 AM Skin and Wound Note:- Date of Service: 11/07/25.- The patient is recommended for routine in house Podiatry evaluation for management of nail trimming and thickened nails. 11/14/25 at 8:34 AM HP Skin and Wound Note:- Date of Service: 11/14/25.- The patient is recommended for routine in house Podiatry evaluation for management of nail trimming and thickened nails. The evidence shows that on 10/14/25, 10/21/25, 10/28/25, 11/07/25 and 11/14/25, the wound care practitioner recommended routine in house Podiatry evaluation for management of nail trimming and thickened nails. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the following: clear speech, understands others and able to make self understood; A Brief Interview for Mental Status (BIMS) summary score of 13 indicating intact cognitive response; required supervision or touching assistance for shower/bathe self, lower body dressing, putting on/taking off footwear. A document provided to the surveyor showed that a podiatrist was in the facility to see residents on 10/24/25, 11/11/25, and 12/19/25. 12/29/25 Weekly Skin Assessment -Licensed Nurse:No skin impairment.Plan of care continued. 01/05/26 Weekly Skin Assessment -Licensed Nurse:No skin impairment.Plan of care continued. 01/13/26 Weekly Skin Assessment -Licensed Nurse:- No skin impairment.- Plan of care continued. During an observation on 01/14/26 at 10:15 AM, Resident #2 was observed laying in bed with his feet not covered. Upon inspection by the surveyor, the following was noted:Resident's left foot: all five toes had overgrown, thickened, yellow nails. The nail on the second toe was overgrown and curved downwards and touching the big toe. The nails on the third, fourth and fifth toes were more overgrown, curved and digging into the skin on the bottom of the resident's left foot. Resident's right foot: all five toes had overgrown, thickened, yellow nails. The nails on the fourth and fifth toes were even more overgrown, curved downwards, and digging into the skin on the bottom of the resident's right foot. The surveyor called Employee #3 (assigned Certified Nurse Aide/CNA) and Employee #4 (assigned Licensed Practical Nurse/LPN) into the resident's room at 2:24 PM where they made the same observations. Employee #4 stated, I did my assessment of [Resident #2] this morning that included a skin assessment and noticed that his toenails are long and that he needed to see podiatry. When asked if the resident had seen a podiatrist since his admission on [DATE], Employee #4 stated that she was not sure and would check with the unit manager. At 2:30 PM, Employee #2 (Director of Nursing) and Employee #5 (3rd Floor Unit Manager) were pulled into Resident #2's room and they also observed the condition of Resident #2's feet and toenails. When asked if the resident has been seen by a podiatrist since his admission on [DATE], Employee #5 stated, No. Employee #2 further stated, He is on the list to be seen but has not been seen yet. During a face-to-face interview on 01/14/25 at 3:09 PM, Employee #1 (Administrator) stated, [Resident #2] was admitted with Medicare part A. His DC (District of Columbia) Medicaid application is still pending so he does not have insurance to cover podiatry services. His application was submitted on 11/18/25. When asked will the resident have to wait as long as it takes the application to get approved before being able to get his diabetic feet and toenails addressed by a podiatrist, Employee #1 stated, No, we could always make exceptions for him to be seen and the facility would cover the cost. The evidence showed that since his admission on [DATE] to 01/14/25, three (3) months, facility staff failed to provide the necessary podiatry consult, treatment and foot care to Resident #2, who is a diabetic with increased risk to developing foot problems. Cross Refence 22B DCMR Sec. 3228.3

Based on record review and staff interview, for one (1) of four (4) sampled residents, facility staff to ensure that one resident's Quarterly Minimum Data (MDS) assessment was accurately coded for a facility acquired pressure injury (deep tissue injury/DTI). Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, Muscle Weakness and Major Depressive Disorder. Review of the resident's medical record revealed the following: 10/29/25 at 1:53 PM Nurses Note: During routine ADL/incontinent care, writer was called by the nursing staff assigned to resident room and observed open area to sacrum. NP made aware, wound team and dietitian notified. 10/30/25 at 12:07 PM Skin and Wound Note: Date of Service: 10/30/25.Reason for visit: comprehensive skin assessment.Wound assessment: location - sacrum.Primary etiology - pressure ulcer/injury.On exam today, 10/30/25, the sacrum presents with full-thickness tissue loss with a central area of marooning to the wound bed indicating deeper tissue involvement. Until the true extent of this injury is revealed, the wound team will follow this as a DTI (a serious type of pressure injury (pressure sore) that damages underlying soft tissues, often starting at the muscle-bone interface, appearing as purple/maroon intact skin or a blood blister, and can quickly progress to severe wounds despite initial skin appearance ). 11/11/25 at 2:02 PM Wound/Pressure Ulcer Note: Type of Break in Skin Integrity: Pressure Ulcer/InjuryStage/Severity: DTI.Location: Sacrum.In house acquired. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the following: severely impaired cognitive skills for daily decision making; at risk for pressure ulcers; has one (1) unstageable pressure injuries present upon admission. The evidence showed that facility staff incorrectly coded Resident #1's sacral ulcer as present on admission instead of facility acquired. During a face-to-face interview on 01/16/26 at 10:26 AM, Employee #6 (MDS Coordinator) reviewed the MDS assessment, acknowledged the findings and stated, I miscoded that the sacral wound was present on admission, and it's not supposed to be. I will do the correction right now. Cross Reference 22B DCMR Sec. 3231.12

Based on observations and staff interviews, facility staff failed to: (1) distribute and serve foods under sanitary conditions, as evidenced by using wet dome covers on the tray line to help maintain food temperatures in serving plates; (2) follow infection control standards and practices to prevent the spread of infections and communicable diseases; and (3) ensure there were no breaks in infection control standards and practices to prevent the widespread of commnicable diseases. Resident #332. The findings included: 1. Facility staff failed to distribute and serve foods under sanitary conditions. During observations in dietary services on February 4, 2025, at approximately 1:15 PM, dietary staff used wet dome covers on the tray line, to help maintain hot food temperatures in serving plates. This deficiency exposes foods to moisture and potential contamination as the insulated dome covers were not allowed to air dry before use. Employee #8 acknowledged the findings during a face-to-face interview on February 5, 2025, at approximately 11:00 AM. 2. Facility staff failed to follow infection control standards and practices to prevent the spread of infections and communicable diseases. During an observation on the 3rd floor on 01/28/25 starting at 3:50 PM, Employee #12 (Registered Nurse) was observed walking in the hallway, wearing gloves, carrying an Insulin syringe into a resident's room. When asked what he was doing, the employee stated that he's going to administer Insulin to a resident. The employee was observed administering the Insulin injection in the lower right abdomen of the resident. The employee then exited the room, still wearing his gloves, holding the now used syringe, with the needle exposed, and walked down the hall to where his medication cart parked. Once at the medication cart, the employee discarded the dirty syringe in the sharps container and proceeded to touch the computer and unlock the medication cart, while still wearing the same gloves. The surveyor asked the employee to stop, remove his gloves and perform hand hygiene. During a face-to-face interview at the time of the observation, Employee #12 acknowledged that he failed to follow infection control standards and practices and made no further comments. Cross Reference 22B DCMR Sec. 3217.6 3. The facility staff failed to ensure there were no breaks in infection control standards and practices to prevent the widespread of commnicable diseases as evidenced by: 1) impoperly disposing of a resident's soiled incontinent pads/brief in a trash can located in two resident's room; 2) failing to intervene when a resident with a history of behavioral symptoms was observed wearing gloves and masks, in patient care areas throughout the facility. Subsequently, the resident with behaviors was observed wearing gloves in the hallway while carrying soiled incontinent pads belonging to his roommate and disposing of the trash in a common patient care area. Resident #337 Resident #332 was admitted to the facility on [DATE] with diagnoses that included Depressive Disorder, Anxiety Disorder, Dementia, Peripheral Vascular Disease, and Substance Abuse History A review of Resident #337's medical record showed : A Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed that Resident #337 had a Brief Interview for Mental Status (BIMS) summary score of, 09, indicating that the Resident had moderately impaired cognition, was independent with ambulation and mobility, required set-up for activities of daily living, and was not taking antidepressants, antianxiety or antipsychotic medications. A care plan initiated on 10/23/23 documented: Focus/Problem: [Name of Resident #337] has non-compliance behavioral concerns by putting on gloves and putting on double (two) masks despite staff redirection provided, Goal: [Name of Resident #337] will have fewer episodes of non-compliant behavior with putting on gloves and double mask through the next review date x 90 days with Target Date: 02/11/2025; Interventions (Initiated on: 10/23/23): Approach [Name of Resident #337] with a soft and calm voice to avoid escalation and improve compliance; Encourage and redirect [Name of Resident #337] to take out his gloves for safety precaution; Redirect [Name of Resident #337] to wear a single mask as appropriate. A care plan initiated on 11/06/23 and revised on 01/29/25 documented: Focus/Problem: [Name of Resident #337] has a behavior problem being resistant to care; Taking out the trash in his room and putting it in the dining room; Goal: [Name of Resident #337]will have fewer episodes of behavior by review.Target Date: 02/11/2025; Interventions: Anticipate and meet the resident's needs; Caregivers to provided opportunity for positive interaction, attention; .If reasonable, discuss the resident's behavior; Explain/reinforce why the behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others; Approach/Speak in a calm manner; Divert attention .Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations; Document behavior and potential causes .Psych consult with behavioral disturbance[when the resident is] non-compliant, noncooperative. During an observation on 01/29/25 at 10:15 AM, Resident #337 opened the door to the 3rd-floor dayroom (an activity room for residents) and entered the doorway wearing two masks, and gloves. The resident was observed carrying two soiled, incontinence pads and a dirty/soiled brief(s) under his right arm. The Resident entered the room without saying anything or making eye contact with the surveyors who were sitting at a table in the room. Employee #17 (3rd-Floor Unit Secretary) entered the doorway behind him and called his name, however, the Resident did not respond. The Resident then walked directly over to a trash can that was situated in the left corner of the room, threw the soiled trash in the trash can, and walked out of the day room. Employee #17 left the doorway and returned wearing gloves, and she immediately went to the trash can and removed the trash bag that contained the soiled briefs and soiled incontinence pads. During an interview on 01/29/25 at 10:15 AM,, Employee #17 (Unit Secretary) stated that Resident #337 was known to have behavior issues. She added that she was at the nurses' station when she observed the Resident wearing a mask and gloves and walking quickly toward the 3rd-floor day room. She added that the Resident walked by other staff in the hallway, but could not verify which staff. She added that she recalls looking up and saw that the Resident was carrying soiled incontinent pads and a soiled brief. She tried to stop him but couldn 't before he entered the 3rd floor day room. During a face-to-face interview with Resident #337 on 01/29/25 at 10:20 AM, the Resident stated that when there is dirty trash in his trash can in his room, he takes the trash to the 3rd-floor day room and empties it. He added that he does not call for facility staff or wait for them to empty it because they take too long and he does not want dirty trash in his room because it smells. During a face-to-face interview on 01/29/25 at 10:24 AM with Employees #1 (Administrator) and Employee #2 (Director of Nursing/DON ) stated that the resident is known to have behavior symptoms, but does not pose a safety risk to himself or others. Employee #2 stated, that the Resident had never entered another resident's room and she had never observed or heard that the resident was disposing of trash in the day room. He just likes things a certain way. The Employees then stated they would notify the doctor/Psych and speak with the resident so it does not happen again. During a second observation and face-to-face interview on 02/05/25 at 11:23 AM with Resident #337, the Resident was observed lying in his bed watching television. The Resident was observed wearing two masks over his mouth and wearing gloves. The Resident stated things were a little better since the facility staff had started to empty the trash can in his room a few times a day. He added, however, that they were still dumping dirty pads that belonged to his roommate in his trash can. The Resident then got out of bed and used the foot pedal to open his trash can, the resident opened the trash can and showed the surveyor a wet, dirty incontinent pad. The Resident further commented, I can get up and use the bathroom myself, so that is not my pad, They dump my roommate's dirty diapers and pads in my trash. That's why I had been taking the trash around in the other room. I don't like the smell. Observations made of Resident #337's behaviors and a further review of the Resident's medical record lacked evidence that facility staff provided no breaks in infection control standards and practices to prevent the widespread of commnicable diseases. During a telephone interview on 02/05/25 at 11:46 AM Employee #18 (Certified Nurse Aide/CNA) stated that a few times she had observed the resident wearing a mask and gloves in the hallway while he was on the phone talking to his sister. She stated that on the day of the observation, she stated she did not see the Resident carrying trash anywhere and she did not see the Resident wearing gloves and a mask in the hallway. When asked where CNAs dispose of incontent pads and briefs,she stated, Iin a rolling cart that, we put outside the resident's room, Then after we have provided incontinent care for the resident, we roll the cart to the soiled utility room and throw the trash down the chute. During a face-to-face interview on 02/05/25 at 12:28 PM Employee #19 (Registered Nurse/RN) stated that she had observed the Resident she had randomly seen Resident #337 wearing double masks and gloves in the hallway when the Resident was standing at the meal cart waiting for his meal tray to be handed to him. She added that the Resident was easily redirectable, and that was the intervention she used most of the time to get him to change his behavior. She stated that on the day of the observation, she did not see the Resident carrying trash and she did not see the Resident wearing gloves or masks in the hallway. She also stated that she had never seen the Resident pick trash up out of the trash can in his room. During a face-to-face interview on 02/05/25 at 12:53 PM, Employee #3 stated that Resident #337 had a history of being noncompliant with wearing gloves, and despite facility staff speaking with him, the Resident continues to wear two masks and gloves all day around other residents. She added that most of the time staff tried to redirect the Resident, and when necessary consulted Psych. She acknowledged that the approaches needed to be updated and revised to address the resident's behavior. She further stated that she was not aware that the CNAs were placing dirty briefs belonging to Resident # 337 's roommate in the Resident 's trash can. She added they have a cart marked as Soiled Linen, that they put outside of the Resident 's room when they provide incontinent care, and once they are finished they roll the cart to the soiled utility room and throw the soiled trash into the dumpster chute. The Employee acknowledged that both the Resident's behavior and the assigned CNA's behavior could compromise infection control. She then stated that she would conduct an inservice with the staff that afternoon and she made no further comment about the findings.

Based on observations and staff interviews for seven (7) of 56 sampled residents, facility staff failed to properly store medications in accordance with Standards of Practice as evidenced by: (1) Employee #29 failed to ensure Resident #12's individual compartment did not contain Resident #74's medication; (2) Employee #30 failed to ensure Resident #138's individual compartment did not contain Resident #32's medication and Resident #135's individual compartment did not contain Resident #59's medication; (3) Employee #31 failed to ensure Resident #158's individual compartment did not contain Resident #153's medication, Resident #98's individual compartment did not contain Resident #36's medication, Resident #118's individual compartment did not contain Resident #113's medication and also failed to ensure that Team 1's medication cart did not contain four (4) blister packs of medications prescribed for Resident #113 that should have been properly stored on Team 3's medication cart in the resident's individual medication compartment with the other prescribed medications; and (4) Employee #32 failed to ensure Resident #143's individual compartment did not contain Resident #73's medication. The findings included: A facility policy titled 'Medication Storage' with a review date of 01/2025 documented: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner and 10. For any discrepancies with medications, including controlled substances, the supervisor must be informed immediately. 1.Resident #74 was admitted to the facility on [DATE] with multiple diagnoses that included: End Stage Renal Disease, Hypertension, Psychotic Disorder, Anxiety and Depression. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '11,' indicating the resident was moderately impaired. A review of Resident #74's medical record revealed the following physician orders: Order date - 01/12/25, Acetaminophen Tablet 500 MG (milligram) Give 1 tablet by mouth every 6 hours as needed for Temperature 100° (degrees) F (Fahrenheit) or above Do not exceed 3g(grams)/24hrs(hours) from all acetaminophen source Order date - 01/12/25, Acetaminophen Tablet 500 MG Give 1 tablet orally (by mouth) every 6 hours as needed for generalized body ache Do not exceed 3g(grams)/24hrs(hours) from all acetaminophen source During an observation conducted on 01/24/25 at 10:55 AM of a medication cart located on the second floor and labeled 'Team 1,' it revealed Resident #74's blister pack of medication labeled 'Acetaminophen 500MG TAB' stored within the medication section assigned to store medication for Resident #12. During a face-to-face interview conducted on 01/24/25 at 10:56 AM, Employee #29 acknowledged the findings and stated, I think I made a mistake and put it back in the wrong slot. 2. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypothyroidism, Peripheral Vascular Disease, Hypertension, Diabetes Mellitus and Unspecified Symptoms Involving Cognitive Function. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '06,' indicating the resident was severely impaired. A review of Resident #32's medical record revealed the following physician order: Order date - 07/28/23, Levothyroxine Sodium Oral Tablet 50MG (milligram) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for Hypothyroidism During an observation conducted on 01/24/25 at 11:00 AM of a medication cart located on the second floor and labeled 'Team 3,' it revealed Resident #32's blister pack of medication labeled 'levothyroxine 50MCG (microgram) TAB' stored within the medication section assigned to store medication for Resident #138. During a face-to-face interview conducted on 01/24/25 at 11:01 AM, Employee #30 acknowledged the findings. 3. Resident #59 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Coronary Artery Disease and Hypertension. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '14,' indicating the resident was cognitively intact. A review of Resident #59's medical record revealed the following physician order: Order date - 03/31/21, Donepezil HCl (Hydrochloride) Tablet 10MG (milligram) Give 1 tablet by mouth one time a day for Dementia During an observation conducted on 01/24/25 at 11:05 AM of a medication cart located on the second floor and labeled 'Team 3,' it revealed Resident #59's blister pack of medication labeled 'Donepezil 10MG TAB' stored within the medication section assigned to store medication for Resident #135. During a face-to-face interview conducted on 01/24/25 at 11:06 AM, Employee #30 acknowledged the findings. 4. Resident #153 was admitted to the facility on [DATE] with multiple diagnoses that included: Hyperlipidemia, Atherosclerotic Heart Disease, Hypertension and Cognitive Communication Deficit. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '10,' indicating the resident was moderately impaired. A review of Resident #153's medical record revealed the following physician order: Order date - 09/27/24, Atorvastatin Calcium Oral Tablet 80MG (milligram) (Atorvastatin Calcium) Give 0.5 (1/2) tablet by mouth at bedtime for HLD (Hyperlipidemia) give 40mg During an observation conducted on 01/24/25 at 12:05 PM of a medication cart located on the third floor and labeled 'Team 1,' it revealed Resident #153's blister pack of medication labeled 'atorvastatin 80MG TAB' stored within the medication section assigned to store medication for Resident #158. During a face-to-face interview conducted on 01/24/25 at 12:06 AM, Employee #31 acknowledged the findings and stated, I don't know how that happened. 5. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Cerebrovascular Accident (CVA), Hypertension and Left Hip Fracture and Spine Compression of T(Thoracic)4, T12 and L(Lumbar)3. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '11,' indicating the resident was moderately impaired. A review of Resident #36's medical record revealed the following physician orders: Order date - 01/12/25, Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 2 tablet[s] by mouth every 6 hours as needed for Generalized body ache 2 tabs x 325mg = 650mg total. Do not exceed 3g (grams) /(per) 24hrs (hours) from all acetaminophen sources. Order date - 01/12/25, Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 2 tablet[s] by mouth every 6 hours as needed for Temperature 100°(degrees) F (Fahrenheit) or above Give 2 tabs (tablets) x 325mg = 650mg total. Do not exceed 3g (grams) / (per) 24hrs (hours) from all acetaminophen sources. During an observation conducted on 01/24/25 at 12:15 PM of a medication cart located on the third floor and labeled 'Team 1,' it revealed Resident #36's blister pack of medication labeled 'Acetaminophen 325MG TAB' stored within the medication section assigned to store medication for Resident #98. During a face-to-face interview conducted on 01/24/25 at 12:17 PM, Employee #31 acknowledged the findings. 6. Resident #113 was admitted to the facility on [DATE] with multiple diagnoses that included: Pancreatic Cancer with Bone Metastasis, Seizures, Failure to Thrive, Pressure Ulcer of Sacral Region, Type 2 Diabetes Mellitus and Chronic Shoulder Pain. An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '12,' indicating the resident was moderately impaired. A review of Resident #113's medical record revealed the following physician orders: Order date - 12/29/24, Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 2 tablet[s] by mouth one time a day for pain management r/t (related to) wounds Give 2 tabs (tablets) x 325mg = 650mg total. Give 30 minutes prior to wound care. Order date - 01/12/25, Acetaminophen Oral Tablet 500 MG (milligram) (Acetaminophen) Give 2 tablet[s] by mouth every 8 hours as needed for Generalized body ache 2 tabs 500mg = 1000mg total. Do not exceed 3g (grams) /(per) 24hrs (hours) from all acetaminophen source[s]. Order date - 01/12/25, Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 2 tablet[s] by mouth every 6 hours as needed for Temperature 100°(degrees) F (Fahrenheit) or above Give 2 tabs (tablets) x 325mg = 650mg total. Do not give more than 3g (grams) / (per) 24hrs (hours) from all acetaminophen source[s]. Order date - 01/14/25, Gabapentin Oral Capsule 100MG (milligram) (Gabapentin) Give 2 capsule[s] by mouth 3 times a day for Diabetic Neuropathy/Chronic Pain. 2 caps (capsules) of 100mg = 200mg. During an observation conducted on 01/24/25 at 12:25 PM of a medication cart located on the third floor and labeled 'Team 1,' it revealed the following blister packs of medications labeled with Resident #113's name: 'Acetaminophen 325MG TAB,' 'Acetaminophen 500MG TAB,' and two (2) blister packs that both contained 'Gabapentin 100MG CAP' for a total of four (4) blister packs of medication, but stored within the medication section assigned to store medication for Resident #118 who both shared the same last name. It should also be noted that Resident #113's four (4) blister packs of medications, that were found on the Team 1 medication cart, were on the wrong medication cart and should have been with the rest of the resident's medications that were stored on the Team 3 medication cart. During a face-to-face interview conducted on 01/24/25 at 12:30 PM, Employee #31 acknowledged the findings and stated, I don't know how that all got in there. 7. Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included: Hyperkalemia, Dementia, Liver Transplant and Seizure Disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '02,' indicating the resident was severely impaired. A review of Resident #73's medical record revealed the following physician order: Order date 06/24/23, Lokelma Oral Packet 10 GM (grams) (Sodium Zirconium Cyclosilicate) Give 1 packet by mouth one time a day for Hyperkalemia. During an observation conducted on 01/24/25 at 12:40 PM of a medication cart located on the third floor and labeled 'Team 3,' it revealed a clear, plastic zip lock bag that contained two (2) packets of Resident #73's medication labeled 'Lokelma 10GM Packet' stored within the medication section assigned to store medication for Resident #143. During a face-to-face interview conducted on 01/24/25 at 12:42 PM, Employee #32 acknowledged the findings and stated, I didn't mean to put it there.

Based on record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to ensure that Resident #67, who had limited range of motion, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The findings included: Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia, Hemiparesis, and Muscle Weakness. Review of the resident's medical record revealed the following: A care plan focus area last reviewed on 11/13/24: [Resident #67] is on Restorative nursing program for active assistive range of motion of bilateral lower extremities and strength of bilateral lower extremities of all joints in supine/sitting in wheeled chair 3 x 10 reps for 6 days/week for 15 minutes. Goal: The resident will improve current exercise through next review date. Interventions: Restorative Aide staff will assist with daily exercises as per order. Resident on range of motion and transfer exercises. A physician's order dated 12/18/24 that directed, OT (Occupational Therapy) eval and treat as indicated; patient to receive skilled occupational therapy 3-5x/week for 27 days. Review of the facility's Restorative Nursing Care policy dated January 2025 documented: - Residents will receive restorative care as needed to help promote optimal safety and independence. - Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational or speech therapies). An Occupational Therapy Discharge summary dated [DATE] documented: - Dates of service 12/18/24 - 01/15/25 - Discharge recommendations and status: Patient to participate with restorative plan to decrease risk of decline. - Functional maintenance program not indicated at this time. A Significant Change Minimum Data Set (MDS) dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderately impaired cognitive status; had functional impairment in range of motion on one side for upper and lower extremities; and received OT from 12/18/24 - 01/15/25. Review of the Resident on Restorative 3rd Floor document provided to the surveyor on 01/24/25 did not have Resident #67 listed as receiving restorative nursing services. Review of the [Facility Name] List of Residents on Restorative - as of 01/27/25 document provided to the surveyor on 01/28/25 at approximately 10:00 AM, showed that Resident #67 was not on that list either. During a face-to-face interview on 01/28/25 at 9:50 AM, Employee #11 (Occupational Therapist) reviewed Resident #67's occupational discharge summary and stated, Restorative nursing was indicated for this resident. The written plan and orders are put in a folder that is picked up by the Restorative Nursing Program (RNP) manager, who then puts in the orders for the Restorative Nursing Aide to carry them out. When asked to provide a copy of Resident #67's most recent restorative plan/orders, the employee stated, We (OT) do not to keep a copy of the written plan, once it's picked up by the RNP, that's it. During a face-to-face interview on 01/28/25 at 10:14 AM, Employee #2 (DON/RNP Manager) stated, We have a Restorative Nurse who puts in restorative orders. He has a mailbox where the Occupational Therapist drops off the written orders. There's been a delay in restorative orders getting put in PCC (Point Click Care/the facility's electronic health record system) because he was out on medical leave. I did put some orders in but there are some that are delayed. The evidence shows that from the time of discharge from OT services on 01/15/25 to 01/28/25, totaling 13 days, facility staff failed to ensure that Resident #67 was receiving restorative nursing treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Cross Reference 22B DCMR Sec. 3213.2

Based on observation, record review and staff interview, for one (1) of 56 sampled residents, facility staff failed to ensure that Resident #142, who has an indwelling Foley Catheter, received the appropriate care to prevent urinary tract infections. The findings included: Resident #142 was admitted to the facility on [DATE] with multiple diagnoses that included: Benign Prostatic Hyperplasia with Lower Urinary Trach Symptoms. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: severely impaired cognitive skills for decision-making and had an indwelling urinary catheter. A care plan focus area last reviewed on 11/27/24: [Resident #142] has Foley 16 French/ balloon size 10 milliliters (ML) for Neurogenic Bladder, had interventions that included: check for wetness before and after meals, every hour of sleep (qhs) & on rounds during the night; note any changes in amount, frequency, color or odor; and report any abnormalities to Registered Staff. During an observation on 01/29/25 at 9:00 AM with Employee #4 (3rd floor Unit Manager), Resident #142 was noted lying in bed, with his Foley Catheter connection tube and drainage bag on the floor. At the time of the observation, Employee #4 acknowledged that facility staff failed to provide Resident #142 with appropriate care, treatment and services to prevent urinary tract infections to the extent possible and stated, I will talk to the staff, this is not supposed to be on the floor.

Based on observations, record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to demonstrate the competencies and skills to provide appropriate nursing services to ensure resident safety and well-being. Resident #89. The findings included: Review of the facility's Administering Medications policy, dated January 2025, documented: - Medications are administered in accordance with prescriber orders, including any required time frame. - Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. - Insulin pens containing multiple doses of insulin are for single-resident use only. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verifies that the correct pen is used for that resident. - The cart must be clearly visible to the personnel administering medications. According to the Lyumjev (type of Insulin used to lower blood sugar) manufacturer's website: - Do not use a syringe to remove Lyumjev from the prefilled pen. This can cause you to take too much insulin. Taking too much insulin can lead to severe low blood sugar. This may result in seizures or death. https://insulins.lilly.com/lyumjev?gad_source=1&gclid=Cj0KCQiAwOe8BhCCARIsAGKeD56vPk0mulUicpx8fIwP-2DnPUvCf2OnqIIO0C1xMWcbC5I8Ymo2RYMaAtQBEALw_wcB Resident #89 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus (DM), Hypoglycemia, and Metabolic Encephalopathy. Review of Resident #89's medical record showed the following: A physician's order dated 08/21/24 that directed, Metformin (medication to lower blood sugar) HCl (hydrochloride) 500 MG (milligrams), give 1 tablet by mouth two times a day for DM, administer with meals; Lyumjev KwikPen 100 units/ML Solution pen-injector, inject as per sliding scale: if 200 - 250 = 2unit; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units, call MD/NP if BS < 70 or > 400mg/dl, subcutaneously two times a day for DM. A care plan focus area last reviewed on 11/24/24: [Resident #89] has unstable blood glucose r/t (related to) Diabetes Mellitus had interventions that included: Diabetes medications (Lyumjev KwikPen) as ordered by doctor. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive status and received Insulin injections. During an observation on the 3rd floor on 01/28/25 starting at 3:50 PM, Employee #12 (Registered Nurse) was observed walking in the hallway, wearing gloves, carrying an Insulin syringe into a resident's room. When asked what he was doing, the employee stated that he's going to administer Insulin to Resident #89. The surveyor followed him into the resident's room. Upon entering the room, the employee identified Resident #89 and told her that he was administering 6 units of Insulin. The surveyor asked the employee what the resident's most recent blood sugar reading was. He stated, I just checked it, and it was 317, she gets 6 units based on the sliding scale. The surveyor asked the employee what time the resident was expected to get her dinner meal, which he stated, Dinner comes around 5:00 PM. I want to give her the Insulin now, so she doesn't get too hyperglycemic. I checked her blood sugar, it's high, which means my colleague [day shift nurse] didn't give any Insulin during their shift, so I am giving her Insulin now. The employee proceeded to administer the 6 units of Insulin to Resident #89 in her lower right abdomen. The employee exited the room, still wearing his gloves, holding the now used syringe with the needle exposed, and walked down the hall to where his medication cart parked. Once at the medication cart, the employee discarded the dirty syringe in the sharps container and proceeded to touch the computer and unlock the medication cart and while still wearing the same gloves. The surveyor asked the employee to stop, remove his gloves and perform hand hygiene. At 3:56 PM, the surveyor asked Employee #12 to review Resident #89's orders. Upon review of the orders, it was noted that Resident #89 had an active physician's order that directed, Lyumjev KwikPen 100 unit/ml (milliliters) solution, inject per sliding scale subcutaneously two times a day for DM, at 6:00 AM and 9:00 PM; if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; call medical doctor (MD)/Nurse Practitioner (NP), if blood sugar (BS) is less than 70 or greater than 400 milligrams (mg)/deciliter (dl). When asked why the Lyumjev was administered using an Insulin syringe and not the KwikPen, Employee #12 stated, It's hard to measure out the exact amount in the KwikPen, so I used the Insulin needle to aspirate the 6 units out. When asked why he administered the resident's Lyumjev five (5) hours before the scheduled time, Employee #12 answered, I know my resident. I did not want her to get hyperglycemic. When asked if he called the medical doctor prior to administering the Insulin, the employee stated, No. I would call only if it was over 400. When asked if that is within his scope and practice to make medication administration decisions without consulting the medical doctor, the employee stated, No. The evidence showed that Employee #12 failed to ensure Resident #89's safety and well-being by failing to: - Administer medications in accordance with the prescriber's orders. - Ensure medications were administered within one (1) hour of their prescribed time. - Follow the manufacturer's guidance to not use a syringe to remove Lyumjev from its prefilled pen. - Follow infection control practices by not removing gloves and performing hand hygiene. - Ensure that the medication cart was visible when he went into the resident's room for medication administration. The findings were brought to the attention of Employee #2 (Director of Nursing/DON), Employee #3 (Assistant DON), and Employee #4 (3rd floor Unit Manager) at 4:00 PM. They all acknowledged the findings and removed Employee #12 from the unit. It should be noted that Resident #89 did not suffer any harm or ill effects from this deficient practice. Cross Reference 22B DCMR Sec. 3211.1(a)

Based on record reviews and staff interviews for two (2) of 56 sampled residents, facility staff failed to show documented evidence in the resident's medical records that the pharmacist's monthly medication regimen reviews and recommendations were reviewed and acted upon by the physician. Resident's #40 and #30. The findings included: A review of the facility's policy titled Medication Regimen Review with a revision date of 01/2024 documents . Actual and potential clinically significant medication issues identified will be communicated to the physician for clarification. Documentation will be maintained in the resident ' s medical record. 1. The facility staff failed to show documented evidence in Resident #40's medical record that the pharmacist recommendations were reviewed by the physician for three (3) out of 12 months in the year 2024. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Diabetes Mellitus Type 2, Heart Failure and Dementia. A review of Resident #40's medical record revealed the following: A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the facility staff coded that the resident has a Brief Interview for Mental Status summary Score (BIMS) of 13 which indicates intact cognition, has medically complex conditions and diagnoses of anxiety and depression. A review of a physician order dated 04/17/24 documented Buspirone (anxiolytic) HCL (hydrochloric acid) oral tablet 5 mg (milligram) give 1 tablet by mouth one time a day for anxiety During a review of Resident #40's medical record it was noted that the pharmacist checked recommendations sent to IDT (interdisciplinary team) for the resident on the following dates 03/04/24, 07/04/24, and 10/06/24. The pharmacist's recommendation notes, or detail and the physician's responses were not documented in the medical record. During a face-to-face interview conducted on 01/29/25 at 11:00 AM, Employee #9 (first floor unit manager) stated that the unit secretary uploads the pharmacist recommendations and the doctor's response into the electronic health record, and she keeps the paper copies in a box in her office. Employee #9 retrieved the pharmacist recommendations and the physician's response from a box in her office and acknowledged that the records were not in Resident #40's electronic health record. The surveyor reviewed the records from Employee # 9's box and noted that pharmacist recommendations and physician responses were documented on the following dates 03/04/24, 07/04/24, and 10/06/24. These documents were titled (Facility Name) 1st Floor Consultant Pharmacist Inspection Report and the forms documented the following: -On 03/04/24 the pharmacist documented 2/8 K (potassium) should it be retried. The physician responded by checking agree and this was signed and dated on 03/14/24. -On 07/04/24 the pharmacist documented please evaluate use of multiple antidepressants in considering GDR (gradual dose reduction). On that documentation the physician checked agree and wrote a note that was signed and dated 08/01/24. -On 10/06/24 pharmacist documented could buspar (buspirone) (anxiolytic) GDR (gradual dose reduction) be considered? The provider checked disagree and documented an illegible handwritten note that was signed and dated 10/18/24. It is noted that the pharmacist recommendations and the providers responses to those recommendations for 3 out of 12 months were not in Resident #40's medical record. During a face-to-face interview conducted on 02/05/25 at approximately 1:30 PM Employee #2 (director of nursing) acknowledged the findings. Cross Reference 22B DCMR Sec. 3207.6 2. Facility staff failed to show documented evidence in a Resident #30's medical record, that the physician recieved, reviewed, and accepted the pharmacist's recommendations to a resident's drug/medication regimen. Resident #30 was admitted to the facility with diagnoses that included: Dementia, Intermittent Explosive Disorder, and Unspecified Psychosis not due to a Substance or Known Physiological Condition. Mood Disturbance, Anxiety Disorder, Visual Hallucinations, Auditory Hallucinations, Restlessness, Agitation, and Unspecified Convulsions A review of Resident #30's medical record showed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of, 05, indicating that Resident #03 had severely impaired cognition, In addition, the assessment documented that the Resident had received the following medications during the last 7 days of the assessment: antipsychotic, anticoagulant, diuretic, and anticonvulsant. A review of the physician orders that documented that the Resident was to receive the following medications on a routine basis as follows: An order dated 05/05/15 at 1:26 PM that directed, Keppra Tablet 500 mg (milligrams) (Levetracetam). Give 1 tablet by mouth two times a day for Seizure disorder. An order dated 05/18/20 at 6:52 PM that directed: Benztropine Mesylate Tablet 0.5 mg. Give 1 tablet by mouth at bedtime for EPS (extrapyramidal) prophylaxis, An order dated 12/11/23 at 10:08 PM that directed: Amantadine HCl (Hydrochloride) Oral Solution 50 mg/5 ml (milliliters) (Amantadine). Give 5 ml by mouth one time a day for EPS. An order dated 07/24/24 at 10:25 PM that directed: Depakote ER (Extended Release) Oral Tablet Extended Release 24 Hour 250 mg (Divalproex Sodium). Give 1 tablet by mouth two times a day for mood stabilizer related to Intermittent Explosive Disorder. An order dated 07/30/24 At 5:55 {PM that directed: : Haloperidol Oral Tablet 2 mg (Haloperidol). Give 0.5 tablet by mouth one time a day related to Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition. A review of the Monthly Pharmacy Drug Regimen Reviews for Resident #30, from 06/10/24 to 12/08/24, showed that the pharmacist made recommendations for the resident ' s drug regimen on 09/10/24 and documented: Recommendations given to the IDT. Of note, the pharmacist did not specify what the recommendations were. Further review of Resident #30 's medical record showed that there was no documented evidence of the pharmacist's actual recommendations to the resident's monthly medication review (MMR) in September 2024. In addition, there was no documented evidence that the physician received, reviewed and responded to the pharmacist's recommendations from the Septempter MMR in the Resident's medical record. During a face-to-face interview on 01/29/25 at 11:56 AM, Employee #5 (Registered Nurse/Second Floor Unit Manager), stated that the medical records department scans the pharmacist ' s recommendations and the physician ' s response into the residents ' electronic health records, or the physician or Nurse practitioner documents their response in the resident ' s medical record. The Employee did not provide documented evidence of the physician ' s response to the pharmacist ' s recommendations for Resident #30 ' s September 2024 drug regimen review in the resident ' s medical record, and the Employee made no further comment.

2. Facility staff failed to accurately code Resident #11's Quarterly Minimum Data Set (MDS) assessment to reflect that she was receiving opioid medications. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Pain, Type 2 Diabetes Mellitus (DM), Bipolar Disorder, and Edema. Review of the resident's medical record revealed the following: A care plan focus area last reviewed on 11/20/24: [Resident #11] is on pain medication therapy Oxycodone (type of narcotic pain reliever) r/t (related to) osteoarthritis and polyneuropathy. A physician's order dated 01/12/25 that directed, Oxycodone HCl (Hydrochloride)Tablet 5 MG (milligrams), give 1 tablet by mouth two times a day for severe pain (#7-10). A physician's order dated 01/14/25 that directed, Tramadol (type of narcotic pain reliever) HCl Tablet 50 MG, give 1 tablet by mouth every 8 hours as needed for moderate pain (#4-6). A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 15, indicating intact cognitive response and in Section O - medications, did not receive opioid medications. Review of Resident #11's January 2025 Medication Administration Record (MAR) showed that the resident was administered Oxycodone 5 MG twice a day, from 01/01/25 to present (01/29/25). During a face-to-face interview on 01/29/25 at 11:46 AM, Employee #6 (MDS Coordinator) acknowledged the findings and stated, We will do a modification to correct it. Cross Reference 22B DCMR Sec. 3231.10 Based on record review and staff interviews, for three (3) of 56 sampled residents, the facility staff failed to ensure that resident's Minimum Data Sets (MDS) were accurately coded. Residents' #331 , #11 and #34. The findings included: 1. Facility staff failed to accurately code a resident's admission MDS assessment to reflect that the Resident was receiving antibiotic therapy. Resident #331 was admitted to the facility on [DATE] with diagnoses that included: Cervical Disc Stenosis, Chronic Lumbar Stenosis, Generalized Weakness, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Obstructive and Reflux Uropathy. A review of Resident #331's medical record revealed the following: A physician's order dated 01/10/25 at 4:12 PM directed: Ciprofloxacin (type of antibiotic) HCl (Hydrochloride) Oral Tablet 250 mg (milligrams). Give 1 tablet by mouth two times a day for elevated PSA (Prostate-specific antigen) for 21 Days, for H/o (history of) BPH (Benign Prostatic Hyperplasia), Cystitis, and Obstructive Uropathy. Review of Resident #331's medication administration record documented that the facility staff administered the first dose of Ciprofloxacin HCl to the Resident on 01/10/25 at 1:00 PM, and the last dose of the antibiotic medication was scheduled for 01/30/25. An admission Minimum Data Set (MDS) assessment dated [DATE] that showed that facility staff coded the resident had not received antibiotic treatment within the past 7 days of the assessment. The evidence showed that facility staff failed to accurately code Resident #331's admission MDS assessment to reflect that the Resident was receiving antibiotic therapy. During a face-to-face interview on 01/29/25 at 11:45 AM, Employee #6 (MDS Coordinator) acknowledged that the admission MDS assessment for Resident #331 was incorrect, and stated that the MDS should have reflected that the Resident was receiving antibiotic treatment. She then added that a correction will be made. Cross Reference 22B DCMR Sec. 3231.12(l) 3. Facility staff failed to accurately code a resident's assessment that was reflective of her use of prescribed medications, as evidenced by documenting that the resident was receiving an antiplatelet and a diuretic medication when they were not currently prescribed. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Seizure Disorder, Anxiety, Depression and Diabetes Mellitus. A review of Resident #34's medical record revealed: A physician's order dated 09/08/24 documented the following medications that were active during the quarterly assessment dated [DATE]: ARIPiprazole Oral Tablet 20 MG (milligram) (Aripiprazole) Give 1 tablet by mouth one time a day for Schizophrenia levETIRAcetam Oral Tablet 750 MG (Levetiracetam) Give 1 tablet by mouth two times a day for Seizure Vimpat Oral Tablet 150 MG (Lacosamide) Give 1 tablet by mouth two times a day for Seizure A physician's order dated 09/21/24 documented the following medication that was active during the quarterly assessment dated [DATE]: Dulaglutide Subcutaneous Solution Pen-injector 1.5 MG/0.5ML (milliliter) (Dulaglutide) Inject 1.5 mg subcutaneously one time a day every Sat for DM2 (Type 2 Diabetes Mellitus) It should be noted that Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth two times a day for Edema for 30 Days was discontinued on 10/03/24, which was 80 days prior to the assessment dated [DATE]. A physician's order dated 10/19/24 documented the following medications that were active during the quarterly assessment dated [DATE]: Insulin Detemir Subcutaneous Solution 100 UNIT/ML (milliliter) (Insulin Detemir) Inject 20 unit subcutaneously one time a day for DM (Diabetes Mellitus) with meals. Hold if BS < (less than) 100 Januvia Oral Tablet 100 MG (Sitagliptin Phosphate) Give 1 tablet by mouth one time a day for DM Jardiance Oral Tablet 25 MG (Empagliflozin) Give 1 tablet by mouth one time a day for DM It should also be noted that there were no documented orders for an Antiplatelet since Resident #34's admission and through the assessment period dated 12/13/24. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '14,' indicating the resident was cognitively intact. Section N - Medications documented that the resident was receiving the following class of medications: Antidepressant, Diuretic, Antiplatelet, Hypoglycemic (including insulin) and Antipsychotic. During a face-to-face interview conducted on 01/29/25 at 09:56 AM, Employee #6 and Employee #27 both acknowledged the findings and stated, It was an honest mistake.

Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to refer a resident to the appropriate state-designated authority, known as PASRR Level II, for evaluation and determination to ensure a resident received specialized services to meet the resident's needs. Resident #34. The findings included: A Level I Preadmission Screen/Resident Review (PASRR) dated 09/06/24 documented, Beneficiary is likely to require less than 30 days nursing facility services? No and Does the beneficiary have a known diagnosis of a major mental disorder? Yes and If yes, list diagnosis: Schizophrenia and Does the beneficiary have a diagnosis or evidence of a major mental illness limited to the following disorders: schizophrenia: Yes and Specify diagnosis based on DSM (Diagnostic and Statistical Manual of Mental Disorders)-5: Schizophrenia and Notice of referral for Level II, if applicable, distributed to Beneficiary/Representative? Yes. It should also be noted that, on the Level I PASRR, there was a check mark placed in the box that documented, Beneficiary has negative screen for serious mental illness and no further action is necessary although the resident has a documented history of Schizophrenia and should have been referred for a Level II PASRR. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Seizure Disorder, Anxiety, Depression and Diabetes Mellitus. A physician's order dated 09/08/24 documented, ARIPiprazole Oral Tablet 20 MG (milligram) (Aripiprazole) Give 1 tablet by mouth one time a day for Schizophrenia. A care plan dated 09/09/24 documented: Focus - [Resident #34's name] uses psychotropic medications(Aripiprazole) r/t (related to) Schizophrenia; Goal - [Resident #34's name] will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date; Interventions - Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-SHIFT. Consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate at least quarterly. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '14,' indicating the resident was cognitively intact. Section N - Medications documented that the resident was receiving an Antipsychotic. It should be noted that Resident #34's Medication Administration Record documented that facility staff administered Aripiprazole for Schizophrenia since admission to the facility. During a face-to-face interview conducted on 01/29/25 at 11:33 AM Employee #28 acknowledged the findings and stated, She didn't get a Level II PASRR because she was supposed to be a 30-day stay only, but then she was extended to long-term care. We had a discussion with [the] admission team that she need[ed] to be referred for a Level II PASRR about a month or so ago. It's the Social Worker's responsibility on admission or whenever [the residents] transition to long-term care to complete the Level II PASRR if they have a major mental illness like Schizophrenia. I was aware, but just didn't have time to get to it yet.

Based on record review and staff interview for two (2) of 56 sampled residents, facility staff failed to provide written notification to the resident and/or the resident's representative of the facility policy for bed hold, remaining bed hold days and reserve bed payment for two (2) residents who were transferred from the facility to the hospital. Residents' #20 and #51. The findings included: 1. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses that included: End Stage Renal Disease (ESRD), Type II Diabetes Mellitus, Bilateral Above the Knee Amputation and Heart Failure. A face sheet showed that Resident #20 had a representative. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' indicating the resident was cognitively intact. A physician's order dated 01/23/25 at 14:30 [2:30 PM] documented, ER (emergency room) transfer for CT (Computed Tomography) scan and forehead wound sutures. A nurse's note dated 01/23/25 at 16:40 [2:40 PM] documented, At 2:25pm resident was observed on the floor on a prone position, 3 staff assisted resident back into bed, when asked what happened resident stated she slides [sic] out of the wheelchair on skin assessment resident was observed with bump on forehead 2 cuts also observed on forehead. Ice pad applied. Neuro (neurological) check was initiated. Resident tolerated ROM (range of motion) to her limit. [Nurse Practitioner's name] come and assessed resident and gave a PO (verbal) order to send resident to hospital for further evaluation. A Resident Transfer Form dated 01/23/25 at 5:15 PM documented, Resident was transfer[red] to [Hospital name] on stretcher by 2 EMS (emergency medical services). During a face-to-face interview conducted on 01/31/25 at 09:20 AM, Employee #25 stated that she is only responsible for sending notification of the resident's transfer from the facility to the hospital to the Ombudsman and she does not speak with the resident or the resident's representative. During a simultaneous face-to-face interview conducted on 01/31/25 at 09:50 AM, Employee #5 acknowledged the findings and stated, [Employee #26's name] notified the resident's representative of the transfer to the hospital. However, when Employee #26 was asked what she provided to the resident's representative she stated, The manager (Employee #5) handles the bed hold information. I only notified [the resident's representative] of the resident's condition and transfer to the hospital. It should be noted that Employee #5 and Employee #26 were unable to show documented evidence of the written notification provided to the resident's representative of the facility's bed hold policy, the remaining bed hold days and reserve bed payment regarding the resident's transfer from the facility to the hospital on [DATE]. 2. Resident #51 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Aphasia, Psychotic Disorder and Cerebrovascular Accident (CVA) with Hemiplegia. A face sheet showed that Resident #51 had a representative. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Severely Impaired,' indicating the resident was cognitively impaired. A physician's order dated 01/23/25 at 10:15 AM documented, transfer resident to hospital via 911 for respiratory distress. A nurse's note dated 01/23/25 at 11:00 AM documented, resident noted with audible lungs sounds (crackles) and labored breathing and No improvement on O2 (oxygen)-SAT (saturation) and [Doctor's name] called back with the new parameters, he gave a T/O (telephone order) to send resident to ER for further evaluation and Resident emergency contact [emergency contact's name] contacted via phone call to update on resident change in condition. A Resident Transfer Form dated 01/23/25 at 11:40 AM documented, send resident to ER (emergency room) for further evaluation. 911 called at 9:03am. 911 EMT (emergency medical technician) arrived at 9:50 AM. EMT called and requested for paramedics. 911 left the facility at 10:42[AM]. During a face-to-face interview conducted on 01/31/25 at 09:20 AM, Employee #25 stated that she is only responsible for sending notification of the resident's transfer from the facility to the hospital to the Ombudsman and she does not speak with the resident or the resident's representative. During a simultaneous face-to-face interview conducted on 01/31/25 at 09:50 AM, Employee #5 acknowledged the findings and stated, [Employee #26's name] notified the resident's representative of the transfer to the hospital. However, when Employee #26 was asked what she provided to the resident's representative she stated, The manager (Employee #5) handles the bed hold information. I only notified [the resident's representative] of the resident's condition and transfer to the hospital. It should be noted that Employee #5 and Employee #26 were unable to show documented evidence of the written notification provided to the resident's representative of the facility's bed hold policy, the remaining bed hold days and reserve bed payment regarding the resident's transfer from the facility to the hospital on [DATE].

Based on record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to conduct a thorough investigation of Resident #56's injury of unknown origin (fracture of right index finger). The findings included: Review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy (dated 01/2025) documented: - All reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility management. Resident #56 was readmitted to the facility on [DATE] with multiple diagnoses that included: Surgical Aftercare Following Surgery on the Digestive System and Adult Failure to Thrive. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: unclear speech; a Brief Interview for Mental Status (BIMS) summary score of 00, indicating severe cognitive impairment; no functional impairment in range of motion for upper extremities; and total dependent on staff for all activities of daily living (ADLs). A 01/13/25 at 1:32 PM Nurses Note documented: - Resident right index finger swollen; x-ray ordered by Nurse Practitioner (NP). A 01/14/25 at 12:08 PM Nurses Note documented: - [Radiology company] came, x-ray of right index finger was done. A 01/14/25 at 1:25 PM Nurse Practitioner Progress Note documented: - Asked to evaluate the resident's right hand x-ray report. - X-ray results - acute fracture of the base of the proximal phalanx of the 2nd finger. - Transfer to the emergency room for further evaluation and treatment. A Facility Reported Incident (FRI), DC~13383, submitted to the State Agency on 01/14/25 at 2:49 PM documented: - The patient was observed with a mildly swollen right index finger during grooming care yesterday morning 01/13/25. - NP in house was notified, assessed the patient and gave an order for x-ray. - The x-ray was completed this morning, result showed Acute fracture of the base of the proximal phalanx of the 2nd finger. - NP was notified of the x-ray result; she gave an order to send the patient to the nearest ER for further evaluation. - The Administrator started an investigation related to the resident acute fracture. The facility's investigation documents were reviewed on 01/29/25 which revealed that facility staff failed to conduct interviews with or obtain statements from all appropriate staff as part of their investigation. During a face-to-face interview on 01/29/25 at 3:29 PM, Employee #2 (Director of Nursing/DON) reviewed the investigation documents, acknowledged the findings and stated, We did not get statement from all employees as we should have. Cross Reference 22B DCMR Sec. 3232.2

Based on record review and staff interviews, for one (1) of 56 sampled residents, facility staff failed to timely report Resident #176's injury of unknown injury to the Administrator and the State Agency. The findings included: Resident #176 was admitted to the facility on [DATE] with multiple diagnoses that included: Bipolar Disorder, Anxiety Disorder, Anemia and Type 2 Diabetes Mellitus. Review of the resident's medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: unclear speech; difficulty communicating some words or finishing thoughts but can, if prompted or given time; comprehends most conservations; severely impaired cognitive skills for decision making; required partial/moderate assistance for personal hygiene; no skin conditions issues. A 10/31/2023 at 2:56 AM Weekly Skin Assessment documented: No new wounds, skin is intact. An 11/01/23 at 9:42 AM Nurses Note documented: - Resident noted with swelling on forehead. - Resident unable to say what happened; denies having pain when asked. - Nurse Practitioner (NP) made aware, monitor swelling for pain or any change. An 11/01/23 at 2:00 PM Situation Background Assessment Request (SBAR) Communication Tool documented: - This morning, during rounds Certified Nurse Aide (CNA) called the writer to resident room and notified the writer that resident has swelling in the middle of her forehead. - Assessment: skin is intact at the site; the resident denies having any pain or discomfort; pupils equal and reactive to light. - NP notified on 11/01/23 at 10:00 AM. - Name of family/representative notified: [daughter's name] on 01/01/23 at 9:00 AM. An 11/01/23 at 4:28 PM Skin Observation Tool documented: Mild swelling to the forehead, no wounds, bruises, or redness. An 11/02/23 at 4:05 PM Nurse Practitioner Progress Note documented: - Critical lab report - 11/02/23 hemoglobin 5.7 (low). - Recurrent rectal bleed with severe anemia. - Transfer to the emergency room for further treatment. A Facility Reported Incident (FRI), DC~12419, submitted to the State Agency on 11/03/23 at 11:43 AM documented: - The writer received a call from [daughter's name] at 10:00 AM today. - [Resident's daughter] stated that she was informed by a staff member that someone put his hands on [Resident #176's] face. - Daughter said the incident occurred on Wednesday 11/01/23 during the evening shift. - Daughter said she went to the hospital on Thursday 11/02/23 and observed that the resident had bruises on her face. A Complaint, DC~12420, received by the State Agency on 11/06/23 documented: - The nursing home called me, the week of 10/30/23 and stated my mother had a bump on her face and they did not know how it got there. - On 11/01/23, they called and stated she was having some bleeding at the bottom. - She was sent to [hospital name]. When I got to the hospital and saw her face it was not a bump it was a bruise in the corner her right eye which is black & another bruise under her left eye with is black. - I called back to the nursing home, and it appears nothing was reported to the manager about the bruises. - They are supposed to be doing an investigation. This is not the first time something like this has happened. During a face-to-face interview on 01/28/25 at 1:15 PM, Employee #5 (2nd floor Unit Manager), the staff member who submitted report on 11/03/23 to State Agency, stated, I was aware that the resident had swelling on her forehead prior to the family calling and making an allegation of abuse. I did not suspect abuse. When asked if swelling of the forehead is considered an injury of unknown origin and should have been reported to State Agency and the Administrator in a timely manner (within 24 hours), the employee stated, Yes. During a face-to-face interview on 01/28/25 at 2:07 PM, Employee #3 (Assistant DON) acknowledged that facility staff failed to identify Resident #142's swelling of the forehead as an injury of unknown origin, therefore failed to report it to the Administrator and the State Agency in a timely manner. Cross Reference 22B DCMR Sec. 3232.4

Based on observation, record review, family and staff interviews, for one (1) of 56 sampled residents, facility staff failed to exercise reasonable care for the protection of one resident's property from loss. Resident #142. The findings included: Resident #142 was admitted to the facility on [DATE] with multiple diagnoses that included: Malignant Neoplasm of Laryngeal Cartilage and Benign Prostatic Hyperplasia with Lower Urinary Track Symptoms. Review of the resident's medical record revealed the following: A face sheet that documented the resident's sister as his responsible party (RP). A Personal Property Inventory sheet signed and dated 08/28/24 that listed Resident #142's clothing and other personal items. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the resident as having severely impaired cognitive skills for decision-making. During a telephone interview with Resident #142's sister on 01/23/25 at 12:42 PM, she stated, His clothes are always going missing despite them getting labeled. I buy him clothes all the time. I bring them in and let the staff know but I am not sure if they are being put in his inventory sheet. During an observation of Resident #142's closet against his inventory sheet with Employee #4 (3rd floor Unit Manager) on 01/25/25 at 9:48 AM, multiple clothing items listed on the inventory sheet were not found in the resident's closet or drawers. It was also noted that there were multiple items not labeled with his name or listed on his inventory sheet that were found in his drawers. The employee stated, Sometimes the family brings things in and does not tell us. Every time we do our quarterly care plan meetings, I ask a CNA (Certified Nurse Aide) to check the inventory sheet with the resident's belongings and update the inventory sheet as needed. When asked when the last time Resident #142's personal property was inventoried, the employee stated, It should've been done during the last care plan meeting in November [2024]. When asked to provide documented evidence that this was done, Employee #4 was not able to.

Based on record review, resident interview and staff interview for one (1) of 56 sampled residents, facility staff failed to provide a quarterly statement to a resident or resident's legal representative of the resident's personal funds account. Resident #103 The findings included: Resident #103 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebrovascular Accident (CVA), Anxiety, Bilateral Hip Arthritis and Morbid Obesity. A review of Resident #103's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] documenting a Brief Interview for Mental Status (BIMS) summary score of '14,' indicating the resident was cognitively intact. During a face-to-face interview conducted on 01/23/25 at 12:54 PM, Resident #103 stated that she had not been receiving statement balances of her account maintained at the facility and she was unaware that she should be receiving regular statement balances of her personal funds account at least quarterly. It should be noted that a review of the Resident Fund Statement for Resident #103 revealed that she did not receive quarterly statements of her personal funds account for the following quarters dated: 12/30/23 - 03/29/24; 03/30/24 - 06/28/24; 06/29/24 - 09/30/24; and 10/01/24 - 12/30/24. 5. Individual accounting records are made available to the resident through quarterly statements and upon request. Quarterly statements will include the following information: a. The resident's balance at the beginning and end of the statement period; b. The total of deposits and withdrawals by the resident for the quarter; c. Interest earned on the resident's funds; d. Resident funds available through petty cash; and e.The total amount of petty cash on hand. A facility policy titled 'Accounting and Records of Resident Funds' with a review date of 01/2025 documented: During a face-to-face interview conducted on 01/31/25 at 09:43 AM Employee #24 acknowledged the findings and stated, The account balance is on their [the resident's] receipt when they withdraw money from their account and it's on their quarterly statement. I make a copy of the original quarterly statement and have them sign each one before I give them their copy. I missed giving her a copy of her quarterly statement for the past quarters.

Based on observations, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to treat a resident with dignity and respect while also recognizing the residents individuality as evidenced by staff observed entering the resident's room without first knocking on the closed door or addressing the resident and informing the resident who they were and why they were there upon entering the room. Resident #93. The findings included: Resident #93 was admitted to the facility on [DATE] with multiple diagnoses that included: Paraplegia Complete, Neuromuscular Dysfunction of Bladder, and Other Artificial Openings of Urinary Tract Status. Review of the resident's medical record showed the following: A care plan focus area that documented, [Resident #93], is at risk for altered thought processes r/t (related to) Schizophrenia and Bipolar Disorder, was initiated on 04/11/23 and had the following interventions that included, Speak clearly and directly to patient in a simple and professional manner. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed that the facility staff coded the resident as having a Brief Interview for Mental Status (BIMS) summary score of 15 indicating intact cognition. During an observation on 01/24/25 at approximately 10:00 AM, a laminated sign with large print was noted on Resident #93's door that documented, Please knock before entering Thank You. Employee #7 (Registered Nurse) was seen opening the door to Resident #93's room and entering, leaving the door open and walked past Resident #93, towards the resident's roommate, located by the window. The employee was observed looking out the window and adjusting the window treatments. The surveyor introduced themselves and Employee #7 stated that she came into the room to adjust the curtains. During a face-to-face interview conducted on 01/24/25 at approximately 10:01 AM, Resident #93 stated that staff enter her room and do not say anything, and that staff do not pull the curtain (privacy curtain) in between her and her roommate when providing care. During a face-to-face interview conducted on 01/24/25 at approximately 11:30 AM, Employee #7 (Registered Nurse) was asked by the surveyor why she did not knock on the closed door or ask the resident if she could enter the room prior to entering. Employee #7 stated that she knew the surveyor was in the room and she entered just to close the shade. During a face-to-face interview conducted on 01/24/25 at approximately 11:45 AM, with Employee #9 (Unit Manager First Floor) stated that education would be provided and acknowledged the findings. Cross Reference 22B DCMR Sec. 3269.1 (f)

Based on observations, record review, and staff interviews, for one (1) of 56 sampled residents, the facility staff failed to revise interventions on a resident's comprehensive care plan to address the resident's behavior of wearing gloves and two masks throughout the facility. Resident #332. The findings included: Resident #332 was admitted to the facility on [DATE] with diagnoses that included Depressive Disorder, Anxiety Disorder, Dementia, Peripheral Vascular Disease, and Substance Abuse History A review of Resident #332's medical record included: A care plan initiated on 10/23/23 documented: Focus/Problem: [Resident #337] has non-compliance behavioral concerns by putting on gloves and putting on double (two) masks despite staff redirection provided. Goal: [Resident #337] will have fewer episodes of non-compliant behavior with putting on gloves and double mask through the next review date x 90 days with Target Date: 02/11/2025; Interventions (Initiated on: 10/23/23): Approach [Resident #337] with a soft and calm voice to avoid escalation and improve compliance; Encourage and redirect [Resident #337] to take out his gloves for safety precaution; Redirect [Resident #337] to wear a single mask as appropriate. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed that Resident #337 had a Brief Interview for Mental Status (BIMS) summary score of, 09, indicating that the Resident had moderately impaired cognition, was independent with ambulation and mobility, required set-up for activities of daily living, had exhibited no behavioral symptoms and was not taking antidepressants, antianxiety or antipsychotic medications. A further review of Resident #337's comprehensive care plan showed no documented evidence that facility staff revised interventions to address the Resident's current behavior of wearing double masks and gloves in patient care areas throughout the facility. During an observation on 01/29/25 at 10:15 AM, Resident #337 opened the door to the 3rd-floor dayroom (an activity room for residents) and entered the doorway wearing two masks, and gloves. The resident was observed carrying two soiled, incontinence pads and a dirty/soiled brief(s) under his right arm. The Resident entered the room without saying anything or making eye contact with the surveyors who were sitting at a table in the room. Employee #17 (3rd-Floor Unit Secretary) entered the doorway behind him and called his name, however, the Resident did not respond. The Resident then walked directly over to a trash can that was situated in the left corner of the room, threw the soiled trash in the trash can, and walked out of the day room. Employee #17 left the doorway and returned wearing gloves, and she immediately went to the trash can and removed the trash bag that contained the soiled briefs and soiled incontinence pads. During an interview on 01/29/25 at 10:15 AM,, Employee #17 (Unit Secretary) stated that Resident #337 was known to have behavior issues. She added that she was at the nurses' station when she observed the Resident wearing a mask and gloves and walking quickly toward the 3rd-floor day room. She added that the Resident walked by other staff in the hallway, but could not verify which staff. She added that she recalls looking up and saw that the Resident was carrying soiled incontinent pads and a soiled brief. She tried to stop him but couldn't before he entered the 3rd- floor day room. During a telephone interview on 02/05/25 at 11:46 AM Employee #18 (Certified Nurse Aide/CNA) stated that a few times she had observed the resident wearing a mask and gloves in the hallway while he was on the phone talking to his sister. She stated that on the day of the observation, she stated she did not see the Resident carrying trash anywhere and she did not see the Resident wearing gloves and a mask in the hallway. During a face-to-face interview on 02/05/25 at 12:28 PM Employee #19 (Registered Nurse/RN) stated that she had observed the Resident she had randomly seen Resident #337 wearing double masks and gloves in the hallway when the Resident was standing at the meal cart waiting for his meal tray to be handed to him. She added that the Resident was easily redirectable, and that was the intervention she used most of the time to get him to change his behavior. During a face-to-face interview on 02/05/25 at 12:53 PM, Employee #3 stated that Resident #337 had a history of being noncompliant with wearing gloves and continued to consistently wear masks and gloves around other residents, throughout the facility and in resident care areas. She acknowledged that the Resident's behavior had been ongoing and stated that most of the time staff redirects the Resident, and when necessary consults Psych. She further acknowledged that the interventions on the Resident's care plan needed to be updated and revised. [Cross reference DCMR 3210.4(c)]

Based on record review and staff interviews for one of fifty-six (56) sampled residents, the facility staff failed to monitor and supervise a resident with a history of elopement and failed to ensure that all doors were secure in the facility after a fire drill. Subsequently, on 08/14/24, the Resident eloped. Resident #59. The findings included: A review of the facility's Elopement policy documented: Residents that are at risk for elopement must be checked every hour for their location. If they are not found, the supervisor must be notified immediately. Resident #59 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Bipolar Disorder, Behavioral Disturbance, Personal History of Other Mental and Behavioral Disorders, Hypothyroidism, Hypertension, and Congestive Heart Failure. The Department of Health received the following incident on 08/15/24 at 3:55 AM that documented: [Name and date of birth of Resident #59] is reported missing from Serenity Rehab and Health Center. Resident's BIMS (Brief Interview for Mental Status) score is 14. A code pink [Elopement], called neighborhood searched, DC Police were notified. Investigation and search ongoing. Resident's guardian unable to be reached at this time . During an observation on 01/28/25 at 1:11PM Resident #59 was observed in his room sitting in his wheelchair on the right side of his bed, The resident was wearing a Wander Guard bracelet on his right wrist. When asked if he ever left the facility without the staff knowing, the Resident responded No, I didn't break any rules. A review of Resident #59's medical record showed: The resident had a history of elopement attempts and had a history of exit-seeking behaviors prior to elopement on 08/14/24, as evidenced by: A review of care plan initiated 03/10/21 that documented: Focus: [Name of Resident] was observed with winter coat, and a walking cane, with a bag, resident stated I want to leave this place . A physician's order dated 05/17/21 that documented: Wander Guard: check placement and function every shift every shift for elopement precaution. A care plan initiated on 07/25/21 that documented: [Name of Resident] has [had]an actual elopement, and is at risk for elopement and has a Wander Guard to wrist . A care plan initiated on 08/11/21 that documented: At 3 am, [Name of Resident], had a face cap and glasses on, and stated that he wanted to go to Walmart to get a new pair of glasses . A physician's order dated 11/15/21 at 11:00 PM that documented: Monitor resident for risk for elopement every shift. A care plan initiated on 12/11/22 that documented: [Name of Resident] moved the chairs on the patio close to the gate he escaped from before, resident hid a bag under his clothes as well as going to the bank a lot . A care plan initiated on 12/01/23 that documented: [Name of Resident] came to the nurses station and stated I want to leave this place, I don't want nobody to go around with me Two Elopement Risk Assessments (version 2) completed on 03/18/24 and 06/19/24 which documented that Resident was assessed at being a high risk for elopement. A Quarterly Minimum Data Set assessment dated [DATE] that documented that Resident #59 had exhibited wandering behaviors 4-6 days, but less than daily during the assessment period. A treatment administration record (TAR) for August 2024, which showed that Employee#15 (Registered Nurse assigned to Resident #59 from 3:00 PM-11:00PM /Evening shift) documented that per the physician's order, he checked every hour to confirm that from 3:00 PM-11:00 PM, the resident was physically in the facility, and he documented that the Resident was in his room on 08/14/24 at 10:00 PM and at 11:00 PM. A care plan initiated on 08/15/24 that documented: Focus: [Name of Resident] eloped on 8/14/2024 . A review of the facility's investigation documents for the Resident's elopement from the facility on 08/14/24 showed: A Code Pink Checklist that documented: [Date]Conducted on: 08/15/24; Start time 12:40AM .Resident: [Name of Resident #5]; Elopement Checklist: Verify all residents in house and confirm missing is not in any other room, bathroom or closet. Time completed: 12:45 AM to 1:15 AM; Staff identified which resident is missing by making copies of face sheet. Time completed: 12:45 AM to 1:15 AM; The front desk (alert Code Pink) paged, 3x (times) Code Pink announced. Time completed 1:00 AM; Supervisor or to be notified within 5 minutes, Time completed 1:00 AM; The DON (Director of Nursing) and Administrator notified. Time completed: 1:35 AM . Of note, per the facility's policy, facility staff should have notified the DON and the Administer immediately once the resident was not located within the facility. The DON and the administrator were notified that Resident #59 was not located within the facility until 1:35AM which was 50 minutes from the start of the Code Pink Checklist, 35 minutes after the Code Pink, was called. A signed witness statement dated from Employee #15 (Registered Nurse assigned to Resident #59 3:00 PM-11:00PM Evening shift) that documented: At the start of shift, [Name of Resident] was received in the unit in stable condition. By 4:30 PM the writer came out of an in-service and met with the resident [who was] at the front desk [1st floor] saying, 'He wants to go home.' The writer took him back to the unit [2nd floor] and asked him to wait for dinner. At 5:15 PM, dinner was served to the Resident. At 6:00 PM, [The] resident was offered his evening medications. All [medications] were well tolerated. [The] Resident was stable and continued to pace on the floor. The writer asked him to go to his room. At 7:30 PM, snacks were offered to the Resident. The Resident was sitting in his room at this time, while [the] writer continued to pass meds (medications) to [the] other residents. [The] Resident was last seen at 8:20 PM watching TV in his room. Vital Signs [Blood Pressure/BP] 132 / 70, 72 [Heart Rate/HR], 18 [Respiration rate/RR], 97.8 [Temperature/T], 98% [Oxygen on room air/RA]. Of note these were not the vital signs that the Employee documented on Resident #59's treatment administration record (TAR) during the 3:00 PM-11:00 PM on 08/14/24. However, the vital signs were identical to those that were documented on the TAR by another nurse for Resident #59 during the 3:00 PM-11;00 PM shift on 08/12/24, two days prior to the incident. A signed witness statement dated from Employee #16 (Registered Nurse assigned to Resident #59 11:00 PM-7:00 AM/ Night shift), that documented: Writer came on the floor at 11:15 PM, did rounds, and [Name of Resident] was not in his room. Because [the] Resident is a wanderer and never stays in [his] room and [he] always goes to other units, I thought that he was around the unit. Later, I had to attend to other residents and before signing the treatment orders, I went at about 12:30 AM to check on the Resident again in his room and [he was] still not in his room. At that time, I started searching in other residents' rooms but could not find him. At about 12:53 AM, I notified the supervisor, and we all started searching and later a Code Pink was announced. During a telephone interview, on 02/04/25 at 2:25 PM, Employee #16 (RN Assigned to Resident #59 from 11:00 PM-7:00 AM) stated that when she got on the unit at the start of her shift (approximately 11:15 PM), she did her rounds on the residents, and she noticed that Resident #59 was not in his room. During rounds she got side-tracked by a few of residents who asked for water, so she got water for the residents and then returned to the nurse's station to get report from Employee #15. She stated that she got her assignment from the Employee but forgot to ask Employee #15 if he had seen Resident #59. She also stated that the Employee left and did not state whether he had seen the Resident. The Employee stated that she continued with her rounds and at 12:00 AM, when she noticed the resident was still not in his room, she asked the assigned CNA, and other CNAs and nurses on the shift to assist with locating the resident. During a face-to-face interview on 02/03/25 at approximately 12:35 PM, Employee #1 (Administrator) indicated the following interventions were implemented to address the deficient practice: - Resident #59 had a head-to-toe assessment conducted by the Medical Director and the Charge Nurse upon his return to the facility on [DATE]. - Resident had a score of 15/15 indicating intact cognition on 08/15/24 - A list of Resident at Risk for Elopement was checked and validated on 08/16/24. - Routine Resident Checks/Supervision/Rounding every 2 hours Log, used by nursing staff was initiated on 08/16/24. - Nursing staff (Nurses and CNAs), Environmental, Maintenance and Security staff were in-serviced (in-person) on Code Pink (Elopement)/Missing Residents on 08/16/24. - Nursing Supervisors were in-serviced on securing doors after fire drills on 08/16/24. To 08/17/24. - Maintenance staff were in-serviced on securing doors after fire drills on 08/16/24. - Security staff were in-serviced on: camera surveillance, fire drill protocol, facility protocol for monitoring unusual occurrences, activity by staff, residents, visitors via surveillance cameras on 08/16/24. - An Ad hoc Committee with the Quality Assurance and Performance Committee was conducted on 08/16/24. - A Wander Guard audit for all residents at risk for elopement was initiated on 08/16/24 - An audit tool to check all exit doors by maintenance weekly was implemented on 08/16/24. - An audit tool to check all exit doors by nursing supervisors daily was implemented on 08/16/24. - No other residents were affected by this deficient practice. The previously mentioned interventions were implemented before the State Agency's on-site visit of 01/23/25.

Based on observations, record reviews, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to provide Resident #5 with the necessary care and service to ensure that their ability to perform activities of daily living do not diminish as evidenced by the facility staff failing to ensure the residents malfunctioning hearing aides were replaced. The findings included: A review of a Social Work Progress Note dated 01/24/23 at 4:33 PM: The daughter stated that one of resident's hearing aids is broken and she will follow up with the doctor at (facility name) to schedule an appointment for the repair and will notify the facility. A care plan last reviewed on 06/07/23: (Resident #5) has a communication problem r/t (related to) bilateral hearing impairment AEB (as evidenced by) use of bilateral hearing aid. Interventions: Anticipate and meet needs, (Resident #5) requires hearing aid to communicate. Ensure availability and functioning of adaptive communication equipment. Ensure hearing aid(s) on bilateral ear is in place. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Hearing Loss Bilateral, Vascular Dementia, and Paroxysmal Atrial Fibrillation. A physician's order dated 07/16/24 documented, Audiology eval (evaluation) and treat as needed. A Personal Property Inventory form signed and dated by Resident #5 on 09/04/24 documented a handwritten check mark beside the printed selection hearing aid. Complaint DC~13174 submitted to the State Agency on 10/02/24 documented in part The resident has experienced significant hearing loss. Since her admission, the family purchased a microphone system with a long wire extending from the television to the bed via the ceiling. However, the facility required removal, citing that nothing could be attached to the TV. The resident has not been provided with any assistive devices to aid her hearing. As an alternative, the family purchased a pocket talker, but it has offered little help. A rgrievance submitted by the resident's representative dated 10/03/24,on the form titled Concerns and Comments documented, Getting assistive devices for the mom, visual alert systems to assist with communication and other issues. A physician's order dated 12/04/24 documented, Return to Audiology appointment with (physician's name) for hearing aid evaluation after receipt of medical clearance from ENT (Ear Nose Throat). During an observation and interview on 01/27/25 at approximately 11:00 AM, in Resident #5' room, the resident was observed sitting upright in bed and had television turned up loud. When questioned by the surveyor about whether the resident had hearing aids the resident stated that the hearing aids do not work, and she did not know where they are. During a face-to-face interview conducted on 01/27/25 at 1:49 PM, Employee #22 (Certified Nurse Aide) stated that they were not sure if the resident has any hearing aids. During a face-to-face interview conducted on 01/27/25 at 2:00PM Employee #21 (Registered Nurse) stated that they did not know if (Resident #5) had a hearing aid but they know she has an amplifier that her family brought to the facility that she uses to hear. During a face-to-face interview conducted on 02/05/25 at 1:10 PM, Employee #4 (3rd Floor Unit Manager) stated that the resident has a (Amplifier) that her daughter brought to the facility and that is the residents hearing aid. It is noted that there is no documented evidence in the medical record that the facility staff assisted the resident in acquiring or using hearing aids.

Based on observations, record reviews, staff and resident interviews, for one (1) of 56 sampled residents, facility staff failed to implement Resident #5's care plan intervention to have the resident have access to functioning hearing aids. The findings included: A care plan with a last reviewed date of 06/07/23: (Resident #5) has a communication problem r/t (related to) bilateral hearing impairment AEB (as evidenced by) use of bilateral hearing aid had interventions that included: (Resident #5) requires hearing aid to communicate. Ensure availability and functioning of adaptive communication equipment. Ensure hearing aid(s) on bilateral ear is in place. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Hearing Loss Bilateral, Vascular Dementia, and Paroxysmal Atrial Fibrillation. A physician's order dated 07/16/24 directed, Audiology eval (evaluation) and treat as needed. A Complaint DC~13174 submitted to the State Agency on 10/02/24 documented in part, The resident has experienced significant hearing loss. Since her admission, the family purchased a microphone system with a long wire extending from the television to the bed via the ceiling. However, the facility required removal, citing that nothing could be attached to the TV. The resident has not been provided with any assistive devices to aid her hearing. As an alternative, the family purchased a pocket talker, but it has offered little help. An observation and interview were conducted on 01/27/25 at approximately 11:00 AM in Resident #5' room. Resident #5 was observed sitting upright in bed and had her television turned up loud. When questioned by the surveyor about whether the resident had hearing aides, the resident stated that the hearing aides do not work, and she did not know where they are. During a face-to-face interview conducted on 01/27/25 at 1:49 PM, Employee #22 (Certified Nurse Aide) stated that they were not sure if the resident has any hearing aids. During a face-to-face interview conducted on 01/27/25 at 2:00PM Employee #21 (Registered Nurse) stated that they did not know if (Resident #5) had a hearing aid but they know she has an amplifier that her family brought to the facility that she uses to hear. During a face-to-face interview conducted on 02/05/25 at 1:10 PM, Employee #4 (3rd Floor Unit Manager) stated that the resident has an Amplifier that her daughter brought to the facility and that is the residents hearing aide. It is noted that the facility staff failed to implement Resident #5's care plan intervention of ensuring hearing aids were provided to the resident. Cross Reference 22B DCMR Sec. 3210.4 (a)

Based on record review and staff interview, the facility's staff failed to ensure two (2) of seven (7) residents in the sample with allegations of abuse, were free from alleged/witnessed non-consensual sexual contact by Resident #126. (Residents #108 and #145). This failure resulted in actual harm to Residents #108 and #145. The findings include: Review of the facility's policy titled, Prohibition of Abuse, with a revision date of 05/22, defined sexual abuse as . non-consensual sexual contact of any type with a resident includes but is not limited to sexual harassment coercion or sexual assault . Resident #126 was admitted to the facility on [DATE] with multiple diagnoses including Major Depressive Disorder and Dementia without Behavioral Disturbances. Review of the resident's medical record showed the following: A Quarterly Minimum Data Set-(MDS) assessment dated [DATE] documenting a Brief Interview for Mental Status (BIMs) summary score of 99, indicating the resident was unable to complete the assessment. The resident was not coded for exhibiting physical behavior symptoms directed toward others. Further review of the MDS showed the resident was coded for using a wheelchair, not walking in the room or corridor, and being frequently incontinent of stool. Review of a Care Plan with an initial date of 05/27/22 revealed the following Focus Area - [Resident #126] has problematic manner in which resident acts characterized by inappropriate sexual behavior physical related to: resident touches other residents &/ or staff inappropriately . Goal: [Resident #126] will have reduced incidents of inappropriate sexual behavior. Interventions: Protect other residents if unable to protect themselves; Remove resident from the public area when behavior is disruptive/unacceptable .; Document a summary of each episode. A 06/02/22 quarterly MDS documented - Resident #126 had a Brief Interview for Mental Status (BIMs) summary score of 06, indicating the resident was severely impaired cognitively. The resident was not coded for exhibiting physical behavior symptoms directed toward others. Further review of the MDS showed the resident was coded for using a wheelchair, not walking in the room or corridor, and being frequently incontinent of stool. Also, the resident was coded as weighing 257 pounds and being 6 feet tall. Review of Treatment Administrator Records (TAR) from 05/01/22 to 06/17/22 showed nurses documented hourly the resident's location in the facility. -06/13/22 at 1:47 PM [Nursing Note] - .at 1200 [12:00 PM] resident was observed wandering and pacing the hallway with his wheelchair, entering other resident's room, resident was redirected at all times by staff. NP . notified, recommends to monitor and redirect as required and psych consult for behavioral disturbances Review of progress notes, Medication Administration Records, and Treatment Administration Records for 06/13/22 to 06/17/22 failed to reveal documented evidence Resident #126 was re-evaluated by psych for wandering in residents' rooms as ordered by the NP on 06/13/22. A 06/17/22 at 8:04 AM [Nursing Supervisor's Note] documented the following- At about 5:40 AM .writer was informed by nurse [Resident #126] was observed in bed with [Resident #145] .MD order to transfer [Resident #145] . to ER for further evaluation .[Officer's name and Detective's name] . the detective interviewed writer, [Resident #126], assigned nurse .and said they will continue with their investigation . Further review of the June TAR showed that on 06/17/22 at 5:00 AM the nurse documented IB indicating that she observed Resident #126 in bed at that time. Continued review of the Care Plan showed that the facility's staff revised the care plan on 06/17/22 with the following information: -Focus Area - Staff reported that [Resident #126] was observed on top of [Resident #145] in room [ROOM NUMBER] B. -Intervention- One-on-one monitoring X 24 hours every day for safety precautions. 1A. Resident #108 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's Disease and Major Depression. An MDS assessment dated [DATE] documented Resident #108 had a Brief Interview for Mental Status (BIMs) summary score of 99 indicating the resident was unable to complete the assessment. Further review of the MDS showed Resident #108 was coded for being totally dependent on the physical assistance of two staff members for bed mobility and one staff member for personal hygiene. Resident #108 was also coded for always being incontinent of urine and bowel. Review of a Facility Reported Incident (DC00010774) dated 05/26/22 [Thursday] at 11:21 PM, documented, At 3:30 PM .Writer received report that [Resident #126] was observed sitting in his wheelchair at the bedside of [Resident 108] room [ROOM NUMBER]-A at about 8:30 PM on 05/25/22 [Wednesday]. It was reported that [Resident #126] was observed with feces on his left hand .[Resident #108] was observed with feces on her thigh and bed spread .[Resident #126] was transferred to Unit 3 .[MD's name] gave orders to transfer [Resident #108] to ER (emergency room ) for further evaluation of possible physical abuse . Review of Resident #108's medical record showed the following: -05/26/22 at 3:30 PM [ADON Note] - At about 3:30pm writer received [two police officers names and badge numbers] in the facility who said they had a call for alleged abuse for [Resident #108] in room [ROOM NUMBER]-A. Writer received report from staff that [Resident #126] who resided in room [ROOM NUMBER] Bed A was observed sitting in his wheelchair at the bedside of [Resident #108] room [ROOM NUMBER]-A at about 8:30pm on 5/25/22. It was reported that [Resident #126] was observed with feces on his left-hand front, back, and underneath his fingernails. It was also reported that [Resident #108] was observed with feces on her thigh and her bed spread. [Resident #126] was immediately removed from the scene and [MD's name] notified and order given to transfer [Resident #126] to Unit 3 - room [ROOM NUMBER]-B. Also, [Detective's name and badge number] was called to the facility by the police. After meeting with the residents and talking to staff members the detective issue report . No arrest was made. However, [MD's name] also gave order to transfer [Resident #108] to ER (emergency room ) via 911 for further evaluation for possible physical abuse . Resident . left the facility at 17:28pm [5:28 PM] to [local hospital] . -05/26/22 at 4:41 PM [Physician's Order] transfer resident to ER via 911 for further evaluation for possible physical abuse Late entry dated 05/27/22 at 5:16 PM showed, 05/25/22 at 5:03 PM [Activity Note]- Incident Report: When preparing to leave for the evening I [Employee #26 Activities Director] found [Resident #126] . sitting in his wheelchair at the bedside of [Resident #108] in room [ROOM NUMBER]-A. Writer [Employee #26] observed feces on [Resident #126's] left hand front, back, and underneath his fingernails. Feces was also noticed on [Resident #108's] thigh and her bed spread. [Resident #126] was immediately removed from the scene and . relocated to Unit-3 room [ROOM NUMBER]-B. It should be noted that this was a late entry note that was created on 05/27/22 at 5:16 PM (approximately 2 days after the incident) with an effective date of 05/25/22 at 5:03 PM. Late entry created on 05/27/22 at 7:33 AM showed, 05/25/22 at 8:30 PM [Nursing Supervisor Note]- During the evening shift at about 8:30pm writer was made aware by the nurse that Activity Director saw [Resident #126] in resident`s [Resident #108's] room. [Resident #126] was sitting at the bedside in his wheelchair and had feces on his left hand. [Resident #108] was assessed from head to toe. No injury was observed. No sign of pain nor discomfort expressed upon assessment. [Resident #108] was assisted with incontinent care and resident`s [responsible party's name] made aware. resident was monitored through the shift with no other concerns reported . BP (blood pressure) 122/67, P(pulse) 74, R18, O2 (oxygen) 99% ra (room air), T temperature) 97.8. It should be noted that this was a late entry note that was created on 05/27/22 at 7:33 AM (approximately 2 days after the incident) with an effective date of 05/25/22 at 8:30 PM. A 05/27/22 at 6:53 AM [Nursing Note] documented- [Resident #108] returned from [local hospital] at about 5:10am . The medic . who accompanied her from the hospital stated no evidence of physical assault was observed after examination by the doctor and she is free to resume all activities and treatment active prior to transfer to the ER . The Situation, Background, Assessment, Result Form signed and dated on 5/31/22 by Nursing Supervisor (Employee #11) showed, During the evening shift at about 8:30 pm writer was made aware by the nurse that Activity Director saw [Resident #126] .sitting at the bedside [of Resident 108] in his wheelchair and had feces on his left hand. [Resident #108] was unable to explain what happened due to diagnosis of Cognitive Communication Deficit. [Resident #108] was assessed from head to toe by the nurse, no sign of pain/discomfort nor facial grimace expressed. No physical signs of trauma observed, no redness, no bruises around the perineal area and buttocks. [MD's name] made aware, new order was given to transfer resident to ER (emergency room ) via 911 for further evaluation for possible physical abuse. During multiple observations from 06/19/22 to 06/22/22 from approximately 11:00 AM to 4:00 PM, Resident #108 was observed in bed sleeping or eyes open and not responding to verbal stimuli. Resident #108 was not interviewable. During a face-to-face interview on 06/22/22 at 3:00 PM, Employee #26 (Activity Director) stated that he was made aware that Resident #126 was in another resident's room uninvited but could not remember the date. The employee stated on 05/25/22 at approximately 8:00 PM, he went to look for Resident #126's and could not find him in his room (#147) or in the hallway where he usually sits playing cards with other residents. Employee #26 said he then alerted the nursing staff, and they all started looking for the resident. The employee said he found Resident #126 in room [ROOM NUMBER] sitting in his wheelchair at the bedside of Resident #108, who was in bed A. The employee then called nursing staff to room [ROOM NUMBER] and moved Resident #126 into the hallway. Further interview revealed Employee #26 asked the resident why he was in Resident 108's room, but Resident #126 did not provide an answer. The employee also observed the resident with feces on his left hand. The employee asked the resident if he had a bowel movement, and the resident said, No. However, when he went back into room [ROOM NUMBER] with the nursing staff, he noticed Resident #108's bedspread had stool on it. When asked did Resident #108 say anything, he stated, No, she's non-verbal. Additionally, the employee stated that Resident #126 was moved to the third floor 310B after the incident. During a face-to-face interview on 06/23/22 at 9:37 AM, Employee #3 (ADON) stated that the incident with Resident #126 and Resident #108 was discussed in the morning stand-up meeting on 05/26/22. However, he was unaware the incident was a physical assault until he saw the police in the facility on 05/26/22 responding to a call for alleged abuse against Resident #108. When asked who called the police, Employee #3 said that he did not know. Additionally, the employee said he made the physician aware and was given an order to transfer Resident #108 to the emergency room to be evaluated for possible physical assault. During a face-to-face interview on 06/24/22, Employee #25 (CNA) stated she was looking for Resident #126 when Employee #26 called her to room [ROOM NUMBER]. Resident #126 was sitting in the hallway with stool [feces] on his left hand. She also observed Resident #108 diaper was off, and she had stool [feces] smeared all over her stomach and thighs. The employee said she provided incontinent care for Resident #108. When asked did Resident #108 say anything, the employee said, No, she doesn't talk. She just had tears rolling down her face. Additionally, the employee stated that when she assisted Resident #126 to his room, the resident kept trying to hide his left hand under his leg. When she asked him what was on his hand, the resident said, Dirt. The employee said that it was not dirt; it was stool [feces]. The employee stated, I changed him [Resident #126], and he was not incontinent of stool. I only found stool on his hand. The employee said, The police came the next day [05/26/22] when they received an anonymous call. A review of records and staff interviews revealed that the facility's staff failed to ensure Resident #108 was safe from Resident #126's alleged inappropriate non-consensual sexual touch. (Cross reference 42 CFR 483.12, F607 Resident #121) 1B. Resident #145 was admitted on [DATE] with multiple diagnoses including Dementia in other Disease classified elsewhere without Behavioral Disturbances, Cognitive Communication Deficit, and Generalized Muscle Weakness. Review of the 05/06/22 Quarterly Minimum Data Set (MDS) revealed the following: Resident #145 had a Brief Interview for Mental Status summary score of 99 indicating the resident was unable to complete the assessment. Further review of the MDS showed Resident #145 was coded for requiring extensive assistance from one staff person for bed mobility, transferring, and personal hygiene. Also, the resident was coded as weighing 93 pounds and being 5 feet tall. Review of the Facility Reported Incident (DC00010821) dated 06/17/22 at 10:32 AM, documented, .Writer was informed by the nurse that [Resident #126] was observed in bed with [Resident #145] in room [ROOM NUMBER]B .[Resident #126] was redirected to leave the room . [Resident #145] was assessed . no signs of trauma observed .[MD's name] gave orders to transfer [Resident #145] via 911 to ER (emergency room ) for further evaluation . Review of the medical record revealed the following: -06/17/22 at 5:07AM [Physician order] - Transfer resident to ER for further examination due to possible physical abuse. -6/17/22 at 7:38 AM [Nursing Note] - .At 5:00 AM . CNA [Employee #15] was doing AM care .she observed the Resident in [from] room [ROOM NUMBER]B [Resident #126] was on top of the [Resident #145] in room [ROOM NUMBER]B .Writer called the supervisor immediately and the other staff on the floor. Supervisor redirected the resident [Resident #126] to his room. Initiated a 1:1 (one-to-one) around the clock monitoring until further notice. A head-to-toe assessment was done [for Resident #145] by supervisor and writer. No bruises .skin tear . bleeding noted. Resident denied pain or any discomfort at this time. Police was called on the seen [scene]. Emergency responders were called on the seen [scene] too. An assessment was done by emergency responders, and they came to a conclusion to transfer resident to the nearest ER for further evaluation per physician's orders. Responsible party was notified. V/S (vital signs) T 97.6 P 87 BP 142/67 R 18 O2 SAT 98% Room Air. -06/17/22 at 8:23 AM [Nursing Supervisor Note]- At about 5:40am, writer received a call from [Resident #126's name] assigned nurse requesting writer to report to the third floor ASAP (as soon as possible). When writer arrived on the floor, writer observed [Resident #126's name] walking to his room. He had his gown on and he was wearing a diaper. Writer was informed by the nurse that [Resident #126] was observed in the bed with [Resident #145] in room [ROOM NUMBER]B. According to the nurse, [Resident #126] was immediately redirected to leave the [his] room . [Resident #145] was assessed by writer and the two other nurses on the floor. Her skin warm and dry to touch, she denied pain upon further assessment. No signs of trauma observed as resident remain calm and cooperative .brief was intact and appropriate, no moisture/urine observed. Writer and the other nurses could not observe any signs of an open brief on full head to toe assessment .MD (medical doctor) gave order to transfer .via 911 to ER for further evaluation/treatment . [Resident #145] left facility . During a face-to-face interview on 06/17/22 at approximately at 8:30 AM, Employee #14, LPN (assigned nurse) stated that the CNA [Employee #15] was very upset and called her to room [ROOM NUMBER]. When she arrived at the room, she observed Resident #126 naked laying on top of Resident #145, who was also naked. The employee then said that the staff helped her get Resident #126 off Resident #145. Then the staff helped him get dressed and escorted him to his room. A Situational Background, Assessment, Request (SBAR) dated 06/17/22 at 8:32 AM documented, . At about 5:40 AM writer was informed by the nurse that [Resident #126] was observed in the bed with [Resident #145] in room [ROOM NUMBER]B .[Resident #145] was assessed no signs of pain expressed. Her brief was intact/appropriate, no moisture/urine observed .911 called [Resident #145] left facility .to ER .police called [Officer's name and Detective's name] came to facility . and interviewed writer [Employee 20], nurse [Employee #14], and [Resident #126] . During a face-to-face interview on 06/17/22 at approximately 9:15 AM, Resident #126 stated that he went to Resident #145's room naked, sat on her bed, rubbed her legs, then pull her gown up and open her incontinent pad and laid on top of her. When asked, if she [Resident #145] invited him into her room, Resident #126 stated, No. When asked, what did [Resident #145] do when he laid on top of her, Resident #126, stated, She didn't do nothing and didn't say anything. When asked, why did he lay on top of [Resident #145] if she didn't invite him into her room, Resident #126 stopped answering questions. A nursing note documented by the Unit Manager on 6//17/22 at 10:26 AM indicated, Writer made a f/u (follow-up) call to the RP (responsible party) .to notified about the resident [Resident #145] transfer .to ER for further examination due to possible physical abuse. A note from the Attending Physician dated 06/17/22 at 6:37 PM documented . Nursing staff reported that during monitoring round that a male resident [Resident 126] was found in bed with resident [Resident #145] early morning of 7/17/2022 [06/17/22] . Resident [Resident #145] has been evaluated by assault forensic specialist at the acute care hospital emergency department . I have updated resident's daughter . She has requested another facility for resident . Review of witness statements for staff on duty at the time of the incident (Employee #15-CNA, Employee #14-LPN, Employee #16-RN, Employee #19-LPN, and Employee #20-RN Nursing Supervisor consistently indicated that staff reported to Resident #145's room and noted Resident #126 naked on top of Resident #145 who was also naked. During a face-to-face interview on 06/17/22 at 3:00 PM, Employee #45 (Unit Manager) stated that Resident #126 was recently [05/26/22] moved to her floor from the first floor after staff suspected that he inappropriately touched a female resident. The employee then said that the staff consistently monitored Resident #126 for inappropriate sexual behavior. When asked if she provided staff education about Resident #126's alleged inappropriate behavior after he moved to the floor, the employee stated that she did but did not have documented evidence of what she taught to staff. During a face-to-face interview on 06/17/22 at approximately 3:30 PM, Employee #22 (Temporary Nursing Aide), stated that she worked on the floor since April 2022. The employee said that she was not provided any education about Resident #126 when he was moved to the floor. During a face-to-face interview on 06/22/22 at approximately 7:30 AM, Employee #24 (CNA), stated that she worked on the floor for three years. The employee said that she was not provided any education about Resident #126 when he was moved to the third floor. During a face-to-face interview on 06/22/22 at approximately 7:45 AM, Employee #25 (CNA) stated that she has worked on the floor for 5 years. The employee said she was not provided any education about Resident #126 when he moved to the floor. It should be noted that Employee #25 worked the morning of 06/17/22 when Resident #126 was observed naked on top of Resident #145. During a face-to-face interview on 06/24/22 at approximately 4:00 PM, Employee #13 (Educator) stated that she provides education annually, as needed, and when there is a concern in the facility. When asked did she provide education to staff after Resident #126 was moved to the third floor for allegedly inappropriately touching a female resident, she stated that she did not provide education to staff. An attempt was made to interview the Administrator and the Director of Nursing regarding the failure to keep residents safe from Resident #126, however they did not provide a response. It should be noted that after the incident on 06/17/22 the facility implemented an intervention of one-to-one services for Resident #126, and he remained on that intervention throughout the survey.

Based on staff and resident interviews and record review for three (3) of three (3) residents, it was determined that facility staff failed to utilize two (2) persons to assist with bed mobility. Subsequently, Resident #1 fell out of bed, sustained a laceration to the forehead and was subsequently sent to the hospital by 911. The findings include: Resident #1 was admitted to the facility on (MONTH) 11, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 19, (YEAR), Resident #1 scored 9/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). Resident #1 was assessed as requiring extensive assistance with two person assist for bed mobility (Item GO110A on the MDS) in Section G (Functional Status) Resident #2 was admitted on (MONTH) 9, (YEAR). According to the MDS with a target date of (MONTH) 16, (YEAR) Resident #2 scored 15/15 for the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14 a score of 13-15 suggests the resident is cognitively intact. Resident #2 was assessed as requiring extensive assistance with two person assist for bed mobility in Section G (Item GO110A on the MDS). Resident #3 was admitted on (MONTH) 30, 2010. According to the MDS with a target date of (MONTH) 21, (YEAR), Resident #2 scored 10/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14 a score of 8-12 suggests the resident has moderately impaired cognitive skills for daily decision making. Resident #3 was assessed as requiring extensive assistance with two person assist for bed mobility in Section G (Item GO110A on the MDS). Face-to-face interviews were conducted with Residents #2 and #3 on (MONTH) 23, (YEAR) between 12:00 PM and 2:00 PM. Both residents acknowledged that they consistently receive the assistance of one (1) person for bed mobility. Residents #1, #2 and #3 utilized an air mattress. A face-to-face interview was conducted with Employee #6 on (MONTH) 23, (YEAR) at 10:00 PM. Employee #6 stated, Right after that happened, when Resident #1 fell , I gave an in-service to everyone. I stressed that every resident on an air mattress must have two persons to do care, to help with the turning of the resident. Face-to-face interviews were conducted with Employees #4 and #5 on (MONTH) 23, (YEAR) between 9:00 AM and 12:00 PM. Employee #4 cared for Resident #2 and Employee #5 cared for Resident #3 on (MONTH) 23, (YEAR). Both employees acknowledged that they assisted Resident #2 and Resident #3 with ADL care (including bed mobility) by themselves, without a second person to assist on (MONTH) 23, (YEAR). Employee #2 acknowledged that the above findings.

Based on policy review, medical record review, personnel records review and staff interviews for two (2) of 56 sampled residents, the facility failed to provide necessary care and treatment with an acute change in condition as evidenced by failure to perform a comprehensive assessment and reassessments to determine appropriate treatment and interventions to prevent Harm and prevent hospitalization for one (1) resident (Resident #158) with [DIAGNOSES REDACTED].#158, and #96. Findings included . 1. Facility failed to provide necessary care and treatment with an acute change in condition as evidenced by failure to perform a comprehensive assessment and reassessments to determine appropriate treatment and interventions to prevent hospitalization for Resident #158. On (MONTH) 17, (YEAR), the State Agency received a facility reported incident that showed that Resident # 158 experienced a choking episode with total airway obstruction on (MONTH) 17, (YEAR) at approximately 9:50 PM. The resident subsequently became unresponsive. Cardiopulmonary resuscitation was initiated and the resident was transported to the emergency room . Resident #158 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Speech Evaluation and Plan of Treatment dated (MONTH) 13, (YEAR) at 4:38 PM showed reason for referral: Resident referred to SLP (Speech Language Pathology) evaluation due to difficulty speaking and coughing while eating. The speech evaluation included recommendations for mechanical soft textures, mechanical soft/ground textured solids; nectar thick liquids with close supervision for oral intake. Swallowing strategies included seated in chair or edge of bed for all PO (oral) intake. Liquids consumed with head posture chin down. Review of medical record on [DATE] at 10:00 AM showed an Admission Minimum Data Set ((MDS) dated [DATE]. Review of the MDS Section C showed the Brief Interview for Mental Status score was coded as 13, which indicates the resident is cognitively intact. Section G0110 (Functional Status) Resident # 158 was coded as requiring supervision for all activities of daily living except bed mobility, personal hygiene and bathing. Under section G0120 (Bathing) resident is coded as 4 which indicates total dependence. Section G0110 Eating resident was coded as 1 which indicates set up help only. Under Section K0100 (Swallowing/Nutritional Status) resident was coded as none of the above for Swallowing Disorder. However, under Section K0510 (Nutritional Approaches) the resident is coded as requiring a mechanically altered diet (requires change in texture of food or liquids, e.g. pureed food, thickened liquids). Review of the Nutrition problem care plan dated [DATE], showed interventions listed as provide regular mechanical soft diet as ordered. A further review showed an ADL Self-care Performance Deficit care plan initiated on [DATE], with the following interventions praise all efforts at self-care, physical therapy and occupational therapy evaluation and treatment as per doctor orders, staff to assist with bed mobility and transfers, as well as locomotion on and off unit as needed, staff to assist with hygiene and toileting as needed, encourage resident to participate to the fullest extent possible with each interaction and encourage resident to use call bell to call for assistance. Review of the Oral/Dental Health problem care plan dated [DATE] showed the resident has difficulty in chewing and broken teeth need for altered textured diet, Interventions the resident requires mechanical soft diet. Consult with dietician and change if chewing/swallowing problems are noted. The medical record lacked documented evidence the care plan included swallow strategies recommended by the speech therapist. Speech Therapy Treatment Encounter note dated [DATE] at 5:42 PM, showed regular nectar thin liquids presented mild cues for head posture chin down during liquid intake. The Nurse's Note dated (MONTH) 17, (YEAR), at 11:15 PM showed that Resident #158 was in the Day Room with other residents eating a steak and cheese sub from a local carry out when a staff member yelled for help at about 9:40 PM. Upon entering the Day Room, the nurse observed the resident sitting in his wheelchair coughing/choking and his eyes rolling backward. The nurse called for help and performed five (5) back blows on each shoulder blades. Resident #158 coughing increased. In addition, the Nurse's Note showed abdominal thrusts were performed three (3) times but the resident condition is not improved. He went into code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, resident was intubated and then transferred to (Hospital Name). The medical record lacked documented evidence the nursing staff provided verbal cues to Resident #158 while eating the steak and cheese in the Day Room, to prevent choking. Further review of the medical record showed an eInteract Change of Condition Evaluation Form dated (MONTH) 17, (YEAR), at 9:59 PM. The form showed Resident #158's [DIAGNOSES REDACTED]. The most recent vital signs recorded as [DATE] at 9:40 AM- ,[DATE], pulse- 78 beats per minutes, respirations- 20 breaths per minutes, and the most recent temperature recorded as 98.4 degree Fahrenheit orally at 2:28 PM on (MONTH) 17, (YEAR). The most recent oxygen saturation recorded as 98% (percent) on (MONTH) 16, (YEAR) at 11:03 PM. The physical assessment showed Resident #158 had no observed neurological changes but was also unresponsive, and choking. Under section summarize your observations and evaluation: Resident was eating outside food steak and cheese sandwich when he began choking. The interventions documented were 911 was called and CPR continued, resident was transported via 911. However, the eInteract Change of Condition Evaluation Form failed to show all interventions implemented to include complete vital signs, administration of oxygen, suctioning and the performance of a comprehensive assessment cardiovascular assessment, respiratory assessment, and neurological assessment at and during the change of condition. Review of the report submitted to the State Agency showed that on (MONTH) 17, (YEAR), at 9:50 PM, in the 3rd Floor Day Room, Resident #158 choked with total airway obstruction while eating a steak and cheese, and became unconscious for about one minute until airway was partial opened. According to the facility report, the [MEDICATION NAME] maneuver was performed and partial opened the airway. The staff administered oxygen via a mask and Ambu bag. Audible wheezing and sweating was observed and resident was lowered to the floor. Cardiopulmonary Resuscitation was initiated simultaneously with intermittent application of oxygen with Ambu bag. The Emergency Medical Services team arrived about three minutes after the [MEDICATION NAME] Maneuver, at which time they administered [MEDICATION NAME] and the Automated External Defibrillator was placed. Review of the facility policy titled Serenity Rapid Response Team dated (MONTH) 27, (YEAR), showed that staff are to respond to all emergencies to include a licensed nurse from each unit and the Director of Nursing/Nursing Supervisor, and Nurse Practitioner , if available. The Director of Nursing/Nursing Supervisor is responsible for bringing the AED (Automated External Defibrillator); while the other assignments are as follows: A. Nurse assigned to the resident stays with the resident and directs the other staff to contact the Rapid Response Team and 911. B. Unit One Team 3 Nurse brings the Crash Cart to the scene of the emergency regardless of the location. C. Unit Two Team 3 Nurse is responsible for providing oxygen, suctioning, and ventilation with the bag valve, if necessary. D. Unit Three- Team 3 Nurse assists with placing the cardiac board under the resident and providing the compressions. During a face-to-face interview on [DATE] with Employee#26 at 4:21 PM regarding the resident's change in condition, I completed the Nursing Home to Hospital Transfer Form on [DATE] and I assisted with CPR (cardiopulmonary resuscitation) for Resident# 158. When I came in the dayroom I saw the resident trying to stick his hand down his throat , we (staff) were trying to get him to stand and he could not stand he was conscious and I was telling him to cough and Employee# 25 did the back slaps over his shoulder blades, he had cup of water he was trying to drink it and it was coming out of his mouth, then he could not breathe he was shaking and he became stiff and he was not breathing and we started CPR we called a code and 911, the supervisor (Employee# 27) came to the floor and took over CPR. During a face-to-face interview with Employee #27 on [DATE] at 5:00 PM, they called a medical emergency and I came from the first floor and I met the Resident# 158 holding his throat he said that he just choked he stood up and we supported him I did the [MEDICATION NAME] Maneuver and then we placed him on the floor and I took over CPR, oxygen and suction with a Yankeur (oral suction tool), by now 911 had arrived and his SP02 (oxygen level) was 62% they (911) took over chest compressions with an automatic chest compression system they (staff) pulled out a big piece of meat, he was alive when he left the floor he was to go (hospital name) but he went to (hospital name). During a telephone interview on [DATE], at 5:35 PM, Employee# 24, stated I was in the dayroom but I was not assigned to the resident and three residents came in with food from the outside; Resident#158 and two other residents. I was not too far away and he asked for sips of water, thickened water. While they were eating I gave him the thickened water and then I asked him if he was choking. He said yes, he only took a few bites before he started choking. It was not a long time at all, if ten minutes, before he started choking. He had a lot of sandwich left. I saw staff in the hall way and called for help they came in and started working on him. Employee #25 provided back slaps over the shoulders blades for Resident # 158's choking episode. However, backs slap are inconsistent with the [MEDICATION NAME] maneuver to address choking in adults and can further lodge food in airway. The [MEDICATION NAME] maneuver includes the performance of abdominal thrust and chest thrust to dislodge foreign object from airway. Pavitt, M. J., Swanton, L. L., Hind, M., Apps, M., Polkey, M. I., Green, M., & Hopkinson, N. S. (2017). Choking on a foreign body: A physiological study of the effectiveness of abdominal thrust maneuvers to increase [MEDICATION NAME] pressure. Thorax, 72(6), 576. doi:http://dx.doi.org.contentproxy.phoenix.edu/10.1136/thoraxjnl-,[DATE] Review of personnel record showed, Employee #25 received Cardiopulmonary Resuscitation training to include the [MEDICATION NAME] maneuver. The medical record lacked documented evidence of monitoring and assessment to include the recording of physiological signs and symptoms of distress when the resident's condition declined prior to transfer to the Emergency Department. The facility's failure to assess, implement interventions, and properly intervene placed Resident #158 at harm. The facility's failure to assess, implement interventions, and properly intervene lead to Resident #158's harm and subsequent death. 2. Facility staff failed to provide treatment and care in accordance with professional standards of practice for Resident #96. Resident #96 was admitted to the facility on [DATE] (initial admitted ) with [DIAGNOSES REDACTED]. Resident interview on [DATE],8 at 3:30 PM the Resident was asked, do you have any problems with vision or hearing? Resident stated I have not had an eye appointment and they stopped giving me my eye drops for my [MEDICAL CONDITION] my vision is real blurry now. Review of the medical record on [DATE], at 9:30 AM showed a physician order dated [DATE] Ophthalmology Consultation for Resident with [MEDICAL CONDITION], [MEDICATION NAME]/[MEDICATION NAME], 0.004% eye drop 1 gtt (drop) to both eyes Q HS (every bedtime) DX (diagnosis) [MEDICAL CONDITION], Dorzolamide-[MEDICATION NAME] 2%-0.5% eye drop 1 gtt (drop) to both eyes BID (twice a day) Dx [MEDICAL CONDITION]. A further review of the medical record showed a Compressive Minimum Data Set (MDS) dated (MONTH) 15, (YEAR), Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing (B1000), Vision the code entered is 0, which indicates no. A review of the medical record on [DATE] at 10:30 AM showed Medication Administration Record [REDACTED] The medication administration showed eye drops were administered to Resident #96 during the months of September, (YEAR) October, (YEAR) November, (YEAR) December, (YEAR) A further review of the medical record on [DATE] at 11:30 AM showed Resident # 96 Medication Administration Record [REDACTED] January (YEAR) February (YEAR) March (YEAR) April (YEAR) May (YEAR) June (YEAR) July (YEAR) However, the Medication Administration Records did not show the order for eye drops Dorzolamide HC-[MEDICATION NAME] Mal Solution 22XXX,[DATE].8 MG/ML (milligram/milliliter) one drop in both eyes two times a day for [MEDICAL CONDITION] and Dorzolamide-[MEDICATION NAME], 2%-0.5% Drops, instill 1 drop in both eyes two times a day for [MEDICAL CONDITION] was transcribed or that the Resident received the eye drops for the past seven months. During an interview on [DATE], at 12:30 PM, Employee# 4, stated I see the eye drops are not on the MAR (medication administration record) and I don't see an order to stop them, let me keep looking. During a telephone interview on [DATE], at 1:00 PM the Physician, stated the Resident had multiple hospitalization s and that is why he (Resident) may not have had the Ophthalmology Consult, and the order for eye drops check to see if the eye drops are on the discharge hospital paperwork, but I understand that he should have received the eye drop order for eye drops. During an interview with Employee #4 on [DATE], at 3:00 PM Employee stated no I could not find that the resident received the eye drops since (MONTH) of (YEAR), the Resident did go in and out of the hospital, he did not receive the eye drops at all this year. Facility staff failed to provide evidence Resident # 96 was provided care and treatment (administration of eye drops) in accordance with professional standards of care. During a face-to-face interview on [DATE], at 3:00 PM Employee# 4 acknowledged the findings at the time of the observation. A further review of the medical record on [DATE], at 10:00 AM showed a physician's order dated [DATE] Latanoprost 0.005% ophthalmic solution (eye drop) at bedtime every day and Dorzolamide HCL Solution 2% one drop twice a day every day. During a face-to-face interview on [DATE], at 10:00 AM Employee# 4 stated here is the order and again acknowledged the finding.

Based on medical record review, policy review, and staff interview, the facility failed to ensure the nursing staff provided necessary care and treatment with an acute change in condition as evidenced by the failure to monitor, assess, evaluate and implement interventions, in accordance with professional standards of care, for one (1) resident with a history of dysphagia that experienced a choking episode. (Resident #158) Findings included . Resident #158 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Speech Evaluation and Plan of Treatment dated (MONTH) 13, (YEAR) at 4:38 PM showed reason for referral: Resident referred to SLP (Speech Language Pathology) evaluation due to difficulty speaking and coughing while eating. The speech evaluation included recommendations for mechanical soft textures, mechanical soft/ground textured solids; nectar thick liquids with close supervision for oral intake. Swallowing strategies included seated in chair or edge of bed for all PO (oral) intake. Liquids consumed with head posture chin down. Review of medical record on [DATE], at 10:00 AM showed an Admission Minimum Data Set ((MDS) dated [DATE]. Review of the MDS Section C showed the Brief Interview for Mental Status score was coded as 13, which indicates the resident is cognitively intact. Section G0110 Eating resident was coded as 1 which indicates set up help only. Section K0510 (Nutritional Approaches) the resident is coded as requiring a mechanically altered diet (requires change in texture of food or liquids, e.g. pureed food, thickened liquids). Speech Therapy Treatment Encounter note dated [DATE] at 5:42 PM, showed regular nectar thin liquids presented mild cues for head posture chin down during liquid intake. The Nurse's Note dated (MONTH) 17, (YEAR), at 11:15 PM showed that Resident #158 was in the Day Room with other residents eating a steak and cheese sub from a local carry out when a staff member yelled for help at about 9:40 PM. Upon entering the Day Room, the nurse observed the resident sitting in his wheelchair coughing/choking and his eyes rolling backward. The nurse called for help and performed five (5) back blows on each shoulder blades. Resident #158 coughing increased. In addition, the Nurse's Note showed abdominal thrusts were performed three (3) times but the resident condition is not improved. He went into code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, resident was intubated and then transferred to (Hospital Name). Further review of the medical record showed an eInteract Change of Condition Evaluation Form dated (MONTH) 17, (YEAR), at 9:59 PM. The form showed Resident #158's [DIAGNOSES REDACTED]. The most recent vital signs recorded as [DATE] at 9:40 AM- ,[DATE], pulse- 78 beats per minutes, respirations- 20 breaths per minutes, and the most recent temperature recorded as 98.4 degree Fahrenheit orally at 2:28 PM on (MONTH) 17, (YEAR). The most recent oxygen saturation recorded as 98% (percent) on (MONTH) 16, (YEAR) at 11:03 PM. The physical assessment showed Resident #158 had no observed neurological changes but was also unresponsive, and choking. Under section summarize your observations and evaluation: Resident was eating outside food steak and cheese sandwich when he began choking. The interventions documented were 911 was called and CPR continued, resident was transported via 911. During a face-to-face interview on [DATE] with Employee #26 at 4:21 PM regarding the resident change in condition, I completed the Nursing Home to Hospital Transfer Form on [DATE] and I assisted with CPR (cardiopulmonary resuscitation) for Resident# 158. When I came in the dayroom I saw the resident trying to stick his hand down his throat , we (staff) were trying to get him to stand and he could not stand he was conscious and I was telling him to cough and Employee# 25 did the back slaps over his shoulder blades, he had cup of water he was trying to drink it and it was coming out of his mouth, then he could not breathe he was shaking and he became stiff and he was not breathing and we started CPR we called a code and 911, the supervisor (Employee# 27) came to the floor and took over CPR. During a telephone interview on [DATE] at 5:35 PM, Employee# 24, stated I was in the dayroom but I was not assigned to the resident and three residents came in with food from the outside; Resident#158 and two other residents. I was not too far away and he asked for sips of water, thickened water. While they were eating I gave him the thickened water and then I asked him if he was choking. He said yes, he only took a few bites before he started choking. It was not a long time at all, if ten minutes, before he started choking. He had a lot of sandwich left. I saw staff in the hall way and called for help they came in and started working on him. During a face-to-face interview with Employee #27 on [DATE] at 5:00 PM, they called a medical emergency and I came from the first floor and I met the Resident# 158 holding his throat he said that he just choked he stood up and we supported him I did the [MEDICATION NAME] Maneuver and then we placed him on the floor and I took over CPR, oxygen and suction with a Yankeur (oral suction tool), by now 911 had arrived and his SP02 (oxygen level) was 62% they (911) took over chest compressions with an automatic chest compression system they (staff) pulled out a big piece of meat, he was alive when he left the floor he was to go (hospital name) but he went to (hospital name). Review of the facility policy titled Serenity Rapid Response Team dated (MONTH) 27, (YEAR), showed that staff are to respond to all emergencies to include a licensed nurse from each unit and the Director of Nursing/Nursing Supervisor, and Nurse Practitioner , if available. The Director of Nursing/Nursing Supervisor is responsible for bringing the AED (Automated External Defibrillator). Review of the American Heart Association Guidelines (YEAR)/ CPR & ECC for Choking Relief in a Responsive Adult includes positioning self behind the choking victim and wrap arms around the victim's midsection and search for their bellybutton. Make a fist with one hand and grasp it with the other hand and thrust both hands inward and upward, until the blockage comes out. If the patient loses consciousness and the blockage remains, lower the patient to the floor. Open the mouth with the head tilt/ chin lift and look inside for the item and begin chest compressions. Reassess for expelled object and pulse until paramedics arrive. The facility failed to show all interventions implemented to include complete vital signs, administration of oxygen, suctioning, the performance of a comprehensive assessment, cardiovascular assessment, respiratory assessment, and neurological assessment at and during the change of condition. In addition, review of the interventions provided during the choking episode showed the interventions taken were inconsistent with acceptable professional standards for care of choking resident. During a face-to face-interview on (MONTH) 20, (YEAR), Employee #1 and 2 acknowledged the findings.

Based on observations, staff interview and record for Resident #1, it was determined that facility staff failed to maintain the automatic mixing valve in safe operating condition which subsequently led to a resident sustaining second [MEDICAL CONDITION] chest, abdomen and left forearm. The findings include: Resident #1 was born on July 19, 1931 and admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #1 was assessed as having long and short term memory loss with severely impaired cognitive skills for daily decision making in Section C (Cognitive Patterns). Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated May 19, 2013 at 6:38 AM: " 136/70 (B/P), 76 P, 20 R, General Comments: CNA was bathing for the resident and checked the temperature of the water and it was lukewarm. But as CNA was bathing for the resident, resident started screaming. Then CNA checked the temperature of the water and discovered that the water temperature was now hot. At this time CNA called the nurse to come and see what happened to the resident. Upon assessment the resident had [MEDICAL CONDITION] the chest area and left forearm with an open area on her left breast measuring 6 cm x 3.5 cm and an open area in the mediastinal area measuring 4.5 cm x 2 cm. Immediately cold compress was applied to the burn area and she was given pain medication Tylenol 2 tabs. His/her pain level was 6/10 and upon reassessment pain level now 2/10 after 1 hour. Doctor was called. He ordered resident to be on [MEDICATION NAME] twice daily till healed. " Face-to-face interviews were conducted with seven (7) residents on May 20, 2013 between 9:00 PM and 9:30 PM, regarding the water temperature. Residents were asked if they had ever experienced the hot water being too hot. None of the residents complained that the hot water was too hot. Face-to-face interviews were conducted with 13 employees and telephone interviews were conducted with three (3) employees who worked on all shifts and all units on May 18, 2013 from May 20, 2013 through May 29, 2013. There were no complaints from employees or residents that the water was too hot until the above cited incident occurred. According to the following physician ' s progress note, dated May 19, 2013, no time noted: " Resident seen. Actual hot [MEDICAL CONDITION] anterior chest wall and left forearm. Resident was in the shower this AM the water became too hot. Hemodynamically stable. Awake, alert, afebrile. Left breast - superficial burn 2?(unable to read) 6 x 8 cm. Blister to left forearm about 3 cm x 3 cm. (Abdomen) about 0.5 x 1.5 cm each 2? degree (unable to read). Plan: [MEDICATION NAME] Cream. Wound team reevaluation. " A face-to-face interview was conducted with Employee #4 on May 20, 2013 at 5:40 PM in the boiler room. Employee #4 identified the automatic mixing valve as the problem which caused the hot water temperature to spike. Employee #4 stated, " This valve is about seven years old. It has been working just fine. There has never been a spike in our water temps. We have always maintained this valve at 110?. When I came in on Saturday morning, the water was at 123?. I replaced the valve Saturday morning and waited about an hour to make sure the temperature was right. I told the nursing supervisor to call me if there was any further problem. They called again on Sunday morning very early, before five (5:00 AM). When I got here the water temperature was back to 123?. I replaced the valve again with the original valve after I cleaned it. The valves need to be cleaned now and then because of the corrosion on the springs that doesn ' t allow the valve to function properly. The valve will stick if it is not clean. " Employee #4 was asked the last time the valve was cleaned. He/she stated, " I cleaned it last winter sometime. " Employee #4 acknowledged that there was no regularly scheduled maintenance on the valve and that he/she had no log that documented the dates that preventive maintenance was completed on the valve. The valve was identified as a " Lawler Model 805 Thermostatic Water Controller. " According to the manufacturer ' s recommendation, under " Maintenance - The controller should be checked periodically and if needed cleaned as outlined in " Inspecting and Cleaning Valve. " The facility identified that the valve was purchased on September 19, 2005. A telephone interview was conducted on May 29, 2013 at 12:10 PM with the Technical Manager at Lawler Manufacturing. He/she was asked about the above concerns and stated, " The average life of a model 805 is three to five (3-5) years. That means some people get 5-7 years and some people get 1-3 years based on water quality, geographical location, and maintenance performed. " The Lawler Model 805 Thermostatic Water controller valve was observed on May 20, 2013 at 6:00 PM. The valve was being adjusted at the time of the observation. The temperature of the valve at the end of the observation was 110?. The temperature of the water in the boiler room, the first output of the hot water from the system, was 110?. Facility staff failed to maintain the automatic mixing valve in safe operating condition which subsequently led to a resident sustaining second [MEDICAL CONDITION] chest, abdomen and left forearm.

Based on observation, staff interview and record review for Resident #1, it was determined that facility staff failed to accurately assess the resident ' s skin which subsequently resulted in the initial identification of pressure sores with necrotic tissue. This is a repeat deficiency from March 17, 2010. The findings include: Resident #1 was born on July 23, 1939 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment completed February 15, 2011, Resident #1 was assessed with [REDACTED]. He/she was assessed as requiring extensive assistance with bathing and being totally dependent for all other Activities of Living in Section G (Physical Status). Disease [DIAGNOSES REDACTED]. The following nurses ' notes were reviewed: According to a " Report of Consultation, " the podiatrist visited on April 11, 2011 and wrote the following: " Long toenails 2 - 5 both feet; first toenails both feet are not long enough to debride. Dry ulcer plantar right foot; no drainage both feet; dark discolorations plantar and lateral both feet. No signs of infection both feet; tx: debrided toenails 2 - 5 both feet. RX: one pair bunny boots Sig: Apply to both feet daily as needed. RX: get wound doctor to examine and treat dark discolorations both feet and get wound doctor to treat ulcer plantar right foot. " April 9, 2011 at 1:00 PM: " Weekly head to toe skin assessment was done. No open areas noted. Skin intact. " April 11, 2011 at 2:00 PM: Evaluated by (podiatrist). Earlier this shift. Recommended bunny boots to bilateral feet to prevent pressure. Evidence on plantar area L foot. (unable to read)/ulceration. " The next entry was dated May 6, 2011 at 12:00 PM: " ...Resident was observed with open area on left and right foot both black in color, no drainage noted ... " According to the April 2011 Treatment Administration Record, under the order, " Weekly head to toe skin assessment every Saturday " April 16, 23 and 30, 2011 were initialed by the nurse that a skin assessment was completed. Employee #3, Licensed Practical Nurse (LPN) completed the skin assessment on April 16 and 23, 2011. A telephone interview was conducted with Employee #3 on May 18, 2011 at 8:25 AM. Employee #3 was asked to recall the two (2) times he/she inspected Resident #1 ' s feet. Employee #3 stated, " I looked from head to toe. I didn ' t see anything. I usually do it with the CNA but I don ' t remember who that was for either day. (Resident #1) doesn ' t wear socks to bed, he/she has bunny boots. I did his/her feet easily. I don ' t remember seeing anything. " Employee #4, LPN, completed the skin assessment on April 30, 2011. A telephone interview was conducted with Employee #4, on May 18, 2011 at 8:35 AM. Employee #4 was asked to recall when he/she inspected Resident #1 ' s feet. Employee #4 stated, " I didn ' t go into the room with anyone else. I went by myself. There was nothing there on his/her feet. I took off the bunny boots and checked his/her feet and heels. I didn ' t see anything. I remember picking up his/her feet to look at the bottoms, because Resident #1 told me I lifted them too high. There was nothing on his/her feet, the bunion area, heels, nowhere. " According to the Nurse Practitioner ' s Note, dated May 6, 2011 at 11:30 AM: " Asked to eval(uate) resident ' s foot ulcers. #1. R lateral distal foot unstageable ulcer 3 cm x 3.5 cm x 0.0 cm no exudates 95% Avascular tissue + 5% [MEDICATION NAME]. #2. L lateral distal foot unstageable ulcer 3 cm x 2.5 cm x 0.0 cm no exudates 100% Avascular. #3. L heel. DTI (Deep Tissue Injury) 2 cm x 4 cm x 0.0 cm. 100% collapsed hemorrhagic blister. No exudates A. (Assessment) Multiple foot ulcers P. (Plan) Santyl ointment with dsg for bilateral foot ulcers. Off load heels. Check arterial Doppler BLE (bilateral extremities) for R/O PAD (rule out Peripheral Artery Disease). Wound specialist f/u. " There was no identification of the bilateral foot ulcers before or after the podiatrist ' s note dated April 11, 2011 until May 6, 2011.

Based on observation, record review and physician interview for Resident #1, it was determined that the physician failed to review the total plan of care for a resident with foot wounds. The findings include: According to a " Report of Consultation, " the podiatrist visited on April 4, 2011 and wrote the following: " Long toenails 2 - 5 both feet; first toenails both feet are not long enough to debride. Dry ulcer plantar right foot; no drainage both feet; dark discolorations plantar and lateral both feet. No signs of infection both feet; tx: debrided toenails 2 - 5 both feet. RX: one pair bunny boots Sig: Apply to both feet daily as needed. RX: get wound doctor to examine and treat dark discolorations both feet and get wound doctor to treat ulcer plantar right foot. " Through a face-to-face interview conducted on May 11, 2011 at 3:30 PM with Employee #1, it was determined that this " Report of Consultation " was filed in the " Consult " section of the resident ' s record. In the physician progress notes [REDACTED]. April 11, 2011, no time indicated: " Podiatry: Findings, [DIAGNOSES REDACTED]. " April 23, 2011, no time indicated by the resident ' s attending physician: " Attending Note - Resident seen. Monthly follow-up. Nurses notes/labs/meds reviewed. Currently came; no interval changes. Weight 190 lb; stable. Chest: clear auscultation CVS: S1S2 heard; S3 no, S4 no ABD: Flat, soft, Bowel Sounds - 4 (present in all 4 quads) Extremities: no [MEDICAL CONDITION] Plan: " Continue treatment. " A telephone interview was conducted with the attending physician on May 25, 2011 at 9:20 AM. He/she was asked about the above cited incident. The physician stated, " When I check for lower extremity [MEDICAL CONDITION] I look at the ankles and legs not the feet. Most of my patients wear stockings and I don ' t take them off. The podiatrist checks feet. No one called me about the consult because I would have agreed to the recommendations. The podiatrist checks on the feet and when I come I concentrate on the other parts of the body. That is what the podiatrist is for. When I come I look at the labs, consults and read over the nursing notes from my last visit. I didn ' t see the consult and no one told me about the consult or the wounds. " The record was reviewed May 1, 2011.

Based on observation, staff interview and record review for Resident #1, it was determined that facility staff failed to notify the physician ' s of a podiatrist ' s consultation report that documented a change in condition. The findings include: According to a " Report of Consultation, " the podiatrist visited on April 4, 2011 and wrote the following: " Long toenails 2 - 5 both feet; first toenails both feet are not long enough to debride. Dry ulcer plantar right foot; no drainage both feet; dark discolorations plantar and lateral both feet. No signs of infection both feet; tx: debrided toenails 2 - 5 both feet. RX: one pair bunny boots Sig: Apply to both feet daily as needed. RX: get wound doctor to examine and treat dark discolorations both feet and get wound doctor to treat ulcer plantar right foot. " A review of the physician's order [REDACTED]. A telephone order was written by Employee #2, dated April 11, 2011 at 2:00 PM: " Bunny boots to both feet @ all times. " There was no evidence that an order was written for the wound doctor to examine and treat the resident ' s foot wounds. A telephone interview was conducted with Employee #2 on May 17, 2011 at 1:45 PM. He/she was asked about the above cited incomplete order. Employee #2 stated, " I can ' t remember what happened that day. I must have gotten distracted while I was taking off the orders. I have been a nurse for [AGE] years and I know how to take off orders. Something must have happened that I didn ' t do all the orders but I don ' t remember. I know that consults are not filed in the chart but in the doctor ' s book. When I came back after attending to a resident, the chart was put away and I didn ' t even think about it anymore. I never called the physician. I got distracted. " A review of the resident ' s record revealed the following order initiated August 30, 2010, renewed on the preprinted 30 day and 60 day physician's order [REDACTED]. " Facility staff failed to inform the physician of the podiatrist ' s recommendations and of +the resident ' s foot wounds. The record was reviewed May 11, 2011.

Based on record review and staff interview for Resident #1, facility staff failed to adequately supervise Resident #1 who had multiple falls and subsequently sustained a fractured left hip. The findings include: A review of Resident #1' s record revealed that the resident was born on November 11, 1921 and admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment completed February 21, 2011, the resident was assessed with [REDACTED]. He/she was assessed as requiring no assistance with transfers, walking in the room and corridor, toilet use. Resident #1 was assessed as requiring supervision for bed mobility and eating. Resident #1 was assessed as requiring limited assistance with bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to the nurses' notes: July 14, 2010 at 3:30 PM: " Resident was observed on blue mat to right of bed in a sitting position. Resident has a bed alarm in place for falls management ..." August 30, 2010 at 12:30 PM: " Resident alert and verbally responsive was observed on the floor sitting upright position in her room. No bruises or injury noted. Denies any pain at this time ..." December 29, 2010 at 5:20 AM: " Resident alert and verbally responsive. No respiratory distress noted. Resident observed on the floor in a sitting position at 4:30 AM by the CNA. Resident was helped to the bed. When asked what happened she stated " I don' t know" " I' m alright" ROM (Range of Motion) to upper and lower extremities. Stated 0/10 pain level at this time. No injury, bruises or open area observed. .." January 31, 2011 at 7:05 PM: " ...Resident noted sitting on the floor trying to stand up and use the bathroom. Denied hitting head and pain. ROM WNL (within normal limits). Able to ambulate self and verbalize no discomfort. Neuro checks initiated ..." February 20, 2011 at 1:50 PM: " Resident found on floor in room' s bathroom in sitting position close to commode. She said that she was trying to use the commode and slipped. Floor noted to be dry during assessment. Skin warm and dry. No laceration, abrasion or discoloration noted during assessment. Respirations even and unlabored. No change in mentation. No complaint of pain or discomfort during active ROM ..." March 16, 2011 at 1:20 PM: " Resident is alert and responsive with intermittent confusion. Resident was observed in a sitting position in her room, room 321B, between bed A and B by a CNA. On assessment, the 2 nurses on the floor assisted resident off the floor ...no open injury observed but resident stated that the left hip and leg hurts ...Neuro check in progress. Neuro check within normal limits." The resident was sent to the hospital on March 16, 2011 and subsequently was found to have a fractured left hip. A face-to-face interview was conducted with Employee #1 on March 24, 2011 at 1:20 PM. Employee #1 was asked what interventions were initiated after Resident #1' s multiple falls. Employee #1 stated, " (Resident #1) has a low bed and floor mats and a bed alarm (initiated June 23, 2010). He/she sits in a big overstuffed chair so a chair alarm doesn' t work. It can't be attached. He/she is schizophrenic and can' t tell you why he/she is on the floor. He/she doesn' t really fall from the bed; he/she falls from the chair usually when he/she tries to get up to go to the bathroom. The staff doesn' t have to ask him/her to go to the bathroom, he/she is continent. You really can' t anticipate his/her needs, he/she is unpredictable. There is no pattern to his/her falling. I don' t know what else we could have done. I guess we could have the pharmacist look at her medications." Employee #1was asked if a toileting program was initiated. Employee #1 stated, " He/she is not incontinent. He/she goes to the bathroom by him/herself. He/she doesn' t remember to call for help. I guess we could try asking him/her if he/she needs to go to the bathroom more often." According to the resident' s care plan dated January 26, 2011: " Problem: Potential for Trauma - Falls injury related to: Decline in cognitive status, unsteady gait." The documented goal was, " No injury, Expresses understanding of need for safety, Gets assist when up." Documented approaches included: " Nurses - observe, record and report all unsafe conditions and situations. Anticipate fall times. Instruct on safety." " Nurse Aide - Encouraged to ask for assistance, Call light in reach, Anticipate needs, Vital signs and report to nurses." There was no evidence that interventions were initiated after the above cited falls that increased facility staff' s supervision of Resident #1 who had multiple falls with a subsequent left hip fracture. The record was reviewed March 24, 2011.

Based on observation, staff interview and record review for one (1) resident, it was determined that facility staff failed to assess the condition of the left gluteal area prior to the development of a Stage III ulcer for Resident #1. The findings include: The resident was observed on December 13, 2010 at 8:45 AM in the presence of Employee #2. Resident #1was in bed turned to his/her right side. There was an air mattress on the bed. His/her buttock was observed with five (5) areas of pink, granulated tissue from healed pressure sores. The pressure sore appeared on the left buttock near the gluteal cleft and appeared to be quarter size, with depth of approximately one inch (1 " ). The depth was cone shaped and the center of the cone at the greatest depth appeared black and was small in size. The surrounding walls of the cone shape were yellow slough. According to the " Nursing Admission Assessment Form " completed on October 26, 2010, under " Skin Assessment, " was written " No pressure ulcer noted. " Additionally, the " Braden Pressure Ulcer Risk Assessment " totaled 11. According to the directions on the form, a " Total of 12 or less represents HIGH RISK " for developing a pressure sore. Under " Problems Identified: Left side weakness. Resident states he/she is unable to move. Needs assistance with moving. " There was no evidence that the admission assessment accurately documented the five (5) areas of previously healed pressure sores on Resident #1 ' s gluteal area. A care plan problem, " Potential for Skin breakdown related to immobility and incontinence " was initiated October 26, 2010. Approaches included: " Nurses ---Assess skin condition daily and note any changes. Keep clean and dry. Nurse Aide --- Reposition every two hours. Minimize pressure on bony prominences. Use lift sheet when moving resident in bed. Barrier cream to peri-area as needed. " There was no evidence that specific interventions were initiated after the resident was assessed as being at high risk for pressure sore development upon admission. There was no documentation in the record from the date of admission until December 8, 2010 that described an assessment of the resident ' s buttocks/skin prior to the development of the Stage III pressure sore. According to a nurse ' s note dated December 8, 2010 at 4:30 PM, " Resident noted with wound to sacrum area. 2.5 x 3 cm. Yellow slough in middle. Surrounding skin intact. New order for Santyl ointment q day. Also for consult with wound doctor. RP notified. 97.8 (temperature orally in degrees Fahrenheit), 101 (pulse), 20 (respirations) 102/77 (blood pressure). " A face-to-face interview with Employee #2 on was conducted on December 13, 2010 at 12:00 PM. He/she acknowledged that there was no assessment of the resident ' s skin prior to the development of the Stage III sacral pressure sore. The record was reviewed December 13, 2010.