Every finding on record at Sibley Mem Hosp Renaissance

Resident #172 Neglect 08/14/24 12:20 PM 609/610 Facility staff failed to report the results of its final investigation to the State Agency Record Review AM Resident # 172 was admitted to the SNF on 02/17/23 with admitting diagnoses that included: Acute cystitis without hematuria, Cancer related pain, Urinary tract infection without hematuria, and Pain. Resident was discharged to her home on [DATE] MDS admission [DATE] Resident # 172 required Extensive assistance for bed mobility, transfer,dressing, toilet use , bathing (total dependence) Progress Note Noted in a progress note dated 3/3/23 at 10:22 PM. Nurse was transporting Res to Cancer Center . Nurse [NAME] Penninah encouraged res to discontinue video chat or recordings because staff cannot be involved in Resident # 172's personal video chat. There would have been no reason for staff to ask her to get off the phone. She was not happy . I would ask do you want me to step out. Facility's Investigation to incident: Included Memo from [NAME] documented as initial incident reported to DOH. A statement dated 2/28/23 at 7:25 PM from [NAME] H. Jeanphillippe, LPN who cared for resident that stated. Pt called to be cleaned. Tech went to clean patient. She refused stated (ing) that the nurse has to come clean her. Nurse went to assist with patient care, Patient then said, I reported you to my family and they are upset at you. I tried my best to attend to my patient's needs. I feel threatened being reported to family. hereafter, patient refused her evening meds and stated she will wait for the next shift to assist her with care. As much as I tried to carry out my duties to the best of my ability, in this situation I feel scared for I do not (know) how her family will react if I continue caring for her in the future. Employee acknowledged that there were no final results reported to the State Agency and Nurse who provded care for Resident was kept on the schedule and reassigned to other residents. Interviews 08/12/24 12;50 PM - Inolene Cozean, CNA She was demanding. I can't recall if she was 1or 2 staff assist. I used to see the son there overnight . She was always talking on the phone. We would ask her if she wanted me to step out of the room and come back if she was on the phone. When the resident wants to go back to bed we (CNA/nursing staff) put them back to bed. We encourage them to call us when they want to get back in bed. 08/12/24 1:02 PM [NAME] Nnnaka,,RN She re max assistance she was a lift tx , she could use upper body. She loved food. Her ADL ability was about the same. She was very particular. She refused care at times, She spent a08/13/24 07:12 PM lot of time on the phone, She did not share with me that she had concerns She wanted her pain medication before going to bed. She was familiar with meds. She was getting pain meds ATC because once you moved her she c/pain. even though she knows I would go through he medication. She was i came on She was in the room most of the time. She did not like to sit the w/c for a long-time . She was a former CNA at WHC. OT would do initial shower. 08/13/24 02:58 PM [NAME] Jeanphillip, RN She passed. She was dependent on care. She had issue with other nurses. She was having phone on the line with her family with the incident. I was one of the nurses that could take care of her. I remember going to her because . It was said I removed . She had an issue with [NAME]. I was assigned regularly to the patient. I was one of her favorites She and her family wanted me to take care of the resident. She was upset That wasn't what it was They said she was filming nurses during care. It wasn't a thing of a big deal. I turned the statement to the /Unit Manager/DON. I continued to work with the Resident # 172 . I never recalled them saying that there was an incident that needed to be investigated. When I found out the resident had complained about me to the family The incident occurred and I was told to put it in writing. Resident #123 Abuse 08/13/24 09:20 AM #123 [NAME] DOB [DATE] DOA 04/15/24 Discharge 06/24/24 DX: - Rupture of Quadriplegic tendon - Lumbar Dengerative Disc Disease - Status Fall F610 The facility failed to ensure an alleged perpetrator did not have access to a resident who made an allegation of rough handling. Additionally, the facility failed to conduct a through investigation. As evidence by not having documented evidence of interview with the companion who was in the room on the night if the alleged incident of rough handling. OBSERVATION Unable to conduct observations, resident was discharged on 06/24/24 RECORD REVIEW MDS ADD Info see hard copy Care Plan- see hard copy 04/27/24 and 04/28/24 flow sheeted did not document any concerns or complaints from the resident. 04/28/24 at 8:37 AM [[NAME] Young's (alleged perpetrator) Nursing Note] Pt. slept well .companion with patient from mid-night resident remains stable with no new complaints/concerns. 05/08/24 Facility Investigation- included statements from all staff who worked that shift. However, there was no statement from the companion who was in the room during the time of the allegation. See note above. INTERVIEWS During a face-to-face interview on 08/12/24 at 2:44 PM, [NAME] (MDS/admission Coordinator) stated that the resident's sister called and mentioned that a female staff member made rough hand poking gestures toward the resident. He text the sister that it was [NAME] and [NAME]. I told her that I would tell the DON and she said don't mke a big deal owut of it. I said we had to report it then I told the DON [NAME]. I gave my statement. He had never had the compliant before. He was admitted in April -June 2024. I did not speak with him about the concern. I did not document the conversation in his record . I just wrote a statement. She said it happened on 04/28/24. I did speak with the sister after the concern but we never discussed the concern again. During a face-to-face interview on 08/12/24 at 2:55 Pm, [NAME] DON stated that she received a phone call from Ms. [NAME] sister and she said the mentioned that the brother text her doing thr night on 04/28/24 had rough hand with him. She told her lets report it. I called the sister and she said it 's really nothing he had been receiving great care. She said she didn 't want to talk about. It she looked through her phone 04/28 or 04/27 and he text a name [NAME]. He said he was sleeping he has confusion. He could not described the nurse. He said she had rough hands. I told I would speak with the brother. After the incident she started providing him with sitter at night but she never told us about her concerns for his safety. I spoke with the resident he said she had rough callous hands. she was not trying to physical because. HHe said he thin it was someone name [NAME] but he could be mistaken about the name. ER hands were just rough and callous. She would tell him she didn't tell have time to wait. I then had staff to go in his room with me to see if he could physically identify. And he could not. I would not ask him in front of staff. I would ask them to help with him. And when they leave to see if I would identify them. Staff was not informed about the resident's complaint of abuse. I didn't want him to feel like he had any repercussion. We do have a [NAME]-Young, RN that worked with him on that night. I did bring her in the room couple of times. When I told him that was [NAME], she said she was just to gentle. Since he could not identify , we provided the sitters until he was discharged . The sister brought in her phone and we found that it occurred on 04/27/24. I'll look for the date she bright her phone in. Everybody was retrained on abuse. [NAME] was not pull off the schedule. It depends on what the allegation is. During a telephone interview on 08/12/24 at 4:10 Pm, Sharmane [NAME]-[NAME], RN I work night shift. I worked with him a few times. I remember that he calls a lot. He likes a lot of attention. He could feed himself, he could turn with minimal assistance in bed. He could make you aware that he needed needed to use the bathroom. He requires assistance with transferring from the bed to chair. He was admitted with sacral wound. He accuses the staff that someone abuse him. He would say things that were not true. During a face-to-face interview on 08/12/24 at 4:17 PM, [NAME] White, Director of HR stated that the employee was hired on 06/05/17. She had no disciplinary actions. Her most recent performance evaluation was conducted on 09/22/23 and she received a score of 4.18/5.0 which means she exceeded expectations. HR is not involved with abuse allegation. Once the allegation is sustained by the investigative teams is when HR gets involve. HR provides recommendation, guidance, and support to management on employment status once the investigation had been sustained. HR is not involved in the investigation with employee to resident abuse. According to her punch sheet, she worked 14.25 hours (punched in 04/27/24 at 6:57 PM and punched out on 04/28/24 at 9:50 AM). 5/3/24, 5/4/24, and 5/5/24 she didn't work 5/6/24 punched in 6:59 Pm pinched out 5/7/24 at 9:02 Am (13.50 hours) 5/7/8/24 punched in 7:01 PM punched out 8:10 AM on 05/08/24 (12.75 minutes). During a face-to-face interview on 08/13/24 at 11:01 AM, the DON stated that she did not interview of the companion and the employee was not removed from the schedule. During a telephone interview on 08/13/24 at 10:30 AM, [NAME] stated that the DON informed her that the resident made an allegation against her about rough handling but he could not physically identify her. The employee stated that she was not removed from the schedule but she was not assigned to him again. She also was asked to write a stament.

2. Facility staff failed to ensure that their infection control policies were reviewed annually. During a review of the facility's infection control policies on 08/09/24 revealed a policy titled Mandatory COVID-19 Vaccination Policy - Policy Number ADMIN033 that documented Effective Date 11/10/2022 and Supersedes Date 09/23/2022. A face-to-face interview conducted on 08/09/24 at 12:50 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated, We adopt our policies from the hospital. We need to show that the policies are being reviewed annually and the review date should be reflected on the policy. Cross Reference: 22B DCMR Sec. 3206.3 FACILITY Infection Control 08/14/24 02:16 PM UIC [NAME] Berrry ICIP [NAME] Pallmer, RN Rahael Abate, Nurse is assigned on a weekly basis to screen all residents and to offer vaccinations. If a resident refuses she documents in the [NAME] reord in progress notes. She uses the VIS to educate residents on vaccinations Clinic upon admission and weekly Staff no regular screeniing for staff Typically staff that aree exposed in an outbreak situation are screened every other day after conf Postive test Day 1,3,5 NHSN Central line, CAUTI, C. diff, MRO, PPE Compliance , MaskReportableC diff Policies - F880 - The facility failed to conduct an annual review of its IPCP (COVID-19) and update their program, as necessary. monthly PPE hand hygiene audits. Staff is educated almost weekly on EBP, when residents are admitted , and we follow an algorithym Influenza and Pneumoccal Policies were last reviewed November 2023 COVID -19 policy was last reviewed November 2022 A etter id distributed to staff and residents. We post a notice . We restrict communal activities. Each staff and residents are notfied . The signage is a copy of the letter. Staff not required to provide neg test upon proff of return. Letters given to resident and or care partner directly [NAME], [NAME] - Covid -19 10/25/21, 3/18/21, 2/18/21 - Moderna 3/14/24 - Pfizer, 10/24/22, 3/31/22 Influenza 11/2/23 [NAME] Juckovsky -Covid-19 - 7/18/24 Anisman, [NAME] Covid-19 10/22/21, 2/13/21, 1/23/21 Covid-19 4/7/24 Covid-19 9/26/22, Covid -19 4/15/22 [NAME], [NAME] Covid-19 3/20/21, 02/20/21 Green, [NAME] Moderna 2/8/21, 1/8/21 Covid-19 7/26/24 Based on observation, record review and staff interview, for one (1) of 18 sampled residents, facility staff failed to follow the facility's policy of acceptable Infection Control Standards and Practices while changing a Peripherally Inserted Central Catheter (PICC) line dressing; and failed to ensure that their infection control policies were reviewed annually. Resident #18. The findings included: 1. Facility staff failed to follow the facility's policy of acceptable Infection Control Standards and Practices while changing a Peripherally Inserted Central Catheter (PICC) line dressing for Resident #18. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including Septicemia, Perforated Appendicitis, Gangrene due to Parastomal Hernia, and Small Bowel Obstruction. A Vascular Access Device policy with an approval date of 01/03/23 instructed staff in part to, .put on sterile gloves to remove and discard the old statlock (device used to secure the central line), remove gloves, clean hands with hospital approve alcohol bases sanitizer, apply second set of sterile gloves .scrub skin with chlorhexidine gluconate 2% with isopropyl alcohol 70% swab .begin directly at the insertion site and scrub in a circular fashion .secure catheter . until new stat lock is in place .apply transparent dressing .being sure statlock and insertion site are completed located under the dressing, remove and discard gloves . An Enhanced Barrier Precautions policy with an approval date of 04/22/24 documented in part, Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves [personal protective equipment] during high-contact resident care activities .High contact resident care activities refers to . device care or use [of] central lines .education is provided to residents and visitors via signage on the door. It should be noted that Enhanced Barrier Precautions is a strategy that uses personal protective equipment to reduce the spread of Multidrug-Resistant Organisms between residents in skilled nursing facilities. A physician's order dated 07/18/24 instructed, PICC (Peripheral Inserted Central Cather) Line dressing change per protocol. Please note: PICC line [central line] used for long term use of intravenous antibiotics, nutrition, medications and for blood draws. A review of two (2) care plans dated 07/18/24 documented in part Problem - Enhanced Isolation Precautions . Interventions- use proper personal protective equipment .Problem- PICC line .Interventions- routine (weekly) dressing changes as ordered using sterile technique . The admission Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 13, indicating an intact cognitive status. Also, the patient was coded as having septicemia and receiving antibiotics via intravenous access. On 08/08/24 at approximately 1:00 PM, an observation showed an Enhanced Barrier Precautions sign posted on the front of Resident #18's door. The sign instructed staff to wear gloves and a gown for high contact resident care activities [such as] device care or use [of a] central line . Also, during the observation Employee #7 (RN) changing the resident's PICC Line dressing revealed the following concerns: 1. Employee #7 (RN) fanned a clean, disposable absorbent pad towards Resident #18's face who was sitting in a chair in front of the employee. After placing the pad on the table, the employee apologized to the resident for fanning the pad toward her face. 2. After the employee put clean gloves on, she started removing the transparent dressing covering the resident's PICC line. The resident then asked the employee why she wasn't wearing a yellow gown like the other nurses. The employee responded, You're right. The employee then removed her gloves, performed hand hygiene, put on a yellow disposable gown and new pair of gloves, and removed the transparent dressing covering the PICC line. Additionally, the employee explained that the resident was on Enhanced Barrier Precautions, thus wearing a gown when changing the PICC line dressing was required. 3. After removing the transparent dressing, the employee failed to remove the stat-lock that was in place to secure the PICC Line. Instead, she attempted to clean the insertion area, but she failed to use aseptic technique. As evidenced by her not cleaning the site in a circular motion, but rather going from clean to dirty, then back to clean. 4. Following the cleaning of the area, the employee applied a new transparent dressing over the PICC line and the old stat-lock. In an attempt to remove part of the dressing covering the stat-lock, the employee's gloves became stuck. Upon being asked why the dressing was being removed, the employee said that she needed to remove the stat-lock and replace it with a new one, which she had to get from the supply room. As the nurse was attempting to get her unstuck from the dressing, the resident face was grimacing. However, the employee never asked the resident how she was feeling doing the dressing change. The surveyor then asked the employee to stop the dressing change and get help once her gloves became unstuck from the dressing. During a face-to-face interview 08/08/24 at 1:30 PM, Employee #7 (RN) stated that she should've don a disposable gown before providing care for the PICC line because the resident was on Enhanced Barrier precautions. Additionally, the employee said she should've removed the old statlock before cleaning the area and applying the new transparent dressing. During a face-to-face interview on 08/08/24 at 1:45 PM, Employee #2 (DON) stated that Employee #7 should have followed the policy, and she would have the unit manager assist the nurse. Resident #18 FTag Initiation 08/09/24 08:57 AM #18 [NAME] DOB - 01/29/37 DOA - 07/18/24 DX - Small Bowel Obstruction - Gangrene due to Parastomal Hernia - Entrapment of Intestine in Abdomen Adhesions admission MDS 07/24/24 C-13 H - Septicemia N - 7 injection, antibiotics O - IV medication, IV Access 483.80 Infection Control [F880] - The facility staff failed to follow Infection Control Standards of Practice while changing a PICC line dressing. OBSERVATIONS During an observation on 08/08/24 starting at 1:00 PM, Nurse- Grace [NAME], RN attempted to change the resident's PICC Line dressing the following was observed: - She failed to remove items from the table to ensure a sterile area for dressing supplies. - Before putting the chux on the table for a clean field, she fanned the chux padding towards the resident's face. She apologize to the resident for shaking the chux toward her face. - She failed to wear a gown to cover her clothes after removing the PICC Line dsg. The resident was on Enhanced Barrier Precautions - She failed to remove the previous stat-lock before cleaning the area. - After cleaning the area she place a new dressing over the old stat-lock. - While trying to lift part of the PICC line dressing to remove and replace the stat-lock , the nurses gloves got stuck to the dressing. - After getting her gloves unstick from the dressing, the surveyor asked the nurse to stop and get help. RECORD REVIEWS DX - Small Bowel Obstruction - Gangrene due to Parastomal Hernia - Entrapment of Intestine in Abdomen Adhesions 07/17/24 MD Order - PICC Line dressing protocol 07/18/24- Care Plan (PICC Line) Interventions: - routine weelky dressing changes as ordered using streil technique -Assessment of insertion site by nursing staff. 07/24/24 -admission MDS C-13 H - Septicemia N - 7 injection, antibiotics O - IV medication, IV Access 07/27/24 MD Order - Rocephin 2gm IV QD. INTERVIEWS During a face to face interview 08/08/24 at 1:30 PM, the nurse stated that she should have put in the gown before providing care because the resident was on Enhanced Barrier precautions. And she should've removed the old stat-lock after cleaning the area and applied the new protective dressing. During a face-to-face interview on 08/08/24 at 1:45 PM, the DON stated that the nurse should have followed the policy and she would have the unit manager assist the nurse.

Based on record review and staff interviews for (one) 1 of 24 sampled residents the facility staff failed to provide documented evidence in the resident's medical record that the medication irregularities identified by the pharmacist were reviewed and failed to provide the rationale for not changing a resident 's medication. Resident #175. The findings included: Resident #175 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Attention Deficit Hyperactivity Disorder (ADHD), Gastroesophageal Reflux Disease (GERD), Anxiety, History of Total Knee Arthroplasty (knee replacement), Type 2 Diabetes, and Coronary Artery Disease (CAD). A review of Resident #175's medical record revealed the following: An admission Minimum Data Set (MDS) assessment on 08/02/24 that documented the Resident as having a Brief Interview for Mental Status BIMS summary score of 15, indicating that the resident was cognitively intact and had received the following medications: Antianxiety, Antidepressant, Diuretic (for fluid overload), Opioid (for pain) and an Antiplatelet (prevent blood clots). A physician's order dated 07/26/24 that directed, Donepezil (Aricept) tablet 15 mg (milligram) nightly for Dementia. The following physician ' s orders dated 07/27/24 that directed: Alprazolam (Xanax) tablet 0.25 mg nightly for anxiety; Dextroamphetamine-amphetamine (Adderall) 24hr capsule 10 mg for ADHD; Bupropion (Wellbutrin XL) (extended-release) 24hr tablet 150 mg 1 tablet for depression; Dextroamphetamine-amphetamine (Adderall XR) (extended-release) 24 hr (hour) capsule 10 mg for ADHD; Furosemide (Lasix) 40 mg tablet for fluid; and Trazodone (Desyrel) tablet 100 mg nightly for Insomnia. The following physician's orders dated 07/29/24 that directed: Hydromorphone (Dilaudid) tablet 4 mg every 3-hour prn for moderate pain (rating) (4-6); and Hydromorphone (Dilaudid) tablet 6 mg every 3-hour prn for severe pain (rating) (7-10). A physician's order dated 08/11/24 that directed, Bupropion (Wellbutrin XL) 24hr tablet 450 mg 3 tablet (3 x 150 mg) for Depression every morning. A monthly medication review (MMR) completed by the pharmacist on 07/31/24 documented the following recommendations: Please consider reassessing patient needs to pharmacologic anticoagulants. (The) Patient is at a high risk for DVT/PE (deep vein thrombosis/pulmonary embolism due to his medical condition, surgery, history of Afib (atrial fibrillation), and use of testosterone. Currently, (the patient) is taking aspirin 81 mg once a day. Also, (the) patient is at increased risk of fall, slowed or difficult breathing and or sedation secondary to use of multiple psychoactive medications. Of note, there was no documented evidence that the physician responded to the pharmacist's recommendations on the MMR or in the resident's medical record. During a face-to-face interview on 08/12/24 at 1:38 PM Employee #6 (Registered Pharmacist) stated that the pharmacist makes recommendations, and the physician will respond either through an email chat or under the Physician Assessment and Review Recommendations section of the MMR in the resident's medical record. The Employee then acknowledged the finding. Resident #175 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 08/12/24 04:02 PM F756 The attending physician (Facility staff) failed to provide documented evidence in the resident's medical record that the medication irregularities identified by the pharmacist were reviewed and failed to provide his/her rationale for not changing a medication. 08/09/24 04:08 PM According to RR the resident has Alzheimers or Dementia. According to RR the resident takes an Antianxiety. According to RR the resident takes an Opioid. According to RR the resident takes an Antidepressant. According to RR the resident takes a Diuretic. Resident # 175 was admitted to the facility on [DATE] with dx that included: Dementia, ADHD, GERD, Anxiety, Hx total knee arthroplasty, Type2 Diabetes, CAD coronary artery disease admission MDS assessment 08/02/24 - BIMS = 15 Resident received the following meds with 7 days of assessment: Antiaxiety Antidepressant Diuretic Opioid Antiplatelet and had not received the following: Antipsychotic Hypnotic Anticoagulant Antibiotic Hypoglycemic Physician orders : 07/27/24 Alprazolam (Xanax) tablet 0.25 mg nightly for anxiety changed from daily to nightly by pharmacist on 7/27/24 7/27/24 Dextroamphetamine -amphetamine (Adderall) 24hr capsule 10 mg for ADHD 7/27/24 Buproprion (Wellbutrin XL) 24hr tablet 150 mg 1 tablet for depression 8/11/24 Buproprion (Wellbutrin XL) 24hr tablet 450 mg 3 tablet (3 x 150 mg) for Depression every morning 07/26/24 Donezepezil (Aricept) tablet 15 mg nightly for Dementia 07/27/24 Dextroamphetamine-amphetamine (Adderall XR) 24 hr capsule 10 mg for ADHD 07/27/24 Furosemide (Lasix) 40 mg tablet for diuresis 07/29/24 Hydromorphone (Dilaudid) tablet 4 mg every 3 hour prn for moderate pain (4-6) 07/29/24 Hydromorphone (Dilaudid) tablet 6 mg every 3 hour prn for severe pain (7-10) 07/27/24 Trazodone (desyrel) tablet 100 mg nightly for insomnia MMR completed by the pharmacist Shahnaz [NAME] on 07/31/24. T Under RPH Medication Recommendations the pharmacist documented: Please consider reassessing patient needs to pharmacologci anticoagulants. Patient is at ahigh risk for DVT/PE due to his medical condition, surgery, history of Afib and use of testosterone. Currently he is taking aspirin 81 mg once a day. Also patient is at increased risk of fall, slowed or difficilt breathing and or sedation secondary to use of multiple psychoactive medication. Interview: The pharmacist will do another MMR sooner than one month if they find an irregularity . The pharnacist makes recommendations and the physician will respond either through an email chat or in the MMR (in the ehr) under Physician Assessmentand Review Reccomendations Resident #17 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 08/12/24 09:58 AM #17 [NAME] Juckovsky DOB - 06/22/49 DOA - 07/11/24 DX: - Gram positive Bacteria -Anemia -Endocarditis -DVT -Thrombophilia -Insomnia 07/18/24 admission MDS C-11 I - Insomnia 483.45 Pharmacy (F756) - The physician failed to documented response to pharmacist recommendations. 08/12/24 10:01 AM OBSERVATION During an observation on 08/08/24 at 11:00 AM, the resident was observed lying in bed. A, OX 3, no bruising noted. RECORD REVIEW 07/16/23 - MMR Please monitor patient for additive CNS depressant effect and QTC prolongation due to DDI between Quetiapane and Mirtazine. The physcian failed to documented hi response. 07/18/24- admission MDS C-11 I - Insomnia N- antipsychotics, anticoags. o 07/29/24 - Eliquis (anticoagulant) 5mg po BID for VTE Tx. no monthly labs need for this mediation o 07/29/24 -Trazadone (psychotropic) 25mg (1/2 tab) prn nightly X1 for sleep. It should be noted the resident has not received this medication since start date. During an interview with the pharmacist she stated that the need to add special instruction to adminster Tradone if melatnin is not effective. o Diuretics, Opioids, Insulin, and Antibiotics - resident is not currently getting these medication types of medications. Care Plans 07/11/24 -Problem- Psychotropic Drug use Interventions-Assess efficacy of drug therapy, assess and reassess resident's level of orientation daily, and administer psy. meds as ordered. 08/06/24 - Problem -Insomnia Interventions- observe for any episodes of insomnia, keep are quiet and calm, administer meds as ordered. INTERVIEW During a face-to-face interview on 08/08/24 at 11:15 AM, the resident and her daughter stated that the staff was wonderful . They had no concerns with medication administration. The resident and daughter stated that staff gives meds as prescribed, as as requested. During a face to face interview on 08/12/24 at 12:30 PM, Nurse TiTi, RN stated the resident was on Melatonin for sleep and she does not recall the resident requesting Trazadone. During a face-to-face interview on 08/12/24 at 12:45 PM, the resident stated that she doesn't request medications for sleep. During a telephone interview on 08/12/24 at 1:49 Pm, Shanaz [NAME] (Pharmacist) stated that the physician should document their response. I do chat with them through electronic health record and they sometime respond back. The pheamicaist she does mointor prn meds to see the effectiveness and how often the medication has been administered. And she finds any concerns she will reach out to the physcian.

Based on record review and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to provide the necessary social and health care services to attain, maintain, or support the behavioral health (emotional and mental well-being) needs of Resident #1. Due to these failures, an Immediate Jeopardy (IJ-J) was identified on February 5, 2024 at 12:07 PM. During this survey, Immediate Jeopardy was identified at 42 CFR S483.40, Behavioral Health (F740), on February 5, 2024 at 12:07 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on February 5, 2024 at 7:52 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on February 6, 2024 at 2:15 PM. After removal of the immediacy, the deficient practice remained at a potential for harm at the scope and severity level of G. The findings included: Resident #1 was admitted to the facility on [DATE] to room [ROOM NUMBER] with multiple diagnoses that included: Orthostatic Hypotension, Rapid Eye Movement (REM) Sleep Disorder, Diabetes Mellitus, Parkinson's Disease, and Coronary Artery Disease. Review of Resident #1's medical record revealed the following: A care plan focus area: Activities initiated on [DATE] had interventions that included: - Monitor for signs and symptoms of activity withdrawal. If withdrawal noted, nurse will assess, document findings and notify interdisciplinary team of results as needed A care plan focus area: Psychotropic drug use initiated on [DATE] had interventions that included: - Assess and re-assess resident's level of orientation, daily - Assess for mood changes - Assess anxiety - Provide emotional support as needed An Admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: clear speech, able to make self understood; clear comprehension; a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; a mood severity score of 06 indicating mild depression; no indicators of psychosis; and received occupational therapy (OT) services that started on [DATE]. An Occupational Therapy Note: Date of service [DATE] at 11:40 AM documented: - Exercise and treatment - focused on hand strengthening with yellow Thera putty (playdough like substance) during morning session. A Physician's Progress Note: Date of service [DATE] at 8:55 AM documented: - Resident #1 expressed to staff and to me on [DATE] when very emotional that he does not want CPR (cardiopulmonary resuscitation) - Reported severe night terrors feeling like he is falling, short of breath thrashing around and blames meds - He is very frustrated - He wants to be discharged immediately and thinks he will be better at home and familiar surroundings - He states he slept well last night - General appearance - alert cooperative, no distress A physician's order dated [DATE] directed, Code status and care directives - no CPR, do not intubate A Nursing Progress Note: Date of service [DATE] at 12:19 PM documented: - Patient made DNR (do not resuscitate) by Medical Doctor today - He refused tech (Certified Nurse Aide/CNA), nurse, social worker and therapy attempted to wake him up, he stated that he just want to sleep - Note sent to Medical Doctor (MD) regarding patient depressed mood, not wanting to participate in any activity. Awaiting order. It should be noted that there is no documented response by the MD to this notification in the medical record. A Social Worker Progress Note: Date of Service [DATE] at 2:25 PM documented, Social Worker met with patient and all he was saying is 'I want to die'. He also clearly stated that he does not want to speak to a psychiatrist. Attending MD and team informed . It should be noted that there is no documented response by the MD to this notification in the medical record. A Nursing Progress Note: Date of Service [DATE] at 4:03 PM documented, At around 3:30 (PM) today during rounding. The tech found patient with yellow stuff. Covering both nostril and mouth was filled with the same stuff (the stuff was play dough that was given to him by therapy to practice motor skills with his hand). Tech called nurse to assist. Nurse removed yellow stuff from his nose and mouth . When asked about it, he (Resident #1) stated that he did not want to live anymore. MD was called and received order to transfer patient to ED (emergency department) to get psychological evaluate . During a telephone interview conducted on [DATE] at approximately 2:45 PM, Employee #11 (Medical Doctor) stated, I saw the resident that morning ([DATE]) and talked to him. He expressed wanting a code status change from CPR/full code to DNR, which was addressed. There was no ideation or expression of self-harm when I talked to him that day. He was ready to go home because he felt it was better for him than being here. He was offered psych services or to talk to someone multiple times due to his feelings about his current condition, but he flatly refused. Him saying he wants to die was in the context of his code status and wanting to be DNR/DNI (do not resuscitate/do not intubate), not wanting to take his own life. If a patient is suicidal, that's something I would expect for the staff to call me about immediately. The only notification call I remember receiving that day, was right after staff found [Resident #1] with the putty in his nose and mouth. I can't recall the Social Worker mentioning [Resident #1] wanting to die to me any time prior to that. During a face-to-face conference/interview on [DATE] at 3:18 PM with Employees #2 (Director of Nursing/DON), #5 (Social Worker), #7 (Rehabilitation Manager), #4 (Lead MDS/Admissions Coordinator), #6 (Senior Director for Patient Safety and Quality) and #3 (Quality Assurance Coordinator). It should be noted that all the employees stated that were present at a huddle meeting that was conducted on [DATE] at 10:00 AM to include the Administrator. The following was stated during the conference: - Leadership huddles are done every Monday, Wednesday and Friday at 10:00 AM - Official notification to the MD is done via a phone call or the secure chat - The secure chat is not part of a resident's medical record - All notifications are documented in the medical record and whatever the follow-up is, for example no new orders or if new orders, they are recorded and documented in the resident's progress notes - Employee #5 stated that she met with Resident #1 before the huddle meeting held on Monday [DATE] at 10:00 AM [no time specified] and discussed with the team that the resident expressed wanting to die at the huddle - Employee #5 also stated that she met with the resident twice after the leadership huddle meeting - Apart from the Social Worker and the MDS/Admissions Coordinator, all the other employees stated that the only thing discussed regarding Resident #1 during the huddle meeting was his expressed desire change his code status from full code to do not resuscitate (DNR) - When asked was there any follow-up questions asked to Resident #1 after the I want to die statement, Employee #5 stated, I am not a psych doctor, that's why I informed the doctor. I had asked him (Resident #1) if he wanted to talk to a psych doctor and he said 'no' over and over again. I did not follow-up with the doctor when I didn't get a response to the initial notification. At the time of this interview, Employee #3 stated that there is no documentation or record keeping of the huddle meetings, everything is verbal. It should also be noted that a review of Employee #5's training record was conducted and showed that she completed the facility required training, Suicidal Patients, Care in Emergency Department, Perioperative/Procedural Area, and Non-Psychiatry In Hospital Nursing Units last on [DATE]. During a telephone interview conducted on [DATE] at 6:00 PM, Employee #12 (Chair of Psychiatry) stated, I want to die is considered a passive death wish that gets equated with depression versus an active suicidal ideation (SI) with a plan. Passive death wish gets evaluated by either the nurse, social worker or primary doctor by asking follow-up questions to determine if there is any intent of harm behind the death wish, from there, we (psychiatrist) would be consulted. That's the first line, whoever is first made aware of the passive death wish, they ask follow-up, escalating questions for signs and symptoms of active SI. That's the process in the ED. Active SI would get a 1-to-1 until seen by the psychiatrist. Passive death wish wouldn't get a 1-to-1 unless the follow-up questions warrant that. Subsequently, due to these failures, on [DATE] at 3:30 PM, Resident #1 was found alone, in his room, by facility staff, with Thera putty in his nostrils and in his mouth, in an attempt to end his life. According to the medical record, Resident #1 was taken to the ED and admitted to the hospitaal for inpatient psychiatry services on [DATE]. Based on these findings, an Immediate Jeopardy (IJ-J) was identified at 42 CFR S483.40 Behavioral Health (F740) on February 5, 2024, at 12:07 PM. The facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted on February 5, 2024, at 5:55PM. The plan included: 1. The [Hospital Name] Health System policy Suicidal Patients, Care in Emergency Department, Perioperative/Procedural Areas, and Non-Psychiatry In-hospital Nursing Units will be revised and adopted by the [Facility Name]. Revisions to the policy have been made so that the policy is applicable to SNF (Skilled Nursing Facility) residents. 2. The Director of Nursing or Quality Insurance Coordinator of the [Facility name] will educate the [Facility name] staff on the newly implemented policy beginning at each shift huddle starting at 7 PM ([DATE]) to ensure understanding of the responsibilities on suicide screening. Attestations will be obtained. All staff will be educated within 7 days, by [DATE]. 3. As part of the new policy, the [Facility name] will adopt the Ask Suicide Screening Questions (ASQ) screening tool to determine suicidal ideation at admission and any change in status as per newly implemented policy. If the resident has an acute positive screen, staff will secure Constant Patient Observer (CPO) and then make arrangements to send the resident to the Emergency Department for further assessment. For non-acute positive screen, the provider will be notified to assess the resident. 4. The Director of Nursing or Quality Assurance Coordinator of the [Facility Name] will educate the [Facility Name] staff on how to document ASQ responses in the EPIC (facility's electronic health record) medical record. ASQ screenings answers will be entered into EPIC prior to sending the resident to the Emergency Department. 5. All current residents will be screened using the ASQ screening tool by nursing staff within the next 24 hours to be completed by [DATE]. 6. [Hospital and Facility name] Chain of Command policy delegates the authority for staff to escalate concerns. The chain of command ensures that staff know where they are in the chain order to address administrative and/or clinical concerns. 7. The clinical [Facility name] team meets daily doing 7am and 7pm huddles. Staff will be asked to discuss any resident that may require any escalation based on mood or behavior health changes. The Change of Command policy will be retrained by all clinical [Facility name] staff during shift huddles beginning [DATE] to reiterate the escalation process. Staff will be reminded of their responsibility to escalate concerns if not addressed promptly. 8. [Hospital and Facility name] Chain of Command policy delegates the authority for staff to escalate concerns. The chain of command ensures that staff know where they are in the chain order to address administrative and/or clinical concerns. 9. The clinical [Facility name] team meets daily doing 7am and 7pm huddles. Staff will be asked to discuss any resident that may require any escalation based on mood or behavior health changes. 10. All social work staff assigned to the [Facility name] will be retrained by the Interim Social Work Supervisor on the Chain of Command policy to reiterate the escalation process. Staff will be reminded of their responsibility to escalate concerns if not addressed promptly. Verification for the removal of the immediacy was performed by the survey team onsite on February 6, 2024 at 2:15 PM. Cross Reference 22B DCMR Sec. 3229.1

Based on record reviews and staff interviews for one (1) of five (5) sampled residents, the facility staff failed to maintain a complete medical record for Resident #1. The findings included: A review of the facility's policy titled Records and Record Keeping with an effective date 03/24/23, documented .Staff are responsible for maintaining current and accurate documentation of interventions on behalf of the patient utilizing the charting system adopted by (Facility Name) . Entries on the patients electronic medical record should be responsive to physician direction and facilitate communication among all staff members involved in the patient's care . Resident #1 was admitted to the facility on [DATE] to room [ROOM NUMBER] with multiple diagnoses that included: Orthostatic Hypotension, Rapid Eye Movement (REM) Sleep Disorder, Diabetes Mellitus, Parkinson's Disease, and Coronary Artery Disease. A review of the medical record revealed the following: An Admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: clear speech, able to make self understood; clear comprehension; a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; a mood severity score of 06 indicating mild depression; no indicators of psychosis; and received occupational therapy (OT) services that started on 01/03/24. A review of the facility's Secure Chat document revealed that on 01/29/24 at 1:04 PM Employee #5 (Social Worker) communicated the following to Resident #1's attending physician .I met with patient and all he is saying is he want to die. He clearly stated that he does not want to speak to a psychiatrist. On 01/29/24 at 1:21 PM, the attending physician responded .He has said he will be happier at home . Review of Resident #1's medical record lacked documented evidence that message sent from the physician to Employee #5 on 1/29/2024 at 1:21 PM via the secure chat was recorded/documented in the Resident's active clinical record. A review of a Social Worker Progress Note: Date of Service 1/29/2024 at 2:25 PM documented, Social Worker met with patient and all he was saying is 'I want to die'. He also clearly stated that he does not want to speak to a psychiatrist. Attending MD and team informed . During a face-to-face interview conducted on 02/06/24 at 1:20 PM, Employee #1 (Administrator) stated that secure chat information is not documented in the medical record and acknowledged the findings. Cross Reference 22B DCMR Sec 3231.11

Based on record reviews and staff interviews, for one (1) of five (5) sampled residents, the facility's staff (Employee #5) failed to provide appropriate medically-related social services to meet Resident #1's needs, as evidenced by the employee's failure to conduct a follow-up assessment on 01/29/24 after the resident expressed that he wanted to die. The findings included: A review of Employee #5's job description signed on 05/11/22, revealed the following Job title Social Worker II (Department Case Coordination) .Provides expeditious patient assessments and collaborates with medical providers in determining the appropriate disposition and treatment for behavioral health patients and other vulnerable patient populations .Conducts behavioral health assessments using standardized assessment and screening tools in conjunction with the department of psychiatry policies and procedures. Communicates psychiatric crisis intake assessments and clinical information to psychiatric medical provider and develops disposition to be communicated to ED (emergency medical) medical provider . Employee #5's training record showed that she completed the facility required training, Suicidal Patients, Care in Emergency Department, Perioperative/Procedural Area, and Non-Psychiatry In Hospital Nursing Units last on 06/16/22. A review of the facility's policy titled Case Management Services with an effective date of 02/21/23 documented the following: The Case Coordination Department provides services in the following areas: Recognition/ assessment of emotional and social needs 1. Collaboration with the hospital medical, clinical staff, and social work with regard to the identified patients' current, traumatic situation, interpretation of the emotional, social and environmental factors which are contributive, and provision of individual and group services to the patient and/ or family during hospitalization . Care Coordinators will make referrals as appropriate. Resident #1 was admitted to the facility on [DATE] to room [ROOM NUMBER] with multiple diagnoses that included: Orthostatic Hypotension, Rapid Eye Movement (REM) Sleep Disorder, Diabetes Mellitus, Parkinson's Disease, and Coronary Artery Disease. A review of the medical record revealed the following: A care plan focus area: Activities initiated on 01/02/24 had interventions that included: - Monitor for signs and symptoms of activity withdrawal. If withdrawal noted, nurse will assess, document findings and notify interdisciplinary team of results as needed A care plan focus area: Psychotropic drug use initiated on 01/02/24 had interventions that included: - Assess and re-assess resident's level of orientation, daily - Assess for mood changes - Assess anxiety - Provide emotional support as needed An Admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: clear speech, able to make self-understood; clear comprehension; a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; a mood severity score of 06 indicating mild depression; no indicators of psychosis; and received occupational therapy (OT) services that started on 01/03/24. An Occupational Therapy Note: Date of service 1/10/24 at 11:40 AM documented: - Exercise and treatment - focused on hand strengthening with yellow Thera putty (playdough like substance) during morning session. A Social Worker Progress Note: Date of Service 1/29/2024 at 2:25 PM documented, Social Worker met with patient and all he was saying is 'I want to die'. He also clearly stated that he does not want to speak to a psychiatrist. Attending MD and team informed . A Nursing Progress Note: Date of Service 1/29/2024 at 4:03 PM documented, At around 3:30 (PM) today during rounding. The tech found patient with yellow stuff. Covering both nostril and mouth was filled with the same stuff (the stuff was play dough that was given to him by therapy to practice motor skills with his hand). Tech called nurse to assist. Nurse removed yellow stuff from his nose and mouth. Assessed patient. He seems clinical (sp)- stable vss (sp) (vital signs) BP (Blood Pressure) 141/88 hr (Heart rate) 72 Temp (Temperature) 36.6 resp (respirations) 19 oxygen sat (saturation) is 98 on room air. When asked about it, he (Resident #1) stated that he did not want to live anymore. MD was called and received order to transfer patient to ED (emergency department) to get psychological evaluate . A review of a Facility Reported Incident submitted to the State Agency on 02/01/24 reported the following: This resident was found in his room with thera-putty in his nose and mouth at 3:30. Clin tech (Clinical Technician) walked into the room around 3:30 and found the resident with thera-putty in his mouth and nose. She called for the nurse who ran in and removed the substance from the resident's nose and mouth. Vitals were immediately taken and were stable. The resident requested to watch mass. A team member sat with a resident while the attending physician was called. The attending physician ordered a transfer to (Facility Name) ED (Emergency Department) for psychiatric evaluation . The medical record lacked documented evidence that Employee #5 (Social Worker) conducted a follow up assessment for suicidal ideation on 01/29/24 after Resident #1 stated I want to die. During a face-to-face interview conducted on 02/02/2024 at approximately 3:55 PM, Employee #5 (Social Worker) acknowledged that she did not do a follow assessment or ask any follow up questions for suicidal ideation/self-harm after Resident #1 stated that they wanted to die and Employee #5 stated It's not my job to do psych consult doctors do psych consult he said he didn't want to talk to a psychiatrist. During a telephone interview conducted on 02/02/24 at 6:00 PM, Employee #12 (Chair of Psychiatry) stated, I want to die is considered a passive death wish that gets equated with depression versus an active suicidal ideation (SI) with a plan. Passive death wish gets evaluated by either the nurse, social worker or primary doctor by asking follow-up questions to determine if there is any intent of harm behind the death wish, from there, we (psychiatrist) would be consulted. That's the first line, whoever is first made aware of the passive death wish, they ask follow-up, escalating questions for signs and symptoms of active SI. That's the process in the ED. Active SI would get a 1-to-1 until seen by the psychiatrist. Passive death wish wouldn't get a 1-to-1 unless the follow-up questions warrant that. During a face-to-face interview conducted on 02/06/24 at 1:17 PM, Employee #1 (Administrator) stated that Employee #5 should have done a follow-up assessment and acknowledged the findings. Cross reference F740

Based on observation of nine (9) nasal cannulas (delivers oxygen via the nose), facility staff failed to maintain respiratory/oxygen care equipment in accordance with the professional standards of practice. The findings included: During an observation of the Respiratory Equipment Cart on [DATE] at 12:14 PM, nine (9) of nine (9) Vyaire (manufacturer) nasal cannula tubing with expiration dates of [DATE] ([DATE]) were stored for resident use, approximately three (3) months after the expiration date. During a face-to-face interview conducted on [DATE] at 12:59 PM, Employee #12 (Respiratory Therapy Manager) stated, There's no daily or weekly inventory check of the respiratory equipment cart. If supplies are needed, they [the nurses] call us and we bring the supplies. The employee was shown the expired nasal cannula tubing's and stated, Oh wow! I will get rid of these and get new ones. Employee #12 further stated that the nasal cannulas come from central supply. During a face-to-face interview on [DATE] at 2:13 PM, Employee #13 (Supply Chain Manager) stated, We are responsible for checking the expiration dates before putting them [nasal cannula tubing] for use on the units. We would be the root cause of something expired being on the units. DCMR 3215.4

Based on observation, record review, and staff interview, for one (1) of 16 sampled residents, the facility's staff failed to maintain infection control policies and procedures as evidenced by: inappropriately transporting soiled linen; staff not performing hand hygiene and wearing a facemask inappropriately during meal tray distribution. Resident #1. The findings included: Review of the facility's policy titled Wound Care Policy with an effective date of 06/23/20 instructed staff to .maintain standard precautions and isolation precautions as indicated. After completion of the procedure, clean, store and/ or dispose of equipment and supplies in the appropriate manner as identified per facility infection control policy . Review of the policy titled Hand Hygiene Policy with an effective date of 06/15/20 instructs staff to do the following .Hand hygiene with either alcohol-based hand sanitizer and or soap and water is required .Before handling food .when carrying supplies, dietary trays or transporting a patient into or out of a room, hand hygiene is required as soon as hands are free . Review of the CDC (Center for Disease Control) guidelines for best practices for linen and laundry handling instructed, .Never carry soiled linen against the body. Always place it in the designated container. https://www.cdc.gov/hai/prevent/resource 1. Employee #9 failed to appropriately transport soiled linens after providing wound care for Resident #1 who is on contact precautions/isolation. Resident #1 was admitted to the facility on [DATE] with diagnoses including: Pressure Ulcer Sacral Region Stage 4, Non-Healing Right Heal Wound, Multiple Wounds, and Heart Failure. During an observation on 01/06/23 starting at 10:48 AM, Employee #9 (Registered Nurse) was observed performing wound care dressing change to Resident #1's Stage 4, sacral, pressure ulcer. After changing the resident's wound dressings, Employee #9 picked up a soiled blanket, placed it under her arm, which moved the protective gown, causing direct contact of the soiled blanket with the employee's uniform. It should be noted that Resident #1 had a sign on his door stating that he was on Contact Isolation Precautions requiring staff to wear personal protective equipment (gown, gloves, and mask) when entering the room to provide care. A review of the medical record revealed the following: 11/04/22 at 12:34 PM [Physician's Order] .Contact isolation . 01/06/23 at 10:09 AM [Physician's Order] .change dressing .dressing type: cleanse the wound with Vashe (Wound cleanser) with VAC (vacuum-assisted closure) dressing change Site: Sacrum .2 times weekly . During a face-to-face interview conducted at the time of the observation, Employee #9 (Registered Nurse) stated, I wasn't thinking but I know better. 2. Facility staff failed to perform hand hygiene and was observed not wearing their facemask appropriately. During an observation on 01/04/23 at approximately 12:00 PM, Employee #14 (Dietary Aide) was observed on the unit pushing a meal cart down the hallway and stopping at each resident's room. The employee was noted to be wearing a face mask below the nose, and only partially covering their mouth. Employee #14 was also seen not performing hand hygiene in between coming out of one resident's room, and then touching and delivering another resident's meal tray. At the time of the observation, Employee #14 was asked why his facemask was not covering his nose and mouth. The employee refused to answer. This observation was brought to the attention of Employee #2 (Director of Nursing) on 01/04/23 at 12:03 PM. Employee #2 acknowledged the findings and made no comment. DCMR 3217.6

Based on record review and staff interview, for one (1) of 16 sampled residents, facility staff failed to offer a resident or their representative the right to formulate or refuse an Advanced Directive (AD). Resident #79. The findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses that included Osteoarthritis, Osteoporosis, Chronic Pain Syndrome, Right Hip Pain, and Obesity. Review of Resident #79's medical record revealed the following: Review of the Resident's Face Sheet revealed that the resident had a legal guardian. An Admission Minimum Data Set (MDS), dated [DATE], showed facility staff coded the resident as having a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #79's electronic medical record documented, Advance Directives - Living Will - Patient has [an] advance directive. Copy in [physical] Chart. Review of Resident #79's physical chart showed that there were no documents filed under the Advance Directive tab. During a face-to-face interview on 01/06/23 at 9:12 AM, Employee #5 (Unit Manager) acknowledged that there was no documented evidence that facility staff offered Resident #79 or their legal guardian the opportunity to formulate or refuse Advanced Directives. DCMR 3231.12(r)

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in four (4) of eight (8) resident's rooms, and walls marred with peeling paint in three (3) of eight (8) resident's rooms. The findings include: During an environmental walkthrough of the facility on January 4, 2023, at approximately 3:15 PM, the following were observed: 1. Bathroom vents were soiled on the inside and outside in four (4) of eight (8) resident's rooms including rooms #322, #327, #328, and #330. 2. Paint was peeling from the walls in three (3) of eight (8) resident's rooms (#322, #327, #330). These findings were acknowledged by Employee #8 on January 4, 2023, at approximately 4:00 PM.

Based on record review and staff interviews, for three (3) of 16 sampled residents, facility staff failed to implement its policies and procedures for reporting and investigating incidents involving abuse, neglect, and injuries of unknown origin. Residents' #81, #80 and #85. The findings included: Review of the Abuse and Neglect Policy with an effective date of 12/23/21, documented, .The Director of Nursing (DON) shall be notified in order to assist in appropriately implementing the notification requirements . incidents of abuse .shall be reported to the DC (District of [NAME]) Metropolitan Police, the Long-Term Care Ombudsman, and Adult Protective Services: within 2 hours after the allegation has been made if the event(s) that caused the allegation involve(s) abuse .Investigation . All reports of alleged abuse, misappropriation of property, and injuries of unknown origin are investigated promptly in a systematic and thorough manner . The facility shall report the results of all investigations to the Administrator or his/her designated representative and to other officials in accordance with DC law, including the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken . 1. Facility staff failed to follow their policy to investigate a potential allegation of neglect involving Resident #81's witnessed fall with injury and failed to report it to State Agency in the required timeframe. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Fall, Hypertension, and Benign Prostatic Hyperplasia (BPH). Review of a Facility Reported Incident (FRI), DC00010459, submitted to the State Agency on 12/16/21, showed, .Date 12/10/21 Time 1730 (5:30 PM) At 1730H (5:30 PM) Resident requested to be transferred from chair to bed. The patient care tech (technician) (PCT) assisted the resident gait belt in place and help the resident stand and move the chair to give space for resident to turn, after standing started to sit so the PCT assisted the resident to the floor. According to the resident, he thought that the chair is still at the back .RN (registered nurse) assessed resident vital sign (Sp) was stable and treated the small abrasion on the left upper shoulder . A review of Resident #81's medical record revealed the following: An Admission Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates intact cognition; required two-person physical assistance for transfers; used a walker for mobility; and had fall in the last one (1) to six (6) months prior to admission. 12/10/21 [Physician's Order] CT (computed tomography) Head/Brain WO (without) Contrast Order .stat . 12/10/21 at 5:30 PM, the Post Fall Safety Huddle showed facility staff placed a checkmark in the section that stated, .All falls must be reported to the DOH (Department of Health) . to indicate that the incident was reported. 12/10/21 at 8:20 PM [Nurse's Note] .At 1730 (5:30 PM) pt (Patient) had incident, assisted fall when transferred him from chair to bed. After notified to his provider .Pt sent to CT (computed tomography) scan (no Hemorrhage, Mass lesion, Acute infarction). Patient denied pain and has skin abrasion on left upper shoulder . 12/13/21 at 5:57 PM [Physician's Note] .CT of the head WO (without) contrast showed no acute intracranial pathology . The evidence showed that the facility's staff did not report the fall incident that occurred on 12/10/21 to the State Agency until 12/16/21, seven (7) days later and there was no documented evidence that an investigation into the fall incident had been conducted by the facility's staff. The medical record lacked documented evidence that the facility staff conducted a thorough investigation into Resident #81's witnessed fall with staff as evidenced by: no statement from the PCT present at the time of the fall; and no resident interview. During a face-to-face interview conducted on 01/09/23 at 3:14 PM, Employee #2 (Director of Nursing) stated, I have no record of it (Facility incident investigation). 2. Facility staff failed to follow their policy to investigate injuries of unknown origin as evidenced by failing to investigate Resident #80's injury of unknown origin which occurred on 05/12/22. Resident #80 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertension, Dislocation of Internal Right Hip Prosthesis, Presence of Left Artificial Hip Joint, and Infection and Inflammatory Reaction. Review of a facility-reported incident (FRI), DC00010740, submitted by the facility to the State Agency on 05/13/22 documented, .5/12/22 Time: 0515 (5:15 AM) .At around 0515 (5:15) CNA (Certified Nurse Aide) called the attention of the assigned nurse to resident, she stated that the resident was having pain. Interpreter was called. Resident related to interpreter that when she got up with the help of the CNA to go to the bathroom she felt as if her hip was out of place. Resident was assessed. Hip abductor brace was in placed (sp) but noted that the legs are uneven .The Charge nurse was informed and .called the on-call doctor .order was written and carried out, X-ray (X radiation) of rt (right) hip and pelvis was done, result was hip arthroplasty dislocation . A review of Resident #80's medical record revealed the following: An Admission MDS dated [DATE], showed that the facility staff coded: preferred language as Spanish to communicate; a Brief Interview for Mental Status summary score of 15, indicating intact cognition; needed limited assistance requiring one-person physical assistance from staff for bed mobility, transfer, walk-in room, toilet use, and personal hygiene; and the resident was coded as using a walker. 05/12/22 at 9:43 AM [Physician's Note] .Contacted by RN (Registered Nurse) at 7:45 AM that patient is concerned that her right hip has dislocated again RN also confirms that her leg length is uneven. I contacted the Ortho resident who requested Xrays of hip and pelvis. Xrays ordered stat (immediately). At 9:10am - I have been contacted by the Radiologist, patient does in fact have a dislocation .asked for patient to be transferred to the ER (emergency room ) promptly . 05/13/22 at 10:52 AM [Physician's Assistant Note] .Use of language line interpreter .to interview patient. Patient states she woke up yesterday morning and asked for assistance to restroom. As she was ambulating noted that her Right leg felt much shorter than her left it may be dislocated. She denies any difficulty ambulating earlier in the day and denies any occurrence of a sharp pain or a pop in that hip. She was subsequently sent to the ED (Emergency Department) and it was reduced by the orthopedic resident under conscious sedation . A review of the facility's incidents binder and investigation documents lacked documented evidence that the facility investigated Resident #80's injury of unknown origin. During a face-to-face interview conducted on 01/09/23 at 3:19 PM, Employee #2 (Director of Nursing) stated I am not aware of a reason why we did not complete an investigation. 3. Facility staff failed to report an alleged incident of staff-to-resident verbal abuse between Resident #85 and Employee #11 to the State Agency within the required timeframe per the facility's Abuse policy. Resident #85 was readmitted to the facility on [DATE] with diagnoses including Acute and Chronic Pain, Type 2 Diabetes, Diabetic Neuropathy and Anxiety Disorder. Review of Resident #85's medical record revealed: A face sheet that showed Resident #85 resided in room [ROOM NUMBER]. A 5-Day assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status Summary Score of 15, indicating intact cognition; no rejection of care and was almost always in pain. 07/07/22 [Physician's Order]: Hydromorphone (Dilaudid) (narcotic pain medication) Take 1 tablet 8 mg (milligrams) total by mouth every 6 hours as needed for pain (severe pain). 07/07/22 [Physician's Order]: Zolpidem (Ambien) (narcotic sleeping medication) 12.5 mg CR (controlled release) tablet. Take 12.5 mg by mouth nightly as needed for sleep. 07/08/22 at 7:32 AM [Nurses Progress Note written by Employee #11]: Late entry for care provided on the 7th July 2022 - Assumed care of [Resident #85] at 7 PM 7/7/2022. Patient was met sitting in bed watching TV (television), was assisted throughout the night, and medicated for pain and Ambien for sleep; she requested another dose of 8 mg (milligrams) of Dilaudid and was reminded that it was too early for another dose of Dilaudid .She was not happy .but reluctantly accepted the message and went back to sleep at bedtime . 07/12/22 at 1:41 PM, a Facility Reported Incident (FRI), DC00010859, received by the State Agency documented, . [Resident #85] alleges that on Friday, July 8th during the night shift (7p-7a), she was confronted by an RN (Registered Nurse) in her room who said, Do you have a problem with me. The patient was uncomfortable with this interaction and was concerned she wouldn't receive proper care. The RN in question was not assigned to this Resident at the time of the alleged verbal confrontation . 07/12/22 at 3:07 PM [Nurses Progress Note/Late Entry]: This writer met with [Resident #85] at her request on 07.09.2022. [Resident #85] expressed to me an unpleasant interaction she had with an RN. Her perception was that RN was not caring and responsive to her pain med needs .At the Resident's request, the RN involved will not be assigned to her while she is in the facility . The evidence showed that the alleged incident between Resident #85 and Employee #11 occurred on the night shift on 07/07/22. Facility staff reported this incident to the State Agency on 07/12/22, six (6) days later. During a face-to-face interview on 01/09/23 at 2:43 PM, Employee #1 (Administrator) stated that she was not working at the facility when the incident occurred. She acknowledged that facility staff should have reported the incident between Resident # 85 and Employee #11 to the State agency immediately. DCMR - 3232.4 45104

Based on review of facility records, reported incidents, policies, and staff interview for four (4) of 16 sampled residents, facility staff failed to report the following incidents to the state agency in the required timeframes for one (1) resident who had a witnessed fall with staff that resulted in injury, one (1) residents with injuries of unknown origin, and one (1) resident with an allegation of abuse. (Residents' #81, #80, and #85) The findings included: A facility policy titled Abuse and Neglect Policy (Formerly 01-28-01), effective 12/23/2021, documented: .Procedure .E. The Director of Nursing shall be notified to assist in appropriately implementing the notification requirements . incidents of abuse .shall be reported to the DC Metropolitan Police, the Long-Term Care Ombudsman, and Adult Protective Services: within 2 hours after the allegation has been made if the event(s) that caused the allegation involve abuse .Investigation: a. All reports of alleged abuse, misappropriation of property, and injuries of unknown origin are investigated promptly in a systematic and through manner .e. The facility shall report the results of all investigations to the Administrator or his/her designated representative and to other officials in accordance with DC law, including the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken . 1. Facility staff failed to report Resident #81's witnessed fall with staff that occurred on 12/10/21, to the state agency within 24 hours but instead reported the fall on 12/16/2021. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Fall, Hypertension, and Benign Prostatic Hyperplasia (BPH). Review of a Facility Reported Incident (FRI), DC00010459, submitted to the State Agency on 12/16/21, showed, .Date 12/10/21 Time 1730 (5:30 PM) At 1730H (5:30 PM) Resident requested to be transferred from chair to bed. The patient care tech (technician) (PCT) assisted the resident gait belt in place and help the resident stand and move the chair to give space for resident to turn, after standing started to sit so the PCT assisted the resident to the floor. According to the resident, he thought that the chair is still at the back .RN (registered nurse) assessed resident vital sign (Sp) was stable and treated the small abrasion on the left upper shoulder . A review of Resident #81's medical record revealed the following: An Admission Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates intact cognition; required two-person physical assistance for transfers; used a walker for mobility; and had fall in the last one (1) to six (6) months prior to admission. 12/10/21 [Physician's Order] CT (computed tomography) Head/Brain WO (without) Contrast Order .stat . 12/10/21 at 5:30 PM, the Post Fall Safety Huddle showed facility staff placed a checkmark in the section that stated, .All falls must be reported to the DOH (Department of Health) . to indicate that the incident was reported. 12/10/21 at 8:20 PM [Nurse's Note] .At 1730 (5:30 PM) pt (Patient) had incident, assisted fall when transferred him from chair to bed. After notified to his provider .Pt sent to CT (computed tomography) scan (no Hemorrhage, Mass lesion, Acute infarction). Patient denied pain and has skin abrasion on left upper shoulder . 12/13/21 at 5:57 PM [Physician's Note] .CT of the head WO (without) contrast showed no acute intracranial pathology . The evidence showed that the facility's staff did not report the fall incident that occurred on 12/10/21 to the State Agency until 12/16/21, seven (7) days later and there was no documented evidence that an investigation into the fall incident had been conducted by the facility's staff. During a face-to-face interview conducted on 01/09/23 at 3:14 PM, Employee #2 (Director of Nursing) stated, I have no record of it (Facility incident investigation). 2. Facility staff failed to report an injury of unknown origin that resulted in Resident #80's right hip dislocation within 2 hours to the state agency. Resident #80 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertension, Dislocation of Internal Right Hip Prosthesis, Presence of Left Artificial Hip Joint, and Infection and Inflammatory Reaction. Review of a facility-reported incident (FRI), DC00010740, submitted by the facility to the State Agency on 05/13/22 documented, .5/12/22 Time: 0515 (5:15 AM) .At around 0515 (5:15) CNA (Certified Nurse Aide) called the attention of the assigned nurse to resident, she stated that the resident was having pain. Interpreter was called. Resident related to interpreter that when she got up with the help of the CNA to go to the bathroom she felt as if her hip was out of place. Resident was assessed. Hip abductor brace was in placed (sp) but noted that the legs are uneven .The Charge nurse was informed and .called the on-call doctor .order was written and carried out, X-ray (X radiation) of rt (right) hip and pelvis was done, result was hip arthroplasty dislocation . A review of Resident #80's medical record revealed the following: An Admission MDS dated [DATE], showed that the facility staff coded: preferred language as Spanish to communicate; a Brief Interview for Mental Status summary score of 15, indicating intact cognition; needed limited assistance requiring one-person physical assistance from staff for bed mobility, transfer, walk-in room, toilet use, and personal hygiene; and the resident was coded as using a walker. 05/12/22 at 9:43 AM [Physician's Note] .Contacted by RN (Registered Nurse) at 7:45 AM that patient is concerned that her right hip has dislocated again RN also confirms that her leg length is uneven. I contacted the Ortho resident who requested Xrays of hip and pelvis. Xrays ordered stat (immediately). At 9:10am - I have been contacted by the Radiologist, patient does in fact have a dislocation .asked for patient to be transferred to the ER (emergency room ) promptly . 05/13/22 at 10:52 AM [Physician's Assistant Note] .Use of language line interpreter .to interview patient. Patient states she woke up yesterday morning and asked for assistance to restroom. As she was ambulating noted that her Right leg felt much shorter than her left it may be dislocated. She denies any difficulty ambulating earlier in the day and denies any occurrence of a sharp pain or a pop in that hip. She was subsequently sent to the ED (Emergency Department) and it was reduced by the orthopedic resident under conscious sedation . There was no documented evidence that the facility staff reported Resident #80's injury of unknown origin, resulting in a dislocation of the right hip to the State agency within the 2-hour required time. During a face-to-face interview conducted on 01/09/23 at approximately 5:00 PM Employee #2 (Director of Nursing) acknowledged the findings and stated, There were instructions where we should call a number to DOH (Department of Health) and leave a message and that's probably what staff did. 3. Facility staff failed to immediately report an alleged incident of staff-to-resident verbal abuse involving Resident #85 on 07/08/22 to the State Agency. Resident #85 was readmitted to the facility on [DATE] with diagnoses including Acute and Chronic Pain, Type 2 Diabetes, Diabetic Neuropathy and Anxiety Disorder. Review of Resident #85's medical record revealed: A face sheet that showed Resident #85 resided in room [ROOM NUMBER]. A 5-Day assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status Summary Score of 15, indicating intact cognition; no rejection of care and was almost always in pain. 07/07/22 [Physician's Order]: Hydromorphone (Dilaudid) (narcotic pain medication) Take 1 tablet 8 mg (milligrams) total by mouth every 6 hours as needed for pain (severe pain). 07/07/22 [Physician's Order]: Zolpidem (Ambien) (narcotic sleeping medication) 12.5 mg CR (controlled release) tablet. Take 12.5 mg by mouth nightly as needed for sleep. 07/08/22 at 7:32 AM [Nurses Progress Note written by Employee #11]: Late entry for care provided on the 7th July 2022 - Assumed care of [Resident #85] at 7 PM 7/7/2022. Patient was met sitting in bed watching TV (television), was assisted throughout the night, and medicated for pain and Ambien for sleep; she requested another dose of 8 mg (milligrams) of Dilaudid and was reminded that it was too early for another dose of Dilaudid .She was not happy .but reluctantly accepted the message and went back to sleep at bedtime . 07/12/22 at 1:41 PM, a Facility Reported Incident (FRI), DC00010859, received by the State Agency documented, . [Resident #85] alleges that on Friday, July 8th during the night shift (7p-7a), she was confronted by an RN (Registered Nurse) in her room who said, Do you have a problem with me. The patient was uncomfortable with this interaction and was concerned she wouldn't receive proper care. The RN in question was not assigned to this Resident at the time of the alleged verbal confrontation . 07/12/22 at 3:07 PM [Nurses Progress Note/Late Entry]: This writer met with [Resident #85] at her request on 07.09.2022. [Resident #85] expressed to me an unpleasant interaction she had with an RN. Her perception was that RN was not caring and responsive to her pain med needs .At the Resident's request, the RN involved will not be assigned to her while she is in the facility . The evidence showed that the alleged incident between Resident #85 and Employee #11 occurred on the night shift on 07/07/22. Facility staff reported this incident to the State Agency on 07/12/22, six (6) days later. During a face-to-face interview on 01/09/23 at 2:43 PM, Employee #1 (Administrator) stated that she was not working at the facility when the incident occurred. She acknowledged that facility staff should have reported the incident between Resident # 85 and Employee #11 to the State agency immediately. DCMR 3232.5 45104

Based on review of facility records, reported incidents, policies, and staff interviews for two (2) of 16 sampled residents, the facility's staff failed to show evidence of conducting thorough investigations for one (1) resident that had a fall with injury and one (1) resident with an injury of unknown origin. Residents' #81 and #80. The findings included: Review of the facility's policy titled Abuse and Neglect Policy with an effective date of 12/23/21 instructs .The Director of Nursing, and or Administrator or designee of the [Facility Name], will investigate all allegations as soon as they have knowledge of the event .The facility shall report the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with DC law, including the State Survey Agency, within five (5) working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken . 1. Facility staff failed to thoroughly investigate Resident #81's witnessed fall with staff that resulted in an injury. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Fall, Hypertension, and Benign Prostatic Hyperplasia (BPH). Review of a Facility Reported Incident (FRI), DC00010459, submitted to the State Agency on 12/16/21, showed, .Date 12/10/21 Time 1730 (5:30 PM) At 1730H (5:30 PM) Resident requested to be transferred from chair to bed. The patient care tech (technician) (PCT) assisted the resident gait belt in place and help the resident stand and move the chair to give space for resident to turn, after standing started to sit so the PCT assisted the resident to the floor. According to the resident, he thought that the chair is still at the back .RN (registered nurse) assessed resident vital sign (Sp) was stable and treated the small abrasion on the left upper shoulder . A review of Resident #81's medical record revealed the following: An Admission Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates intact cognition; required two-person physical assistance for transfers; used a walker for mobility; and had fall in the last one (1) to six (6) months prior to admission. 12/10/21 [Physician's Order] CT (computed tomography) Head/Brain WO (without) Contrast Order .stat . 12/10/21 at 5:30 PM, the Post Fall Safety Huddle showed facility staff placed a checkmark in the section that stated, .All falls must be reported to the DOH (Department of Health) . to indicate that the incident was reported. 12/10/21 at 8:20 PM [Nurse's Note] .At 1730 (5:30 PM) pt (Patient) had incident, assisted fall when transferred him from chair to bed. After notified to his provider .Pt sent to CT (computed tomography) scan (no Hemorrhage, Mass lesion, Acute infarction). Patient denied pain and has skin abrasion on left upper shoulder . 12/13/21 at 5:57 PM [Physician's Note] .CT of the head WO (without) contrast showed no acute intracranial pathology . The evidence showed that the facility's staff did not report the fall incident that occurred on 12/10/21 to the State Agency until 12/16/21, seven (7) days later and there was no documented evidence that an investigation into the fall incident had been conducted by the facility's staff. The medical record lacked documented evidence that the facility staff conducted a thorough investigation into Resident #81's witnessed fall with staff as evidenced by: no statement from the PCT present at the time of the fall; and no resident interview. During a face-to-face interview conducted on 01/09/23 at 3:14 PM, Employee #2 (Director of Nursing) stated, I have no record of it (Facility incident investigation). 2. Facility staff failed to thoroughly investigate Resident #80's injury of unknown origin later diagnosed as a dislocation of the right hip. Resident #80 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertension, Dislocation of Internal Right Hip Prosthesis, Presence of Left Artificial Hip Joint, and Infection and Inflammatory Reaction. Review of a facility-reported incident (FRI), DC00010740, submitted by the facility to the State Agency on 05/13/22 documented, .5/12/22 Time: 0515 (5:15 AM) .At around 0515 (5:15) CNA (Certified Nurse Aide) called the attention of the assigned nurse to resident, she stated that the resident was having pain. Interpreter was called. Resident related to interpreter that when she got up with the help of the CNA to go to the bathroom she felt as if her hip was out of place. Resident was assessed. Hip abductor brace was in placed (sp) but noted that the legs are uneven .The Charge nurse was informed and .called the on-call doctor .order was written and carried out, X-ray (X radiation) of rt (right) hip and pelvis was done, result was hip arthroplasty dislocation . A review of Resident #80's medical record revealed the following: An Admission MDS dated [DATE], showed that the facility staff coded: preferred language as Spanish to communicate; a Brief Interview for Mental Status summary score of 15, indicating intact cognition; needed limited assistance requiring one-person physical assistance from staff for bed mobility, transfer, walk-in room, toilet use, and personal hygiene; and the resident was coded as using a walker. 05/12/22 at 9:43 AM [Physician's Note] .Contacted by RN (Registered Nurse) at 7:45 AM that patient is concerned that her right hip has dislocated again RN also confirms that her leg length is uneven. I contacted the Ortho resident who requested Xrays of hip and pelvis. Xrays ordered stat (immediately). At 9:10am - I have been contacted by the Radiologist, patient does in fact have a dislocation .asked for patient to be transferred to the ER (emergency room ) promptly . 05/13/22 at 10:52 AM [Physician's Assistant Note] .Use of language line interpreter .to interview patient. Patient states she woke up yesterday morning and asked for assistance to restroom. As she was ambulating noted that her Right leg felt much shorter than her left it may be dislocated. She denies any difficulty ambulating earlier in the day and denies any occurrence of a sharp pain or a pop in that hip. She was subsequently sent to the ED (Emergency Department) and it was reduced by the orthopedic resident under conscious sedation . A review of the facility's incidents binder and investigation documents lacked documented evidence that the facility investigated Resident #80's injury of unknown origin. During a face-to-face interview conducted on 01/09/23 at 3:19 PM, Employee #2 (Director of Nursing) stated I am not aware of a reason why we did not complete an investigation. DCMR 3232.2 45104

45102 Based on record review and staff interviews, for two (2) of 16 sampled residents, facility staff failed to develop and implement comprehensive person-centered care plans with goals and approaches to address one (1) resident who is prescribed nine (9) prescribed medications; and one (1) resident who contracted COVID-19. Residents' #128 and #3. The findings included: 1. Facility staff failed to develop a comprehensive-person-centered care plan with goals and approaches to address Resident #128 being on nine (9) prescribed medications. Resident #128 was admitted to the facility on [DATE] with multiple diagnoses that included: Hypertension, Hyperlipidemia, Benign Prostatic Hyperplasia (BPH), and Hypothyroidism. Review of resident #128's medical record revealed the following physician's orders: 12/21/22 Benzonatate (cough suppressants) . capsule 100mg (Milligram) . 12/21/22 Enoxaparin (anticoagulant) . syringe 40 mg Subcutaneous, every evening 12/21/22 Simvastatin (cholesterol lowering medication) tablet 5 mg oral nightly 12/21/22 Guaifenesin (expectorant) 12 hr (hour) tablet 600 mg oral 2 times daily 12/21/22 Tamsulosin (treats BPH) 24 hr (hour) capsule 0.4 mg oral daily 12/21/22 Polyethylene Glycol (laxative) packet 17 g oral daily 12/21/22 Levothyroxine (thyroid hormone supplement) tablet 88 mcg (microgram) oral every morning 12/21/22 Finasteride (treats BPH) tablet 5 mg oral every morning 12/24/22 Rivastigmine (treats dementia) 4.6 mg/24-hour patch: 1 patch transdermal daily . A review of Resident #128's medical record lacked documented evidence of a polypharmacy care plan to address the resident receiving nine (9) prescribed medications. During a face-to-face interview conducted on 01/09/23 at 4:20 PM, Employee #5 (Charge Nurse) acknowledged the findings and stated, I don't see it [polypharmacy care plan]. 45104 2. Facility staff failed to develop a comprehensive patient-centered care plan that included Resident #3's recent COVID-19 infection on 12/10/22. Resident #3 was readmitted to the facility on [DATE] with diagnoses including a Personal History of COVID-19, Pneumonia due to COVID-19, and Unspecified Intellectual Disabilities. Review of Resident #3's medical record revealed: A 5 Day Scheduled assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status Summary Score of 15, indicating intact cognition. 12/09/22 [Department of Health (DOH) Notice of Discharge Transfer or Relocation] form . (1) The proposed action is transfer (2) The specific reason(s) to this section is .transfer to acute for positive COVID . 12/20/22 [History and Physical/Physician's Note]: .had no new acute problems until 12-10-22 when he developed onset congested cough and rhinorrhea. He had repeat covid testing performed and was positive with [COVID-19] and again transferred to the main hospital Covid Unit . He returns today c/o (complaining of) a stiff neck, resolved cough, generalized weakness, and increased dependence for care . 12/20/22 [Care Plan]: .Problem: Ineffective Breathing Pattern. Start Date: 12/20/23 .Goal: Resident's breathing pattern will be maintained. Interventions: Assess Resident for changes in orientation, increase restlessness, anxiety, and hunger .Monitor vital signs, lung sounds, and presence of secretion every shift. Notify physician for abnormal changes . Position resident with proper body alignment for optimal breathing pattern .Maintain a clear airway .Call Rapid Response for acute respiratory distress for immediate intervention . Of note, there was no documented evidence that facility staff included Resident #3's recent COVID-19 infection and hospitalization in the resident's comprehensive care plan. During a face-to-face interview on 01/06/23 at 10:38 AM, Employee #5 (Unit Manager) stated that facility staff did not include the Resident's recent COVID-19 infection and hospitalization in the Resident's comprehensive care plan. DCMR 3210.4

Based on record review and staff interviews, for two (2) of 16 sampled residents, facility staff failed to revise/update the comprehensive care plan with new goals and approaches that addressed: one (1) resident's family bringing in foods from outside the facility; and one (1) resident's fall. Residents' #277 and #278. The findings included: 1. Facility staff failed to revise/update Resident #277's nutritional care plan to include foods brought in from outside the facility. Policy NUSE-GEN061 dated 11/04/20 documented, .Food and Nutrition Services will not serve food prepared outside the food and nutrition services .The department of Food and Nutrition Services does not accept responsibility for patient illness resulting from foods provided by a family member or outside sources . Resident #277 was admitted to the facility on [DATE], with multiple diagnoses that included Asthma, Congestive Heart Failure, Chronic Lymphocytic Leukemia, Hypertension, and Hyponatremia. During an interview on 01/04/23 at 11:00 AM, Resident #277 stated, I only eat breakfast here. My family brings in my lunch and dinner. At this time, the private aide in the resident's room and resident's daughter both confirmed this statement made by Resident #277. Review of Resident #277's medical record revealed: Admission MDS dated [DATE] showed that facility staff coded a Brief Interview for Mental Status summary score of 15, indicating intact cognition; independent for eating; active diagnosis of Gastroesophageal Reflux Disease (GERD), or Ulcer (e.g. Esophageal, Gastric, and Peptic Ulcers); and was on a therapeutic diet (e.g., low salt, diabetic, low cholesterol). 12/15/22 [physician's order] Nutrition - Oral diet: Heart Healthy (low fat, sodium select) . 12/20/22 at 4:26 PM [Nutrition Recommendation (dietitian) Note] Continue Heart Healthy, 2 g (gram) Na+ (sodium) Diet with easy chew/IDD7 [International Dysphagia Diet Level 7 (Regular/easy to chew)] [and] diet texture; monitor PO (by mouth) intake and document on flow sheet the percentage of meals and volume of supplements consumed . 12/20/22 [Nutritional Assessment] RD (Registered Dietician) provided sitter with Heart Healthy 2gNA+ menu for ease of ordering, noting that some items may not be available due to the Easy to Chew/IDD7 diet texture . Pt (patient) caregiver at bedside stated that .family is bringing in pt lunch and dinner foods that are not in compliance w/heart healthy diet. Caregiver requesting to have pt diet transitioned to regular. Secure chat message sent to attending MD (medical doctor) w/this information. 12/27/22 at 9:56 AM [Nutrition Recommendation Note] Continue Heart Healthy, 2g Na+ Diet with Easy to Chew/IDD7 diet texture. Please consider liberalization to regular diet as pt does not like menu options and is having family bring in lunch and dinner daily. Secure chat sent to MD [with] request. Review of the Nutritional status care plan with a start date of 12/19/22, showed no documented evidence that the facility staff revised this care plan to indicate that Resident #277's family was bringing in foods from outside. During a face-to-face interview on 01/09/23 at 10:00 AM, Employee #4 (Director of Nutrition Food) acknowledged the findings and made no further comments. 2. Facility staff failed to update Resident #278's fall care plan after a fall. Resident #278 was admitted to the facility on [DATE] with multiple diagnoses that included: Sundowning, Spondylosis with Myelopathy, Hypertension and Hyperlipidemia. A Facility Reported Incident (FRI), DC00011445, received by the State Agency on 01/04/23 documented, . Around 12:23 [AM] [on] January 3, 2023, received call from 6B that patient could not reach his call button. Nurse went to patient room, found him lying on his back, beside his bed talking to someone on using the hospital phone. When asked what happened patient said, I tried to [sit] at the edge of the bed to use the urinal and I slid off the bed . Patient said I did not hit my head and I don't feel any hurt. Resident was examined and did not sustain any injuries. Review of Resident #278's medical record revealed the following: An Admission Minimum Data Set (MDS) dated [DATE], where facility staff coded: cognitively intact; extensive assistance with one-person physical assist for bed mobility and transfers; extensive assistance with two-person physical assist for walking in room; extensive assistance with two-person physical assist, for surface-to-surface transfer; functional limitation/impairment in range of motion in both upper and lower extremities; uses a walker for mobility; and no falls since admission/entry of reentry to the facility. 01/03/23 at 8:22 AM [Nurse progress note] Patient is alert x 3, around 0025 (12:25 AM) nurse received telephone call from 6B that patient could not reach his call button Nurse went to patient room and found patient lying on his back on the floor beside his bed. Patient said I wanted to seat at the edge of the bed to urinate but I slide off the bed. Patient is on Aspirin (blood thinner), house supervisor and Rapid Respond called to the unit. Patient denied [hitting] his head and stated he just slide off the bed to the floor .Patient remains stable, safety measures maintained . 01/03/23 at 1:54 AM [Physician progress note] . I saw the patient after rapid response was called for a fall. The patient states that he was sitting at the side of the bed to urinate and was bending over. He states that he did not have his prescription socks on and began to slip forward. He states that he slipped forward but was able to lower himself to the floor with his arms. He states he was down for about 10 minutes before being helped back into the bed by nursing .We will continue to monitor. 01/03/23 at 7:21 PM [Nurse's Note] .safety . and fall precautions in placed (sp) Review of the Fall care plan with a start date of 12/19/22, showed no documented evidence that facility staff revised it to include the actual fall on 01/03/22, or any new goals and approaches/interventions. During a face-to-face interview on 01/06/23 at 11:54 AM, Employee #5 (Charge Nurse) stated that the care plans are being reviewed. DCMR - 3210.4

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by: foods such as grilled chicken and beans that tested below 135 degrees Fahrenheit (F); inconsistent dish machine final rinse temperatures that were below 180 degrees Fahrenheit (F); and a crawling pest that was observed on the kitchen floor. The findings included: 1. Lunch food temperatures were inadequate and failed to test above 135 degrees Fahrenheit (F) or more during a food tray test on January 4, 2023, at approximately 1:00 PM, on two (2) of three (3) observations. Grilled chicken breast tested at 126 degrees Fahrenheit, and black beans tested at 127 degrees Fahrenheit. 2. Final rinse dish machine temperatures failed to reach 180 degrees Fahrenheit during observations on January 4, 2023. Dishes and utensils were disinfected with the disinfectant solution from the 3-compartment sink. Final rinse temperatures were normal on January 5, 2023, at approximately 2:30 PM 3. A crawling insect was observed on the kitchen floor near the grill during observations on January 5, 2023, at approximately 2:30 PM. Employee #4 acknowledged the findings on January 6, 2023, at approximately 10:00 AM.

Based on observation and staff interview, facility staff failed to maintain an effective pest control program as evidenced by a crawling pest observed on the floor, around the flat grill, in dietary services. The findings included: A crawling pest was seen on the kitchen floor, by the flat grill, on January 5, 2023, at approximately 2:30 PM. The vermin was removed and discarded by staff. Employee #4 (Director of Nutrition Food) acknowledged the findings on January 6, 2023, at approximately 10:00

Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by dish machine final rinse temperatures that were below 180 degress Fahrenheit on January 4, 2023, at approximately 2:30 PM. The findings included: During observation in dietary services on January 4, 2023, at approximately 2:30 PM, final rinse temperatures from the dish machine were about 154 degress Fahrenheit and did not reach a minimum of 180 degress Fahrenheit (F) as required. Dishes and utensils were disinfected from the three-compartment sink disinfectant solution. Final rinse temperatures were at or above 180 F on January 5, 2023, at approximately 2:30 PM Employee #4 acknowledged the findings on January 4, 2023, at approximately 3:00 PM.

Based on observation, record review, and resident and staff interview, facility staff failed to ensure that Resident #20, who was admitted to the facility with a bruise to the left heel received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent a deep tissue injury from developing for approximately 14 days, for one (1) of 17 sampled residents. The findings included . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration - Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/joint-commission-online/quick_safety_issue_25_july_ pdf.pdf?db=web&hash=A8BF4B1E486A6A67DD5210A2F36E0180 Resident #20 was admitted to the facility on [DATE], with multiple diagnoses, including Fracture of the (Right) Tibial Plateau, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (Assessment Reference Date of 03/24/21), doucmeted the following: in Section C0500 (Brief Interview for Mental Status), the resident had a summary score of 14, indicating the resident was cognitively intact. In Section M0300 (Current Number of Unhealed Pressure/Ulcers at Each Stage), skipped was documented, indicating Resident #20 did not have a pressure ulcer during the assessment period. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] 03/17/21 at 9:07 PM (Nursing Note) - sole of feet observed with hard skin . 03/18/21 at 3:39 PM (Wound/Ostomy Note) - patient seen today for wound care to surgical incision on right leg, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .offloaded heels, heels are dry, no redness noticed. It is sore to touch . A review of the Wound Nurse's picture of the Resident's left heel (scan date of 03/18/21) showed a dark area approximately the size of a quarter. Review of the Care Plan (Compromised Skin Integrity) with a start date of 03/18/2021, revealed the following interventions: .2. Observe and relieve pressure to boney prominences. 3. Avoid sheering. 4. Keep skin clean and dry .6. Apply or encourage use of lotion/moisturizer on intact skin as indicated .8. Consult with wound, ostomy and/or continence nurse as needed. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .non-weight bearing to RLE [right lower extremity] now presents with pressure sore of [heels L > R]. Although the physician ordered a specialized bed for the resident due to pressure sore(s) of heels, there was no doumented evidence of an assessment of the resident's left or right heel to determine the size, characteristic and staging of the pressure ulcer on 03/29/21. Review of the Nursing Flow sheet from 03/17/21 at 7:40 PM to 04/01/21 at 9:00 PM revealed the following: -Integumentary section [the form used by the nursing staff to monitor a resident's skin appearance every shift). The section was left blank indicating that nursing staff did not observe any impairment or discoloration to the residents left heel. - Pressure Ulcer Prevention Intervention section documented - suspend heels off [the] bed and heel pressure-offloading device . 04/01/21 at 10:30 AM (Wound/Ostomy Note): Subjective: pt [patient] said the left heel was burning last night, it feels somebody scraped the heel. The nurse put some cream on it .gave me some medicine. The pain finally went away . The [left] heel is black, hard to touch, it is very tender to touch. Recommend .x-ray .check for any traumatic changes . pain on left heel when it is touched 9 of 10. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the X-ray dated 04/01/21 at 4:45 PM of the Resident's left heel showed, Impression Osteopenia without acute osseous findings and [CONDITION(S)] changes. 04/01/21 at 5:49 PM (physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 04/02/21 at 5:54 PM (Wound/Ostomy Note) - Patient seen for pressure injury assessment and care. Location- left heel, stage - deep tissue injury .the heel has a localized black area, it is tender and firm to touch, skin is intact. It is likely deep tissue injury .Initial Pressure Injury Staging - Deep Tissue Pressure Injury, Length 3 cm (centimeters), Width 3.5 cm 04/08/21 at 1:00 PM (Wound/Ostomy Note) - The black discoloration on left heel remains dry and intact. Patient said it feels better, it is not tender anymore. Continue to offload the heels . 04/19/21 at 4:10 PM (Wound/Ostomy Note) - patient seen today .assess DTI (Deep Tissue Injury) on left heel .dry black eschar . A face-to-face interview was conducted with Resident #20 in her room on 04/21/2021, at approximately 5:00 PM. During this time, the resident was observed sitting up in the bed eating dinner and reported that there was pain to her left heel. An observation of Resident #20's left heel was conducted and revealed a darkened area that covered the resident's left heel. The area was intact and did not have drainage or smell. A cushion used to elevate the resident's feet/heel(s) was observed at the foot of the bed. At the time of the observation, the resident's heel was not on the cushion as the resident was eating dinner. During a face-to-face interview on 04/23/21 at 9:39 AM, the Director of Nursing (Employee #2), stated that nursing staff assess all resident's skin every shift and document findings on the flowsheets. There was no evidence that facility staff noted and treated the darkened area to Resident #20's left heel for approximately 14 days (3/29/2021) when there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] > R]. Four (4) days later on 04/02/21, the wound/ostomy nurse documented that the resident had an Initial Pressure Injury Staging - Deep Tissue Pressure Injury, Length 3 cm (centimeters), Width 3.5 cm The Care Plan/Compromised skin integrity was not updated with goals and approaches to address Resident #20's left heel (pressure) wound identified on 3/29/2021. During a face-to-face interview conducted on 04/23/2021, at approximately 1:00 PM, Employee #13 stated that she observed a bruise on Resident #20's left heel during her initial assessment on 03/18/2021. However, she did not inform staff about the bruise to the resident's left heel, but she did start the resident on Heelz Up (a pressure-relieving device). Employee #13 also said although she performed wound care to Resident #13's right knee surgical wound twice a week starting on 03/18/21, she did not re-assess the resident's left heel bruise again until 04/01/21 (15 days after her initial assessment) when the resident complained of pain. The left heel was staged as a deep tissue injury on 04/02/21. Employees #'s 1, 2, 13, and 15, acknowledged the finding.

Based on observations and staff interview, facility staff failed to prepare and distribute foods under sanitary conditions as evidenced by one (1) of two (2) soiled convection oven in the bake shop area, two (2) of two (2) soiled convection ovens in the patient hotline area, and 32 of 33 food service trays that were cracked at both handles. The findings included . During a walkthrough of dietary services on 04/19/2021, at approximately 11:15 AM, the following were observed: 1. One (1) of two (2) convection ovens in the bake shop area was soiled with burnt food residue. 2. Two (2) of two (2) convection ovens in the patient hotline area were soiled with burnt food residue. 3. 32 of 33 food service trays stored for use in the dishwashing machine area were cracked at both handles. Employee #4 acknowledged the findings during the walkthrough on 04/19/2021, at approximately 2:00 PM.

Based on record review and staff interview for six (6) of 21 sampled residents, it was determined that facility staff failed to provide the necessary care and services to ensure residents attain or maintain the highest practicable well-being as evidenced by failure to promote wound healing for one (1) resident with altered skin integrity that progressively worsened and developed into a pressure ulcer and failed to clarify physician orders [REDACTED]. Residents' # 258, 29, 273, 279, 280, and 281. The findings include: 1. Facility staff failed to implement necessary care and services when Resident #258 was assessed with [REDACTED]. A review of the clinical record for Resident #258 revealed the resident was admitted on [DATE]. According to the physician ' s History and Physical (H&P) examination dated August 4, 2014, the resident was admitted post acute hospitalization secondary to a chief complaint of " weakness " and new [DIAGNOSES REDACTED]. admitted to (skilled nursing facility named) on " August 4, 2014 for rehabilitation with PT/OT (physical and occupational therapy) and to start [MEDICAL CONDITION] and [MEDICAL CONDITION] therapy in 2 weeks ... "Additional [DIAGNOSES REDACTED]. The section of the H&P labeled 'Skin' read, "no rashes or [MEDICAL CONDITION] noted." A review of the admission Minimum Data Set (MDS) completed August 15, 2014 (ARD date August 11, 2014) revealed Resident #258 was coded as " 12 " under Section C, Cognitive Patterns, indicative that the resident was moderately impaired cognitively. Under Section G, Functional Status, the resident was coded as requiring extensive assistance for bed mobility, transfer, locomotion and bathing. He/she was coded as frequently incontinent of bowel and bladder in Section H and the areas designated to identify skin alterations under Section M, Skin Conditions remained blank, indicative of no skin impairment. The medical record (electronic health record) revealed that Resident #258 was admitted with skin impairment as noted in the following nurse ' s notes: August 4, 2014 (admitted ) at 1606 (4:06 PM), " sacral redness, barrier cream applied. " August 4, 2014 1945 (7:45 PM), " blanchable redness on sacrum, cream applied. " August 5, 2014 at 8:30 AM, " redness to sacrum, blanchable barrier cream applied " August 6, 2014 at 10:00 AM, " applied barrier cream to perianal and sacrum for redness " There was no evidence that nursing staff fully and/or consistently assessed the characteristics of Resident #258's skin impairment. There was no documented evidence of an assessment of the size (length, width and depth), type of tissue and presence (or absence) of odor. Nursing staff failed to notify the physician regarding Resident #258 ' s skin impairment. A period of approximately two (2) weeks lapsed (August 4 through August 18, 2014) before a request for wound consultation was initiated. A " barrier cream " was applied to the affected site for approximately two (2) weeks without evidence of effectiveness and the skin impairment progressively worsened as evidenced by the following nurse ' s notes: August 6, 2014 1600 (4PM) " redness on sacrum; turned every 2 hours " August 7, 2014 9:00 AM "redness to sacrum area, blanchable, barrier cream applied " August 7, 2014 1940 (7:40 PM) "redness on sacrum barrier cream applied" August 8, 2014 11:53 PM " (Dr named) called tonight due to patient complaint of burning sensation while urinated, new orders given " (Note: physician telephone order 8/8/14 for urinalysis, culture and sensitivity) August 9, 2014 2100 (11 PM) "bruising rashes in the groin area. Barrier cream applied at sacral area " August 9, 2014 1900 (7PM) " stage II pressure ulcer on midline sacrum " August 14, 2014 7:05 AM " Rash " August 14, 2014 2311 (11:11PM) " rash sacral area " August 17, 2014 4:33 PM " developed a stage two Decubitus to sacral with measurements of ? x ? cm and ? cm deep. Applied [MEDICATION NAME] to area and ordered a wound consult. We need to order a special mattress and aggressively do our turn and repositioning every 2 hours. " August 17, 2014 1900 (7PM) " excoriation, severe redness to anal area " August 18, 2014 7:12 AM " sacral decub is getting better, chart checked " August 19, 2014 7:21 AM " redness at sacral and perineal area " August 21, 2014 7:19 AM " (relative named) verbalized concerned about (him/her) condition ...(he/she) is out of it ...(resident) is sleepy and not eating and drinking. The nurse have noticed patients poor appetite and difficulty of drinking thin liquid. Patient was constantly coughing when water given ...notified doctor ... " August 24, 2014 8:38 AM " ...perineum is red with rash, sacrum stage 2 measuring 1.0 x 0.8 cm, it is red, treatment applied ... " August 30, (12M) " sacral stage 1 perineal excoriation " The wound specialist consultation was conducted on August 21, 2014 and the following was determined: Notes recorded by Wound Care Nurse: August 21, 2014 6:21 PM (wound specialist initial consult) " requested to see patient by staff for assessment of redness to buttocks and gluteal cleft ...skin is red on both buttocks with mild skin denudement ...indicative of a yeast infection. In addition, the patient has a small 1.0 x 1.0 cm open area in upper gluteal cleft which is moisture associated skin damage (MASD) due to patient ' s incontinence. This is not a pressure ulcer...apply [MEDICATION NAME] powder to yeast infection on medial buttocks and perineal area ...apply silver powder to small wound due to MASD and cover wth [MEDICATION NAME] skin barrier cream light coating only .... " (SIC) August 25, 2014 5:34 PM (4 days post initiation of treatment) (wound specialist) " follow-up wound care to perineal yeast rash ...the rash at the perineum, groins and inner are improving. Skin is less red, some peeling skin. The erosion on the sacrum is smaller ... " (SIC) September 4, 2014 2:36 PM (wound specialist) follow-up perineal yeast rash and erosion on sacrum ...the yeast rash and redness has improved by about 50%. There are some redness and rash at the inner thigh, groins, sacrum and buttocks ... " (SIC) A face-to-face interview was conducted with the Employee #14 (wound care nurse) on September 11, 2014 at approximately 2:00 PM. He/she stated that the initial wound specialty consultation revealed the resident had a yeast infection of the perineum and buttocks and [MEDICATION NAME] (antifungal (yeast) medication) was recommended. Follow up assessments revealed the affected areas were improving. An assessment of the site on September 11, 2014 revealed the site at the gluteal cleft was now a stage 2 Pressure Ulcer and treatment recommendations were made to the physician. According to physician's order [REDACTED]. August 16, 2014 [MEDICAL CONDITION] therapy (outpatient) Mondays, Wednesdays and Fridays August 21, 2014, [MEDICATION NAME] 100,000 unit/gram powder; apply 3 times daily for " rash " to buttocks, sacrum and inner thigh, then apply a thin layer of [MEDICATION NAME] cream (skin barrier cream) to seal in the [MEDICATION NAME] powder The record revealed that [MEDICATION NAME] 100mg daily (antineoplastic agent - oral [MEDICAL CONDITION]) was included in the resident's medication regimen during the period of August 13, 2014 through September 5, 2014. According to Nutrition notes, Resident #258 sustained significant weight loss and poor appetite as evidenced by the following: Initial nutrition assessment dated [DATE] read, " patient with 4 pound weight loss from 8/4/14 to 8/13/14 ...suboptimal oral intake related to exhaustion ...recommendations, feeding assistance, Ensure complete tid (three times daily) " Successive nutrition notes dated August 20, 27, September 3 and 8th included assessments, interventions and physician notification regarding the resident's nutritional status. The nutrition note proximal to the record review read as follows: Nutrition Follow-up, September 8, 2014, 3:43 PM " patient with 14 pound weight loss overall since admission ...on 8/4 with 10 pound weight loss seen in the last 7 days (from 8/20). Overall weight loss is 10.77% in less than one month - significant ...appetite poor but showing signs of improvement ...feeding assistance, regular diet, ensure complete tid (three times daily), " F ' real milkshake (daily), option of 6 small meals per day ... " Resident #258 was admitted with skin impairment assessed at the sacrum, a bony prominence located at the base of the spine (common site for pressure ulcers). Nursing staff failed to consistently assess and document a description of the resident ' s altered skin particularly since the impairment was located at a site commonly associated with pressure-related tissue necrosis. The nursing assessments recorded lacked information related to size, shape, characteristics, wound bed and the condition of surrounding tissues. (ref. Cuddigan Pressure Ulcers in America ). The nursing staff failed to identify the clinical basis of the skin impairment (e.g. pressure-related versus non-pressure-related) and recorded contrasting assessments as evidenced by nursing entries that read: "Stage 2 pressure ulcer "versus" redness of the sacrum." Nursing staff failed to notify the physician of the Resident #258's alteration in skin integrity. A period of approximately two (2) weeks (8/4/ - 17/14) lapsed before a wound consultation was requested. The staff applied skin barrier cream to the affected site for the period of August 4 through August 21, 2014 (date wound consult done) with progressive worsening of the affected site. Facility staff failed to implement necessary care and services for the management of skin impairment for Resident #258. The resident was moderately impaired nutritionally and was receiving [MEDICAL CONDITION] and [MEDICAL CONDITION] therapy. The skin impairment progressively worsened and progressed to a stage 2 pressure ulcer. 2. The facility staff failed to clarify physician's order [REDACTED].#29. A review of the physician's orders [REDACTED]. "Oral Supplements (Nutrition) Ensure Complete three times daily (or with each meal) for supplement" A review of the 'Medication Administration Record' (MAR) dated August 21, 2014 revealed the following order: "Oral Supplements (Nutrition) Ensure Complete three times daily (or with each meal) for supplement" The order lacked evidence of the dose or amount of Ensure Complete to be administered to Resident #29. A face-to-face interview was conducted with Employee #4 on September 9, 2014 at approximately 10:50 AM. He/she acknowledged the aforementioned findings. Facility staff failed to clarify the physician order [REDACTED]. 3. The facility staff failed to clarify physician's order [REDACTED].#279. A review of the physician's orders [REDACTED]. "Oral Supplements (Nutrition) Ensure Complete three times daily (or with each meal) for supplement. Pt. (Patient) prefers strawberry" A review of the MAR indicated [REDACTED] "Oral Supplements (Nutrition) Ensure Complete three times daily (or with each meal) for supplement. Pt. prefers strawberry" The order lacked evidence of the dose or amount of Ensure Complete to be administered to Resident #279. A face-to-face interview was conducted with Employee #4 on September 9, 2014 at approximately 10:50 AM. He/she acknowledged the aforementioned findings. Facility staff failed to clarify the physician order [REDACTED]. 4. The facility staff failed to clarify physician's order [REDACTED].#280. A review of the physician's orders [REDACTED]. "Oral Supplements (Nutrition) Vital 1.0 every morning for supplement" A review of the MAR indicated [REDACTED] "Oral Supplements (Nutrition) Vital 1.0 every morning for supplement" The order lacked evidence of the dose or amount of Vital 1.0 to be administered to Resident #280. A face-to-face interview was conducted with Employee #4 on September 9, 2014 at approximately 10:50 AM. He/she acknowledged the aforementioned findings. Facility staff failed to clarify the physician order [REDACTED]. 5. The facility staff failed to clarify physician's order [REDACTED].#281. A review of the physician's orders [REDACTED]. "Oral Supplements (Nutrition) Ensure Complete three times daily (or with each meal) for supplement "and "Oral Supplements (Nutrition) Magic Cup three times daily (or with each meal) for supplement" A review of the MAR indicated [REDACTED] "Oral Supplements (Nutrition) Ensure Complete three times daily (or with each meal) for supplement" and "Oral Supplements (Nutrition) Magic Cup three times daily (or with each meal) for supplement" The order lacked evidence of the dose or amount of Ensure Complete and Magic Cup to be administered to Resident #281. A face-to-face interview was conducted with Employee #4 on September 9, 2014 at approximately 10:50 AM. He/she acknowledged the aforementioned findings. Facility staff failed to clarify the physician order [REDACTED]. 6. Facility staff failed to administer insulin to Resident #273 in accordance with the physician's order [REDACTED]. A review of the electronic medical record revealed that on September 5, 2014 at 1712 (5:12 PM) resident's blood glucose reading was "237". The physician's order [REDACTED]. " The MAR for September 2014 revealed that nursing staff administered four (4) units of insulin on September 5, 2014 at " 1829 " (6:29 PM). According to the prescribed insulin schedule, the resident should have received three (3) units of insulin. There was no evidence the resident sustained [REDACTED]. A face-to-face interview was conducted with Employee #3 on September 10, 2014 at approximately 2:30 PM who acknowledged the findings. Facility staff failed to administer insulin in accordance with physician's order [REDACTED].

Based on record review and staff interview for one (1) of 34 sampled residents, it was determined that facility staff failed to identify an unplanned 10lbs weight loss within 30 days (from December 8, 2010 to January 12, 2011), a decrease in [MEDICATION NAME] and total protein laboratory values (from December 29, 2010 to January 10, 2011), and nutritional supplement that was not administered in accordance with physician's order [REDACTED]. The findings include: Facility staff failed to follow-up with Resident # 169 with documented unplanned weight loss of 4.73Kg/10 pounds from December 8, 2010 to January 12, 2011. A review of Resident # 169's clinical record revealed the followings: The resident was admitted to the facility on [DATE] and was discharged on [DATE] A physician signed "History and Physical" report dated November 30, 2010. The history and physical report indicated that the resident had an active medical problem of recurrent aspiration peg tube placement. The resident's admission [DIAGNOSES REDACTED]. The resident's other past medical history included positive history of [MEDICAL CONDITION], S/P Appendectomy, [MEDICAL CONDITION], and Hyperlipemia. A review of the facility's Chart Review Trend Report for Resident #169 revealed the following weights: DateWeight in Kilograms (kg)Weight in Pounds (lbs.)November 30, 3.36 kg183 lbs.December 7, 2.73 kg182 lbs.December 8, 2.73 kg182 lbs.December 15, 2.72 kg182 lbs.December 22, 1.09 kg178 lbs.December 30, 0.00 kg176 lbs.January 5, 9.09 kg174 lbs.January 12, 8.00 kg172 lbs. According to the documentation of weights on the facility's Chart Review Trend Report, the resident had an unplanned 4.73Kg / 10 pound weight lost (6%: a severe weight loss) between December 8, 2010 and January 12, 2011's as follows: 0.55% from first weight to obtained on 11/30/2010 to the weight on 12/15/10. 3.83% from the first weight obtained on 11/30/2010 to the weight obtained on 12/30/10. 6.4% from the first weight obtained on 11/30/2010 to weight obtained on 01/12/2011. A review of the resident's clinical record failed to reveal any documentation that addressed the resident's unplanned weight loss of 10 pounds as a severe weight loss. On January 10, 2010, the Dietician's nutrition assessment reviewed the resident's weight record. He/she noted: "stable without significant changes." He/she failed to address the resident's progressive unplanned weight loss of 8 pounds when he/she noted weights for December 7, 2010 as 182 pounds and January 5, 2011 as 174 pounds. In his/her intervention, he/she noted "Continue on current diet order." The dietician's nutrition assessment of January 17, 2011 failed to identify the resident's unplanned 10 pounds weight loss as a severe weight loss. The resident's documented unplanned weight loss on January 12, 2011 was not reviewed by the dietician until January 17, 2011. The resident lost 10 pounds between December 8, 2010 and January 12, 2011: a weight loss of 6%. On January 10 and 17, 2011, the dietician's nutrition intervention noted "Continue on current diet order: [MEDICATION NAME] 1.6 cans per day with 80ml water flush before and after each [MEDICATION NAME], 1 scoop protein powder TID (Three times daily)... Weigh weekly...Encourage and monitor po intake. Recommend initiating 3 day calorie count to determine po intake. " The resident's clinical record lacked documented evidence that facility staff followed-up with the dietician's nutrition intervention to obtain 3-day calorie count to determine po intake. On January 20, 2011 at 1447 (4:47PM), the dietician ' s nutrition consult noted "Attempted to calculate three day calorie count results, only [MEDICATION NAME] feeding recorded. Scheduled for discharge tomorrow, Friday (1/21 per chart. In addition the facility's weight policy a resident with a weight loss greater than 5 pounds should be re-weighed within 48 hours. The resident's clinical record lacked documented evidence that the resident was re-weighed after a documented weight loss of 4.73Kg/10 pounds between December 8, 2010 and January 12, 2011. The dietitian's interventions after the nutrition consult/assessment of January 10, 2011 included weekly weights. There was no evidence in the resident's clinical record that the resident was weighed on January 19, 2011. A further review of the resident's clinical record revealed the following laboratory results: Date [MEDICATION NAME] Total Protein December 29, 2010 3.0 5 December 31, 2010 [MEDICATION NAME] 20.3 January 10, 2011 2.9 5.6 [MEDICATION NAME] reference Range (RG). 3.5-5.0) GM/DL [MEDICATION NAME] Reference 21.0 - 43.0 Unit: mg/dL Total Protein Reference Range 5.9 - 8.1 gm/dl A further review of the resident's clinical record including the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A review of the resident ' s MAR indicated [REDACTED]'s initials across the entry for "1 scoop protein powder via peg tube bid " on the MAR. As evidenced by the absence of facility's staff initials against the entry for " 1 scoop protein powder via peg tube bid", a review of the resident's MAR indicated 1 scoop protein powder in 4 ounces of water BID" was administered as per the physician's orders [REDACTED]. January 1, 2011 at 2000. January 6, 2011 at 2200. January 10, 2011 at 2200 Furthermore, as evidenced by the absence of facility ' s staff initials against the entry for " [MEDICATION NAME] 1.5cal 1 can Q4hrs ... " the resident ' s MAR indicated [REDACTED] January 7, 2011 at " 0400 " January 9, 2011 at " 0000 and 0400 " January 10, 2011 at " 2200 " A face-to-face interview was conducted with Employee # 3 on May 3, 2011 at approximately 12:55 PM. After a review of the resident ' s clinical record including the dietician ' s notes and the MAR, he/she acknowledged the aforementioned findings. The dietician's nutrition consult of January 17, 2011 stated Labs: no recent labs since 1/10/2011. The resident's clinical record lacked documented evidence that facility staff addressed the resident's progressive decrease of laboratory values for [MEDICATION NAME], pre-[MEDICATION NAME] and total protein between December 29, 2010 and January 10, 2011. A follow-up face-to-face interview was conducted with Employee #27 at approximately 10:00AM on May 3, 2011. He/she stated, "I was not aware of the resident's weight loss until January 17, 2011, and I do not have a record that a re-weigh was assessed. When I returned to follow-up with the resident, I was told he/she was discharged . A face-to-face interview was conducted with Employee #3 on May 3, 2011 at approximately 1:00 PM. When queried about the resident's weight loss of 10 pounds between December 8, 2010 and January 12, 2011, after a review of the resident's clinical record, he/she stated that the only reliable weight record for the facility is what is documented in the computer. Employee #3 stated that per the facility's policy, when a resident presented with a weight loss of 5 pounds or more within a month that the resident must be re-weighed within 48 hours. Employee further added that there's was no documented evidence that a re-weigh assessment was done after the resident presented with a weight loss of 8 pounds between December 7, 2010 and January 5, 2011 and a weight loss 10 pounds between December 8, 2010 and January 12, 2011. When queried regarding the dietician's three day calorie count intervention to determine PO intake, after a review of the resident's clinical record, Employee #3 replied, "It is not in the record. It was not done." A follow-up telephone interview was conducted on May 5, 2011 at approximately 11:00 AM, with Employees # 2 and #5. They both stated that the built-in scale in the resident's bed offered an added security of obtaining an accurate and consistent weight while he/she is in bed. Both Employees #2 and #5 acknowledged that the resident's clinical record lacked a documented evidence that the resident was re-weighed when the resident presented with a weight loss of 8 pounds between December 7, 2010 and January 5, 2011 and a weight loss 10 pounds (6%) between December 8, 2010 and January 12, 2011. Employee # 5 added that the "tech/CNA" weighs the resident and a registered nurse confirms the weight for accuracy. Employee # 5 further added, both the CNA and the nurse are privileged to view the trend of the weight and should have noted the weight loss and perform a re-weigh per the facility ' s policy for a re-weigh within 48 hours for a weight loss of 5 pound or greater in a month. When queried regarding the dietician's three day calorie count intervention to determine po intake, after a review of the resident's clinical record, Employees #2 and 5 stated "It was not done." The facility staff failed to follow-up on the resident's severe unplanned weight loss. The resident's weight was not obtained after the weight obtained on January 12, 2011 that indicated a weight loss of approximately 10 pounds or 4.73Kg (6%) between December 8, 2010 and January 12, 2011. There was no documented evidence that the responsible party was informed of the resident's unplanned weight loss. The record was reviewed May 3, 2011.