Every finding on record at Stoddard Baptist Nursing Home

Based on observations, medical record review and staff interviews for two (2) of six (6) sampled residents, facility staff failed to ensure interventions were implemented for a resident who was status post cervical laminectomy and required assistance from staff with transfers; and for a resident with a history of Dementia and Left Below the Knee Amputation (BKA) who required 2-person assistance while performing Activities of Daily Living (ADL) care. Residents' #34 and #35. The findings included: An undated facility policy titled 'Activities of Daily Living' documented in part, [Nursing home facility's name] will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in Activities of Daily Living (ADLs) do not deteriorate and Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 2. Transfer and ambulation. 3. Toileting and A resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, personal and oral hygiene. 1.Resident #34 was admitted to the facility on [DATE] with multiple diagnoses that included: Peripheral Vascular Disease, Status Post Left BKA, Diabetes Mellitus Type II, Anemia and Hypertension. A care plan Focus area initiated 04/05/24 documented in part: [Resident #34's name] has limited physical mobility r/t (related to) BKA and revised Intervention dated 05/28/25 that documented, Resident is a two person assist with ADLs. A physician's order dated 05/28/25 documented, Resident is a two person assist with ADLs every shift. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '10,' indicating the resident was moderately impaired. Functional goals and abilities that documented the resident was totally dependent on staff for all ADLs. A review of certified nursing assistants (CNAs) task sheet dated November 2025 documented that the resident is a two-person assist with ADLs. During a face-to-face interview conducted on 11/19/25 at approximately 3:00 PM, Employee #6 (Certified Nursing Assistant, CNA) stated, I don't call anybody to come with me to clean her; I only call someone if she's agitated. Her care plan says no male CNA can work with her, but I don't know about if it she needs two people to work with her. During a face-to-face interview conducted on 11/19/25 at approximately 4:30 PM, Employee #5 (Unit Manager) acknowledged the findings and stated, They [CNAs] do the 2 people [assistance] so one can validate the other if something is alleged. For meal tray, one person can take her tray into her [room], but for ADL care two people are supposed to do it. I don't know if that's happening all the time when I'm not here. 2.Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Spinal Stenosis, Cervical Laminectomy and Chronic Obstructive Pulmonary Disease. An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating the resident was cognitively intact. Functional goals and abilities that documented that the resident was totally dependent on staff for toileting, personal hygiene, oral hygiene and required maximal assistance from staff for transfers. A care plan Focus area dated 11/14/25 documented, [Resident #35's name] has an ADL self-care performance deficit r/t (related to) cervical laminectomy and Interventions that documented, TRANSFER: The resident is usually dependent on 1-2 [one to two] staff to move between surfaces. During an observation conducted on 11/17/25 at approximately 12:30 PM, facility staff were observed leaving clean linen at the bedside for ADL care to be performed by Resident #35 alone. It should be noted that Resident #35 stated, They leave me by myself when I go to the bathroom to wash myself; they supposed to be monitoring me when I get up. During a face-to-face interview conducted on 11/17/25 at approximately 2:19 PM, Employee #3 (Assistant Director of Nursing/ADON) acknowledged the findings and stated, [Resident #35's name] should be with at least one person during transfers at all times. That's unacceptable if that's not happening.

Based on observations, medical record review and staff interviews for one (1) of six (6) sampled residents, facility staff failed to provide a resident with food prepared by methods that conserve nutritive value, flavor, appearance, and that is palatable and attractive. Resident #35. A review of Resident #35's medical record revealed: Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Spinal Stenosis, Cervical Laminectomy and Chronic Obstructive Pulmonary Disease. An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating the resident was cognitively intact. A review of the facility's resident lunch menu dated 11/17/25 documented: Cream of Mushroom Soup, Tuna Macaroni, Peas & Carrots, Crackers and Strawberry Yogurt. During an observation conducted on 11/17/25 at approximately 12:34 PM, Resident #35's lunch tray was noted on the bedside table untouched. The resident stated she was hungry but didn't eat her lunch because she didn't know what it was and she didn't like it and asked if the surveyor would eat something that looked like that. It should be noted that the lunch tray contained a plate with an item that appeared to have been mashed and mixed with small-sized pasta and a small saucer that contained a soft, white unidentifiable food item that looked like mayonnaise. It should also be noted that the resident's meal ticket documented, [Resident #35's name], room number and Regular Meals, Thin Liquids however, the lunch menu was not listed on the meal ticket. During a face-to-face interview conducted on 11/17/25 at approximately 2:30 PM, Employee #4 (Dietary Supervisor) acknowledged the findings and stated, Yes, I can see that it doesn't look appealing, it looks like slop. Our dietary aides plate the food. I will work with them to make the food more appealing when it is plated.

Based on observations, record reviews and staff interviews for one (1) of seven (7) sampled residents, the facility staff failed to ensure that a resident had adequate assistance while being transferred from the wheelchair to the bed in the resident's room and subsequently the resident sustained injuries and was transferred to the hospital emergency room. Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia, Chronic Atrial Fibrillation and Muscle Weakness. A Facility Reported Incident (FRI) DC~13527 was submitted to the State Agency on 03/14/25 at 10:41 PM, that documented the following: On March 14, 2025, around 21:45 (9:45 PM), Nursing Assistant Ms. (Employee Name) was providing care for resident (Resident Name). After she transferred (Resident Name) on bed, she noted that he had blood coming from his mouth and nose. Once the nursing assistant observed the bleeding, she notified the nurse, nurses attempted to control the bleeding coming from the resident's nose. Nurse (Employee name) performed a complete body and noted a hematoma to (Resident's) right lower leg, which showed no discoloration. A review of Resident #1's medical record revealed the following: A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as having impairment on one side in the upper extremities and impairment on both sides in the lower extremities. The facility staff coded that the resident was dependent on staff with a helper doing all the effort for toileting, personal hygiene and to transfer from chair (wheelchair) to bed. The facility staff coded that the resident uses a manual wheelchair. A review of the State Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident is sometimes understood- ability is limited to making concrete requests and for Cognitive skills for daily decision-making staff coded the resident as being severely impaired- never/rarely made decisions. The facility staff coded the resident as needing a 2-person physical assist and extensive assistance for Transfers-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. The facility staff coded that the resident does not have one or more unhealed pressure ulcers/injuries and as having no venous or arterial ulcers. The facility staff coded that the resident has no other ulcers wounds or skin problems present. It is noted that there was no significant change Minimum Data Set assessment in the resident's medical record dated from 11/25/2024 to 03/14/2025. A review of the documents titled Skin Monitoring: CNA (certified nurse aide) shower report dated 03/03/25 and 03/10/25 both show handwritten documentation that states skin intact and they are both signed by a charge nurse. A review of the document titled Skin Check dated 03/03/25 at 7:29 PM, which is the weekly skin assessment showed that the facility staff did not code any skin issues on either legs or feet for the resident. A review of the document titled Skin Check dated 03/10/25 at 10:08 PM, which is the weekly skin assessment showed that the facility staff marked no skin issues for the resident. It is noted that Resident #1 had no skin issues documented in the medical record in three months prior to 03/14/25. A review of a nursing progress note dated 03/14/25 at 11:44 PM documented the following This writer was called to room [ROOM NUMBER]A by the assigned CNA (certified nursing assistant) reporting resident is bleeding upon assessment resident was observed bleeding from the nose and mouth. Hematoma also noted to his right foot. The write (r) (sp) was unable to control the bleeding. Howevernosebleed (spelling - however nosebleed) was managed with pressure but unresolved. The hematoma to his right leg was swollen but no active bleeding noted. Resident show signs of pain when right foot was touched /moved. No signs of dizziness or distress noted. Breathing is normal. Gentle pressure applied to stop nosebleed (sp). Assessed hematoma for changes in size, color, or pain. right foot elevated and cold compress applied. MD (medical doctor) notified. Order given to transfer resident to the ER for further evaluation. 911 was called and arrived at 22:30 (10:30 PM). Resident was transfer to (hospital name abbreviation) at 23:10 (11:10 PM) via stretcher. RP (Resident Representative) made aware. A review of a nursing progress note dated 03/15/25 at 12:57 AM, documented the following: Observed the resident is sitting in bed without gown and the charge nurse and the CNA (certified nurse aide) at the bedside, assisting Mr. (resident name) and providing care to stop bleeding from the nose and mouth. provide assistance to the resident r/t (related to) nose bleeding by applying gentle pressure nostrils and Ice cubes on the forehead/nose bridge to stop active bleeding for the duration of 5 to 15 mint (minutes) (sp) between 9:30pm to 9: 45pm, able to redirect resident, effective to calm, but unable to stop bleeding. Moderate amount of bleeding from nose and mouth noted via apply 4X4 gaze (gauze) (sp) multiple time. The resident was unable to provide statement regarding. The resident repeated the same word aaaa aaaa aaaa upon assessment observed bump/hematoma to the right lower extremity, no s/s (signs symptoms) of pain or distress noted. Resident was able to move the right leg without any pain, but unable to provide further detail. Provide assistance with incontinent care A physician order dated 03/14/25 documented Transfer to ER (emergency room) A review of a hospital face sheet showed that the resident was admitted to the hospital on [DATE] with an admitting diagnosis of leg hematoma. A review of a hospital document titled Progress Notes-Physician dated 03/17/25 at 2:44 PM, documented the following: presents as Trauma [NAME] (SIC) after being found down. Primary survey revealed no acute life -threatening injury. Secondary survey revealed dried blood over the upper lip, hematoma on the right anterior shin, dried blood bilateral digits. All trauma imaging negative for acute traumatic injury except for a mesentry (mesentery) (sp) contusion on CT (computed tomography). Concerns for elder abuse, so admitted for safe discharge plan. Now w (with) (sp)/ concerns for infection of RLE (right lower extremity) hematoma, plan for OR (operating room) for debridement Wednesday. A review of a hospital document titled Operative Reports dated 03/20/25, documented the following: Indication for surgery RLE (right lower extremity) infected hematoma Operation right lower extremity wound debridement 3X5CM2 (centimeters), wound vac placement, right. Findings superficial necrotic eschar excised, approx (approximately) (sp) 25 cc of old hematoma evacuated, no frank purulence noted. Fibular exposed with intact periosteum. white sponge was attached to black sponge with staple, laid along wound base with white sponge toward exposed fibula. Wound size 3x5 cm (centimeters) at the end of case with some tunneling superiorly. It is noted that the resident was assessed with a right leg wound, identified by facility staff as a hematoma sustained during transfer from wheelchair to bed. The right leg wound was assessed by hospital staff with areas of necrosis and required surgical intervention. An observation was conducted on 04/21/25 at approximately 11:00 AM, Resident #1 was observed in the day room on the first floor sitting in a wheelchair and looking out a large window. Resident #1 responded to his name and made incoherent speech and nodded head but otherwise not interviewable. A review of the facility's incident investigation which contained a typed telephone interview from Resident #1's assigned CNA (Employee #5). The typed telephone interview dated 03/17/25 at 2:15 PM, documented the following: On March 17, 2025, the DON (director of nursing) and ADON (assistant director of nursing) of (facility name) called (Employee #5 (certified nurse aide) to obtain her statement regarding the incident that occurred on March 14, 2025. She (Employee #5) mentioned that Resident #1 started to remove his brief and had feces all over himself and on the floor. Therefore when she transferred (Resident #1), she did not want to get her clothes soiled from the bowel movement. She then put her arms under his quickly transferred him to the bed. She did state that she held the resident a little further away from her body to prevent him from getting bowel movement onto her clothes. When she got to the bed, she placed him on the bed. Unfortunately, she stated that the resident hit his face. When asked what happened to the resident's leg, she mentioned that she forgot to take the foot rest off and that they were still up during transfer. (Employee #5) was asked why she continued to provide care if the resident was agitated and yelling. She stated that she felt she could transfer him to the bed quickly and get assistance to get him cleaned up. (Employee #5) stated that after she saw the resident's face bleeding, she called the nurse and began cleaning the blood noted on the bed. It is noted that Employee #5 attempted to transfer the resident on 03/14/25, without the assistance of at least 1 other staff member as required by the resident's State Minimum Data Set assessment dated [DATE]. Review of Employee #5's human resource record revealed a document titled Review Discussion Form dated 03/21/25 documented the following: Final written warning (performance) date of incident 03/14/25, Date of conversation 03/21/25, Description of incident: Employee transferred a resident from the wheelchair to the bed utilizing unsafe practices. As a result, the resident sustained facial and leg injuries. Because of this incident, the resident was hospitalized and will return to the facility with a wound vac for his leg injury. It is noted that the involved CNA Employee #5 was terminated from the facility on 03/25/25 and the last time Employee #5 clocked into work was 03/14/25 according to the time submission which was reviewed. During a telephone interview conducted on 04/23/25 at approximately 11:30 AM, Employee #9 (LPN licensed practical nurse supervisor) stated that the residents nurse called him to the room, and he saw that the resident was bleeding from his nose, and he had a bruise on his right leg. Employee #9 went on to state that Resident #1 was yelling words he could not understand. The EMS (emergency medical services) would not take the resident until the police got there. During a face-to-face interview conducted on 04/23/25 at 4:07 PM, Employee #1 (Administrator) stated that the CNA (certified nurse aide) (Employee #5) was taken off the unit on 03/14/25 and never returned. Employee #1 went on to state that the employee (Employee #5) was terminated for violation of safety rules. During a face-to-face interview conducted on 04/24/25 at 12:57 PM, Employee #2 (Director of Nursing) stated that the resident did not have any wounds prior to the incident that occurred on 03/14/25 when a CNA attempted to transfer the resident from the wheelchair to the bed. When the surveyor asked about the necrotic tissue debridement that was documented in the hospital documentation Employee #1 stated that They did an evacuation of the hematoma, they opened it (hematoma) in the hospital. He did not have any wounds prior to when he went to the hospital. Cross Reference 22B DCMR Sec. 3211.1 (d) *******************************************************

Based on record reviews and staff interviews for two (2) of seven (7) sampled residents, the facility staff failed to report an allegation of abuse to the State agency in the required timeframe as evidenced by an incident involving a resident-to-resident altercation first documented by the facility on 02/25/25 but not reported to the State agency until 03/03/25. Resident #2 and #3. The findings included: A review of the facility policy titled Prohibition of Resident Abuse/Abuse Prevention updated in 2024, documented the following: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 'Willful' means the individual must have acted deliberately, not that he/she [NAME] have intended to inflict injury or harm. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Reporting/Response Anyone who suspects or witnesses an alleged incident of resident abuse (to include resident to resident) is required to report the incident to the Nursing Supervisor or department head immediately, but not less than 2 hours, if the alleged violation involves abuse or results in serious bodily injury. The Nursing Supervisor/department head will immediately initiate an investigation and give an oral report to the administrator. If the findings are substantial, a report will be submitted to the Department of Health Licensing Regulation Administration (DHLRA). 1A. Resident #2 was admitted to the facility on [DATE] with multiple diagnosis that included the following: Unspecified Dementia, Personal History of Traumatic Brain injury, Blindness Left Eye Category 4, Normal Vision Right Eye, Adjustment Disorder, and Age-Related Nuclear Cataract Right Eye. A review of a Facility Reported Incident (FRI) DC ~13500 submitted to the state agency on 03/03/25 at 7:05 PM, documented the following: On February 25, 2025, (Resident #2) was noted with two scratches to his left hand. MD (medical doctor) was notified as week as RP (resident representative). New orders obtained for bacitracin treatment to the areas until resolved. The two areas that were noted on (Resident #2)'s left hand has since resolved and the treatment discontinued. On March 3 2025 (Resident #2) was interviewed regarding the areas noted. Upon being interviewed (Resident #2) stated that he was in a fight and that's how he sustained the scratches to his hand. During this interview (Resident #2) was asked if he had experienced any pain regarding these areas, in which he replied no. Investigation is in progress . On February 25, 2025, around 11:05p.m., (Resident #2) was involved in a verbal altercation with his roommate. (Resident #3), which was overheard by nursing staff. The nursing supervisor noted two scratches on resident's left hand. Initially, when (Resident #2) was asked about the etiology of the scratch, he told the nursing supervisor that he was not sure of how he sustained those scratches. Additionally, (Resident #3) was interviewed on the day of the incident about the scratched noted on Mr. (Resident #2)'s left hand and he stated that 'I don't know nothing'. On March 3, 2025 Mr. (Resident #2) was asked by the Director of Nursing about the two scratches that he has obtained to his left hand. Initially the resident stated that it is 'none of your business'. After continuing to speak to Mr. (Resident #2) he stated that he was in a fight. Mr. (Resident #2) was than asked who he was in a fight with, and he replied that he was in a fight with his previous roommate. Immediate Action(s): The two resident's were immediately separated when the altercation was observed, and Mr. (Resident #3) was transferred to another room. Both residents were interviewed at the time and none of the residents stated that they were in a physical altercation. Scratches on Mr. (Resident #2)'s hand were noted on February 25, 2025. The initial assessment of the scratches was done by the supervisor on duty. The supervisor noted that the scratches were superficial and that no active bleeding was noted .Education was started with staff with a focus on how to deal with resident-to-resident altercations and the reporting process. Currently Mr. (Resident #3) no longer resides at (Facility Name) . A review of Resident #2's medical record revealed the following: A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as having a Brief Interview for Mental Status (BIMS) summary score of 5 which indicates severe cognitive impairment. The facility staff coded the resident as having no impairment in the upper and lower extremity. A review of a Health Status Progress Note dated 02/25/25 at 11:39 PM, documented the following: At 11:12pm, writer was called to room [ROOM NUMBER] by staff, getting in both (Resident #2) and his room mate were facing each other. Mr. (Resident #2) verbalized go out of his room. Writer tried to calm them down, then noticed scratch from his LT (sp) upper hand, cleanse with NSS (normal saline solution) then said it ok. Refused to be measured. Room mate taken out of the room to the Nurses station. A review of a e-Interact SBAR (Situation Background Assessment Recommendation) Progress noted dated 02/25/25 at 11:46 PM documented the following: Nursing observations, evaluation, and recommendations are: no more bleeding, Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: Cleanse with NSS (normal saline solution), Pat dry and apply bacitracin (antibiotic) ointment BID (twice daily) until resolved. A review of a Health Status Progress Note dated 02/26/25 at 3:05 AM, documented the following: Observed resident has scratch 3cm (centimeters) x(times) 0.1 x(times) 0 cm LT (sp) upper hand, no active bleeding, assess resident, alert and orient x3, verbally responsive, denies pain and discomfort, resident stated 'My roommate coming to my bed making trouble'. Cleanse with normal saline pat and dry, apply bacitracin ointment as Order, MD made aware, on duty nurse was unable to communicate with POA (power of attorney), safety precautions maintained separate both roommate, monitor 1/1, resident remained stayed in 108-B no room change for Mr. (Resident #2), resident verbalized to remain quite and stated 'I do not want MR. (Resident #3) in my room' . staff will continue to provide assistance and support It is noted that the facility reported the incident on 03/03/25 in which resident was observed with scratches on his hand, however this was first documented in the medical record on 02/25/25. A review of a Health Status Progress Note dated 03/03/25 at 1:24 PM documented the following Late Entry Resident verbalized he got he had and altercation with his roommate. A review of a Nursing Progress Note dated 03/03/25 at 5:17 PM, documented the following: Writer went to assess resident's scratches and asked resident how he sustained them. Resident stated that he was in a fight. After resident said he was in a fight, writer asked resident with who in which he replied, none of your business. Writer thenasked (sp) if he was in a fight with the previous roommate and he stated 'yes'. He also stated that the persons name was 'on the door'. MD (medical doctor)/RP (resident representative) updated. An observation was conducted on 04/24/25 at approximately 10:30 AM in which Resident #2 was observed in his assigned single occupancy room sitting in a chair and wearing sweat pants and a sweatshirt. Resident was observed sleeping. 1B. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Alzheimer's Disease with Early Onset, Unspecified Dementia Unspecified Severity, With Other Behavioral Disturbance, and Transient Ischemic Attack (TIA) and Cerebral Infarction Without Residual Deficits. It is noted that Resident #3 was transferred from the facility on 02/26/25 due to a psychiatric emergency and the Resident #3 has not returned to the facility. A review of Resident #3's medical record revealed the following. A review of a Nursing Progress Note dated 02/26/25 at 2:28 AM, documented the following: The writer was called by nursing staff, observed Mr. (Resident #3) is standing in common dining area close to the dietary cart and holding metal bar in hand but quit and the staff standing away close to the elevator and nursing stations. The writer calmly/nicely communicate and able to redirect the resident and able get the metal bar, resident calmly and nicely put the metal bar. redirect the resident to the common area close to the nursing station, upon assessment resident has an argument with roommate, Mr. (Resident #3) 'I will not move out from my bed or room.' Observed Mr. (Resident#3) want to go to room [ROOM NUMBER] A, walked with client to prevent any harm or injury, but his roommate stopping him. The writer was able to redirect both clients and remain stayed between both client not to have any argument, successfully separate both resident nicely and calmly, called Mr. (Resident #3) spouse POA, resident agree to stay in room [ROOM NUMBER] A for the night. A review of a Health Status Progress Note dated 02/26/25 at 2:15 PM, documented: Resident become very aggressive, Agitated, Paranoia, hitting kicking and scratching staffs. Staff were unable to redirect, after multiple times. Resident seeking exit, unit manager wascalled (sp) and also tried to redirect resident but was unsuccessful. Resident continue to swing at staff with on(un) (sp) steady gait. Resident refuse to sit down. Resident become danger to self and other. A review of a Health Status Progress dated 02/26/25 at 3:30 PM, documented the following: Resident was still in the hall way with uncontrolled behavior. Called Ms. (Resident Representative name), explained and informed her regarding resident behavior that earlier staff notified the writer that resident hit and spit on them. Resident was seen by the weiterat (sp) the exit door and tried to redirected to the dining area. called the nurse assigned on him (employee name) on other resident room near the exit door to help the writer redirected, resident was became combative and hit nurse (employee name) to. He keep speaking a different language which identified by the staff as Jamaican patois (sp). Staff and security came and help redirected the resident. Resident follow them at the dining area but unfortunately resident tried to escape again toward the exit doors which couldn't manage anymore that resident start kicking, hitting, scratching staffs and entering other resident room. Several behavioral redirection strategies has been offered, made and unsuccessful. Resident tried to enter room [ROOM NUMBER] DON (Director of Nursing) tried to redirectedthe (sp) resident and resident held pants and arms of DON that was so tight which she couldn't move at the door. Resident behavior couldn't be manage and R/P (resident representative) was informed that MD (medical doctor) made aware to and the recommendation was to sent to ER (emergency room) for further evaluation. 911 has been called as well. R/P verbalized understanding and agreed to sent the resident to the hospital. 2:49PM, 2 EMS (Emergency Medical Services) personnel came and they are awaiting for Police officer to come as well. 3:40PM, police came and they talk to wife to and wife consented them to bring resident to the hospital. resident left the unit at 4PM via stretcher accompanied by 2 EMS and 2 Police personnel. It is noted that the facility did not report Resident #3's combative behavior that is documented in the medical record on 02/26/25 at 3:30 PM, to the State Agency. A review of a Nursing progress Note dated 03/04/25 at 2:46 PM, documented the following: Resident is discharged from the facility. However, writer called wife to inform her of on ongoing investigation regarding the resident and his former roommate. It was mentioned by the other resident in room [ROOM NUMBER]B that he got into a physical altercation with the resident. Wife is aware. Investigation in progress. A review of a physician order dated 02/26/25 documented Transfer to nearest ER (emergency room) for further evaluation. It is noted that an altercation between Resident #3 and Resident #2 was first documented on 02/25/25 and the facility staff did not notify the state agency until 03/03/25 at 7:05 PM. It is also noted that the facility made no separate notifications to the state agency or the ombudsman office of Resident #3's combativeness and exit seeking behaviors documented on 02/26/25. During a face-to-face interview conducted on 04/24/25 at approximately 1:00PM, Employee #2 (Director of Nursing) stated that Do you need to report just a verbal altercation? I did not know that. I interviewed (Resident #2) and that is when I found out that he had an altercation with his roommate. Cross Reference 22B DCMR Sec. 3232.5 ************************************************

Based on record reviews and staff interviews for one (1) of seven (7) sampled residents, the facility staff failed to develop a care plan for a resident who required a 2-person physical assist when transferring from the wheelchair to the bed. Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia, Chronic Atrial Fibrillation and Muscle Weakness. A Facility Reported Incident (FRI) DC~13527 was submitted to the State Agency on 03/14/25 at 10:41 PM, that documented the following: On March 14, 2025, around 21:45 (9:45 PM), Nursing Assistant Ms. (Employee Name) was providing care for resident (Resident Name). After she transferred (Resident Name) on bed, she noted that he had blood coming from his mouth and nose. Once the nursing assistant observed the bleeding, she notified the nurse, nurses attempted to control the bleeding coming from the residents nose. Nurse (Employee name) performed a complete body and noted a hematoma to (Resident's) right lower leg, which showed no discoloration. A review of Resident #1's medical record revealed the following: A review of the State Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as needing a 2-person physical assist and extensive assistance for Transfers-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. A review of Resident #1's care plan revealed that it lacked documented evidence that the resident required a 2-person physical assist and extensive assistance for transfers from the wheelchair to the bed. During a telephone interview conducted on 04/23/25 at 2:17 PM, with Employee #7 (MDS Coordinator stated that Resident #1's State Minimum Data Set assessment dated [DATE] indicates that the resident needed a 2-person physical assist for transfers from the bed to wheelchair. During a face-to-face interview conducted on 04/23/25 at 4:07 PM, Employee #2 (Director of Nursing) stated that the resident has notes from physical therapy that state he only needs a one person assist. The Surveyor asked Employee #2 if a significant change Minimum Data Set assessment was completed and Employee #2 stated No. Cross Reference 22B DCMR Sec. 3210.4 (a)

Based on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to ensure that Resident #52 received care to prevent pressure ulcer development that was first observed at a Stage 3. This deficiency resulted in actual harm to Resident #52 on 02/28/2024. The findings included: Review of the facility's Wound Care Consultant Contract dated 09/14/22 documented,The Wound Care Consultant agrees to serve as the Wound Care Consultant to coordinate medical care in the facility and provide clinical guidance and oversight regarding wound care; provide diagnosis and treatment recommendations for wounds; and sign and date all orders, such as medications. Review of the facility's Pressure Ulcers, Prevention and Care policy revised on 11/10/22 documented: - Skin integrity alteration will be reported to the physician for treatment orders. - Classification of pressure ulcers: Stage 2: a partial thickness of skin is lost (epidermal layer has been lost, but dermis is at least partially intact); may present as blistering surrounded by an area of redness and/or indurations. Stage 3; a full thickness of skin is lost, exposing the subcutaneous tissues; present as a shallow crater (unless covered by eschar - thick brown, black or yellow crust); may be draining. There is also depth at this stage. - A specific plan of care must be developed by nursing and the interdisciplinary care team. Review of the Resident Assessment - Pressure Injuries policy revised on 11/10/22 documented, Accurate assessments addressing each resident's skin status will be conducted by qualified staff and correctly documented in the medical record; and a qualified health professional will document the presence, number, stage and pertinent characteristics of any pressure injury on the wound documentation form in the medical record. Resident #52 was admitted to the facility on [DATE] with diagnoses that included: Adult Failure to Thrive, History of Falling, and Muscle Weakness. Review of the resident's medical record revealed the following: A face sheet that showed Resident #52 had listed a legal guardian, substitute decision maker and emergency contact #1. Physician's orders dated 01/19/24 directed: Apply barrier cream to sacrum, buttocks and peri-area every shift for skin protection; weekly skin assessment, every evening shift every Friday; resident to have shower every day shift, every Monday and Thursday, Licensed nurse will validate and ensure skin assessment is completed. A Hospital Discharge Summary dated 01/27/24 documented: - Admission on 01/20/24 at 1:57 PM. - Chief complaint - altered mental status, low oxygen and blood pressure. - Physical exam at discharge - skin: warm and dry. A Readmission Note dated 01/27/24 at 9:01 PM documented: - Resident readmitted into the facility. - Warm to touch skin, mass around the mid-arm and in the inguinal area was noted, IV (intravenous) related bruises on bilateral upper arm were noted. A Readmission Braden Scale Evaluation dated 01/27/24 documented: - Resident's score 11. - Interpretation of score: 10-12 indicates high risk. - Continue current plan of care. A care plan documented: [Resident #52] has impaired skin integrity related to bilateral upper arm bruises/mass in the mid arm/inguinal area that was initiated on 01/27/24. A Focused Observation Note dated 01/30/24 at 11:21 PM documented, complete bed bath given, no new skin issue noted. A quarterly Braden Scale (a tool used to foster early identification of residents at risk for developing pressure ulcers) dated 02/01/24 at 5:42 PM documented: - Resident's score 11 (interpretation of score: 10-12 indicates high risk). - No referrals necessary. - Continue current plan of care A physician's order dated 02/02/24 directed, Turning and repositioning every 2 hours as tolerated and PRN (as needed) every shift. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 07 indicating severe cognitive impairment; no rejection of care behaviors; required substantial/maximal assistance for toileting hygiene, shower/bathing; frequently incontinent of bowel and bladder; at risk for pressure ulcers/injuries; and had no unhealed pressure ulcers/injuries, wounds or other skin problems. A [nursing] Skin Observation Tool Assessment on Tuesday, 02/06/24, at 8:20 PM documented, complete bed bath given, no new skin issue noted. A [nursing] Skin Observation Tool Assessment on Tuesday, 02/13/24, at 10:53 PM documented, Complete bed bath given. A Skin Observation Tool Assessment on Friday, 02/16/24, at 11:55 PM documented, complete bed bath given, no new skin issue noted. A [nursing] Skin Observation Tool Assessment on Friday, 02/23/24, at 10:37 PM documented, complete bed bath given, no new skin issue noted. A care plan focus area: The resident has limited physical mobility r/t (related to) weakness, that was initiated on 02/23/24 had approaches/interventions that included, monitor/document/report any s/sx (signs and symptoms) of immobility: contractures forming or worsening, skin-breakdown. The Treatment Administration Record (TAR) for February 2024 showed that on Monday, 02/26/24, facility staff documented a check mark and their initials to indicate that Resident #52 had a shower and that the nurse validated and ensured that a skin assessment was completed. A Nursing Progress Note dated 02/26/24 at 2:24 PM documented: - Upon assessment, skin is dry and warm to touch. - Resident turned and repositioned every 2 hours for comfort and pressure relief. A care plan focus area: [Resident #52] is at risk for bladder incontinence related to deconditioning that was initiated on 02/26/24, that had approaches/interventions that included, weekly skin assessment. An Attending Physician's note on Tuesday, 02/27/24, at 10:58 AM documented: - Subjective: [Resident #52] spends most of her time in bed because she has become frailer. There have been no new issues regarding her care. - Objective: remains a well-developed thin black female, in no acute distress when seen. There are no new labs available for analysis. - Assessment: continues to do well and remains clinically stable. We will continue with the current management. A [nursing] Skin Only Evaluation Note on Tuesday, 02/27/24, at 10:50 PM documented: - Skin warm & dry, skin color within normal limits (WNL) and turgor is normal; complete bed bath given, no new skin issue noted. A Wound Care Physician's Note on Wednesday, 02/28/24, at 8:16 AM documented: Wound rounds: Stage 3 sacral decubitus ulcer, moderate drainage with necrotic tissue and slough; Plan: clean with Dakins solution (used to prevent and treat skin and tissue infections), apply collagenase Santyl (debridement agent used on dead tissue) ointment and dry dressing daily. Although the Wound Care Physician documented a treatment order for Resident #52's new Stage 3 sacral ulcer, the medical record lacked documented evidence that the resident's primary care physician was notified about Resident #52's new Stage 3 sacral pressure ulcer/wound on 02/28/24. As a result, no new orders or interventions were implemented until 03/01/24 (over 48 hours later). A Skin Only Evaluation Note dated 02/29/24 at 4:45 PM documented, Skin warm & dry, skin color WNL (within normal limits) and turgor is normal; no skin issues; complete bed bath given. Review of the February 2024 Treatment Administration Record (TAR) dated from 02/01/24 to 02/29/24 showed that facility staff documented a check mark and their initials to indicate that Resident #52: 1. Received a shower everyday shift on Mondays and Fridays and that a licensed nurse validated and ensured that the skin assessment was completed. 2. Received weekly skin assessments every Friday on the evening shift; and 3. Barrier cream was applied to the resident's sacrum, buttocks, and peri-area every shift for skin protection. A Health Status Note dated 03/01/24 at 2:25 PM documented: - Resident remains alert and verbally responsive with intermittent confusion and generalized weakness. - Upon assessment skin is dry and warm to touch. - Resident turned and repositioned every 2 hours for comfort and pressure relief. A [nursing] Skin Only Evaluation Note dated 03/01/24 at 3:06 PM documented, Skin warm & dry, skin color WNL and turgor is normal; no skin issues; complete bed bath given. A physician's order dated 03/01/24 at 3:32 PM directed, Dakin's 1/2 strength External Solution 0.25 % (Sodium Hypochlorite) cleanse sacral ulcer with Dakin's solution, pat dry, apply Santyl and cover with border gauze daily. A physician's order dated 03/01/24 at 3:38 PM directed, Santyl External Ointment 250 Unit/GM (gram), apply to sacral ulcer topically everyday shift for wound care. A Wound Care Physician Note dated 03/04/24 at 8:18 AM documented: - Late Entry: created on 03/07/24 at 8:21 AM. - [AGE] year-old female with cachexia - Stage 3 sacral decubitus ulcer. Decreased slough and drainage. 8 cm (centimeters) long by 6 cm wide by 2 cm deep. - Plan: Continue Santyl dressings daily. A Skin Observation Tool assessment dated [DATE] at 1:08 PM documented: - Site: Sacrum - Type: Pressure - Length: 8 cm - Width: 6 cm - Stage II (Stage 2) [It should be noted that wound care physician staged the resident's sacral wound as a Stage 3 on 02/28/24.] - Notes: Cleanse with [NAME] solution, apply Santyl. Cover with dry gauze. A Health Status Note dated 03/06/24 at 7:56 AM documented: - Fluids offered but poorly tolerated encouraged to take more fluids but refused after several attempts. - Resident on oxygen at 2 liters via nasal cannula for shortness of breath for shortness of breath. - A call was placed to medical doctor in reference to resident with poor intake with order to transfer resident to the nearest emergency room for evaluation and treatment. - A call was placed and spoke with the resident's representative. A Health Status Note dated 03/06/24 at 10:52 PM documented: - Call placed to [Hospital name] at 10:30 PM to check on resident status, resident has been admitted . During a face-to-face interview on 03/06/24 at 11:15 AM, Employee #2 (Director of Nursing/DON) stated, Skin assessments are done weekly in PCC (Point Click Care, the facility's electronic health record system). That form is used to assess the wound for any changes. Once a new wound area is observed, the process is to immediately call the medical doctor and get new orders. The nurse will write a progress note with a description of the wound that includes size, location, drainage, what the surrounding area looks like and then also indicate that the family was notified. A new care plan is either initiated or revised. During a face-to-face interview on 03/13/24 at 11:25 AM, Employee #6 (Medical Director/Resident #52's primary physician) stated, The wound doctor is allowed to put in orders. Any provider that provides services at this facility is credentialed and can put in orders. I can't answer as to why [Wound Doctor] did not directly put in the wound care orders. I did see the resident (on 02/27/24). The nursing staff did not communicate any skin issues to me, and I did not turn her over to do any assessment of her skin during my time with her. During a face-to-face interview on 03/20/24 at approximately 12:30 PM, Employee #1 (Administrator) and Employee #2 acknowledged the findings. Cross reference 22B DCMR Sec. 3211.1 (Facility staff failed to ensure that Resident #52 received sufficient nursing care and services to prevent pressure ulcer development that was first observed at a Stage 3.)

Based on record review and staff interview, for one (1) of 1 residents sampled for pain management, facility staff failed to ensure that Resident #243 received effective pain assessments/evaluation for a known left hip fracture. The findings included: According to National Institute of Health (NIH): - Assessment of pain is a critical step to providing good pain management. - Nurses working with patients with acute pain must select the appropriate elements of assessment for the current clinical situation. - The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format. The assessment parameters should be explicitly directed. - To meet the patients' needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. The time frame for reassessment also should be directed. - Pain assessment should include intensity, location, and quality. https://www.ncbi.nlm.nih.gov/books/NBK2658/ Review of the facility's Pain Management policy (not dated) showed: - The facility will provide optimal pain control, assessment, and monitoring for all identified residents with pain. - Pain will be measured on a 0-10 scale. Cognitively impaired residents will be assessed utilizing behavioral or visual indicators. - Pain assessment will occur with the onset of new pain. Review of the facility's Documentation Criteria policy revised on 07/22/22 showed: - Clinical notes for pain control include location, severity, quality, duration, and cause. - Note when pain medication is given (very important) and note if/when pain relief is obtained and length of relief. Resident #243 was admitted to the facility on [DATE] with diagnoses that included: Muscle Weakness, Other Abnormalities of Gait and Balance and Age-Related Physical Debility. Review of the resident's medical record revealed the following: A care plan focus area: [Resident #243] has chronic pain to back and knees related to Osteoporosis, that was initiated on 05/16/19, had interventions that included: administer medications as ordered. Monitor and record effectiveness; monitor and record any complaints of pain: location frequency, intensity, effect on function, alleviating factors, aggravating factors; monitor and record any non-verbal signs of pain (guarding, withdrawal, crying, restlessness, etc.). A physician's order dated 05/24/19 directed: Turn and reposition every 2 hours, every shift. A care plan focus area: [Resident #243] has complaints of acute pain to right hip related to post fall, that was initiated on 07/07/21, had interventions of: administer medication routine and as needed, as ordered. Evaluate/record/report effectiveness. Monitor and record any complaints of pain: location frequency, intensity. Monitor and record any non-verbal signs of pain (guarding, restlessness). Handle gently and try to eliminate any environmental stimuli. A physician's order dated 08/16/21 directed: Tramadol (narcotic pain reliever), 100 mg (milligrams), 1 tablet, twice a day PRN (as needed) A physician's order dated 08/19/21 directed: Monitor pain every shift. A physician's order dated 03/23/23 directed: Tramadol 50 mg, twice a day. A physician's order dated 04/07/23 that directed, Acetaminophen (pain reliever) 500 mg, 2 tablets three times a day, as needed for pain. An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 12, indicating mild cognitive impairment; received scheduled pain medication regimen; no falls since the prior assessment and did not receive any opioid medications. A Pain Assessment Note dated 05/29/2023 at 5:51 PM documented: - Pain site - left lower extremity. Received scheduled pain medication regimen. - Resident pain interview intensity rating on the Numeric Rating Scale (0-10) 3. - Resident pain interview: verbal descriptor scale severe. A Facility Reported Incident (FRI), DC~11996, received by the State Agency on 05/29/23 at 6:30 PM documented: - At 4:40 PM, the resident got up on her seat to give another resident a hug and she missed her step and fell on her left side. - Resident refused to be assessed by the nurse supervisor, she said she will be fine but verbalized feeling pain to the left thigh, 4/10. - The physician was called and gave an order for an x-ray of the affected leg. - Resident RP was called and was made aware of the fall accident. A physician's order dated 05/29/23 directed Left hip/left knee x-ray A Nursing Progress Note dated 05/30/23 at 6:50 AM documented: - Range of motion within normal limits bilateral upper and right lower extremities with limited mobility left lower extremity. - Denies any pain at rest but complained of moderate pain with guarding to left hip upon assessment. Given PRN Tylenol (Acetaminophen) 1000 mg with good effect. - X-ray to left hip to be done in the morning. Left knee x-ray result dated 05/30/23 at 1:21 PM documented: - No acute fracture, dislocation or degenerative disease. -There is soft tissue swelling and vascular calcification. Left hip x-ray result dated 05/30/23 at 1:21 PM documented: - There is a fracture of the neck of the proximal femur without significant displacement. - Clinical Correlation and follow-up imaging recommended as indicated. A Nursing Progress Note dated 05/30/23 at 2:01 PM documented: - X-ray for left hip/knee done this shift, results received: No acute fracture, dislocation or degenerative disease, there is a swelling tissue and vascular calcification. - Physician's Assistant (PA) made aware; no new order given. - Resident was able to get transferred from the bed to wheelchair with assistance. It should be noted that although Employee #7 documented that she received the results of the left knee/hip x-rays, she failed to inform the PA of the left hip fracture. The Restorative Point of Care documentation dated 05/30/23 showed that Resident #243 received 15 nursing minutes of walking on the day shift (7:00 AM - 3:30 PM). A Nursing Progress Note dated 05/30/23 at 11:37 PM documented: - Day 1 post fall, pain to left hip/knee. Routine pain medication administered as ordered. The Treatment Administration Record (TAR) showed that on 05/30/23, day shift (7:00 AM - 3;30 PM), facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. The TAR for the same date and shift also showed that in the section that directed, monitor for pain every shift, Employee #7 documented her initials to indicate that this task was completed however, there is no evidence that the pain characteristics such as intensity, pattern, frequency, and duration were assessed even though the resident had a known left hip fracture. The TAR also showed that on 05/30/23, evening shift (3:00 PM - 11:30 PM), facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. The TAR for the same date and shift also showed that in the section that directed, monitor for pain every shift, facility staff documented their initials to indicate that this task was completed however, there is no evidence that the pain characteristics such as intensity, pattern, frequency, and duration were assessed even though the resident had a known left hip fracture. A Night Shift (11:00 PM - 7:30 AM) Nursing Progress Note dated 05/31/23 at 6:56 AM documented: - Range of motion within normal limits bilateral upper and right lower extremities with limited mobility left lower extremity. - Complaints of pain upon assessment. Given Tramadol 50 mg with good effect. No visible injuries noted. - Received results of left hip x-rays with impression of non-displaced fracture of neck of left proximal femur. Clinical correlation and follow-up imaging indicated. Morning shift to follow-up with primary physician. It should be noted that although the employee documented that Resident #243's left hip x-ray results showed a fracture, he failed to notify the resident's primary care physician. The TAR showed that on 05/30/23, night shift, facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. The TAR for the same date and shift also showed that in the section that directed, monitor for pain every shift, facility staff documented their initials to indicate that this task was completed however, there is no evidence that the pain characteristics such as intensity, pattern, frequency, and duration were assessed even though the resident had a known left hip fracture. A Night Shift Nursing Supervisor Note dated 05/31/23 at 8:47 AM, written by Employee #8 documented: - Status post fall, no bruise, no redness noted. - Resident guarding her left leg/hip. Medicated for complaints of pain to left upper leg with Tramadol 50 mg and effective. - Result of left hip x-rays received with impression of non-displaced fracture of neck of left proximal femur. Clinical correlation and follow-up imaging indicated. Please follow-up with primary medical doctor. It should be noted that although Employee #8 documented that Resident #243's left hip x-ray results showed a fracture, she failed to notify the resident's primary care physician. The Restorative Point of Care documentation dated 05/31/23 showed that Resident #243 received 15 nursing minutes of walking on the day shift. The TAR showed that on 05/31/23, day shift, facility staff documented their initials to indicate that they were turning and repositioning Resident #243 every two hours. A Nursing Progress Note dated 05/31/23 at 12:22 PM documented: - Status post fall, order given on 5/29/23 as follows: left hip/ Left knee x-ray to rule out fracture. X-ray result received and indicated a fracture of the neck of the left proximal femur without significant displacement. - [Physician's Name] made aware, new order given to transfer resident to the nearest emergency room for further evaluation of fracture of the neck of the left proximal femur. - 911 called at 10:40 AM, resident left at 11:20 AM via stretcher. Representative made aware of before and after transfer. A Hospital Discharge Summary dated 06/12/23 at 6:00 AM documented: - 05/31/23 - Computed Tomography (CT) Scan of pelvis without contrast: acute appearing mildly impacted subcapital left femoral neck fracture. - Percutaneous fixation of left femoral neck fracture completed (the insertion of pins or wires through the skin to hold the bones in a proper position while they heal). During a face-to-face interview conducted on 03/12/24 at 12:20 PM, Employee #7 (Licensed Practical Nurse/LPN who worked on 05/30/23, day shift) stated, The process for when x-ray results are received is to call the medical doctor with the results. I don't think I received both results for [Resident #243] at the same time, or else I would have documented the results in my note. When asked if she received both x-ray results as documented in her progress note on 05/30/23 at 2:01 PM, she replied, I don't remember. I talked about the left knee, not both. So, I don't believe that I had both results at the time. During a telephone interview on 03/13/24 at 8:30 AM, Employee #8 (Night Shift Supervisor who worked on 05/30/23) was asked why there was no notification made to Resident #243's physician or their representative regarding the left hip x-ray result. The employee stated that the facility did not have a physicians on-call list [list of physicians to call on specific days and time frames]. The employe also said Since I have been working here, the instruction has been to not call the medical doctors during the night unless there's an emergency and the patient is at risk of dying. We wait until around 7:00-7:30 AM because most of the doctors get angry when we call them in the middle of the night. During a face-to-face interview on 03/13/24 at 11:25 AM, Employee #6 (Medical Director) stated, There is no on-call schedule for the medical providers at this facility, but I am available 24/7. During off shifts (evening and night), nursing staff are to contact the assigned medical provider and if they can't reach them, then they are to call me. If there's an abnormal result that is not critical, it makes sense to call in the morning and not at 3:00 AM. If there is an abnormal lab, x-ray, or incident, that should be reported to the provider during that shift when it happens. An x-ray result that comes back with a fracture, should not wait until morning, that should be reported immediately. Anything that affects the resident's well-being should be reported immediately. It has not been reported to me that there are any issues with reaching any of the medical providers during the evening or night shifts. During a face-to-face interview conducted on 03/13/24 at 12:25 PM, Employee #2 (DON) acknowledged the findings.

Based on observations and staff interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on six (6) of six (6) observations, two (2) of two (2) convection ovens, and two (2) of two (2) grease fryers that were soiled throughout, ready-to-eat (RTE), open bags of foods such as two (2) of two (2) packs of cold cuts, one (1) of two (2) bags of shredded yellow cheese, three (3) of five (5) packs of sliced yellow cheese, one (1) of one (1) bag of feta cheese, one (1) of one (1) jar of applesauce stored in the walk-in refrigerator, that were not labeled to indicate a use-by ' date, pieces of frozen chicken that were being thawed improperly, and a sanitize water solution in the 3 compartment sink that tested below the recommended 200 parts per million (PPM). The findings include: Test tray food temperatures were inadequate as puree hot foods such as chicken (106.5), spinach (104.1), potatoes (105.8), and regular hot foods such as fried chicken (134.4), spinach (114.4), and potatoes (106.6) tested at less than 135 degrees. Cooking equipment such as two (2) of two (2) convection ovens, and two (2) of two (2) grease fryers, were soiled with cooked food residue. Ready-to-eat foods such as two (2) of two (2) open packs of cold cuts, one (1) of two (2) open bag of shredded yellow cheese, three (3) of five (5) open packs of sliced yellow cheese, one (1) of one (1) open bag of feta cheese, and one (1) of one (1) open jar of applesauce stored in the walk-in refrigerator, were not labeled to indicate a use-By ' date. Numerous pieces of chicken meat were submerged in a sink full of water for thawing, with no running water or water velocity to create constant movement. The water 'sanitize' solution from the three-compartment sink tested at less than 100 parts per million (PPM) on March 4, 2024, at approximately 10:30 am. The recommended water sanitize solution in the 3 compartment sink is 200 parts per million (PPM). These observations were acknowledged by Employee #9 during a face-to-face interview on March 11, 2024, at approximately 3:30 PM.

43776 45102 Based on record reviews and staff interviews, for four (4) of 41 sampled residents, facility staff failed to have documented evidence that they conducted thorough investigations. Resident #'s 192, 294, 244 and 63. The findings included: Review of the facility's policy Prohibition of Resident Abuse/Abuse Prevention revised 09/24/22 documented: - Investigation: Identifying and interviewing all involved persons including the alleged victim, alleged perpetrator and others who might have knowledge of the allegations Review of a facility policy titled, Prohibition of Resident Abuse/Abuse Prevention (#99-12) documented the following but not limited to: Neglect-means failure to the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Investigation of alleged Abuse and Neglect - Focusing the investigation on determining if neglect has occurred, the extent, and the cause. Providing complete and thorough documentation of the investigation. A policy entitled, Missing Residents (#99M-010) documented in part, The Search Director is to assign personnel to search the boiler, storage, and equipment rooms, laundry and kitchen areas, the roof and basement, if any, beneath beds and other furniture, beneath stairways, parked vehicles and shrubbery. 1. Facility staff failed to have documented evidence that they conducted thorough investigations of Resident #192's elopement from the facility. Resident #192 was admitted to the facility on [DATE] with multiple diagnoses including: Encephalopathy, Seizures, Muscle Weakness and Cirrhosis of the Liver. Review of the medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the following: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating the resident had an intact cognitive status. Additionally, the resident was coded for requiring supervision from staff with activities of daily living. A Facility Reported Incident Intake form (DC~11829) received by the State Agency that was dated 04/04/23 at 10:59 AM documented the following but not limited to: At 6:55 am, resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink (Missing Resident) was initiated and 911 was called at 7:20am and residents detailed information provided to the police. A search team comprising of nursing staff and security were dispatched to search the community area, especially at the bus stops and metro stations. Resident [was] wearing a white sweat pants and white hooded top long sleeve sweater. Temperature outside at the time is 58 degrees at 7:30 am. MD (medical director), DON (Director of Nursing), and the responsible party (ex-wife) was notified. Eventually we got a call from the facility security that the police found resident. Investigation is still in the process. A nursing supervisor note dated 04/04/23 at 12:16 PM documented that, At 6.55 am, I was informed that the resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink was initiated. 911 was called at 7:20am and information about resident given. Search team comprising of nursing staff and security were dispatched to search for him around bus stops and metro stations. The DON was notified. [Responsible party's name] was called, and she said [resident's name] call(ed) her from bus stop around the facility. The search team converged around the community area. Eventually we got a call from the facility security that the police found resident at a bus stop. Upon returning to the facility, resident was found at the parking lot accompanied by the police officer. At this point, resident refused coming into the facility, it took about 40 to 45 minutes to encourage and convince resident to come into the facility. At 8:50am, [Resident's name] returned to the unit after much encouragement. Resident remains alert and verbally responsive, not in acute distress. Head to toe assessment done. Denied pain, no discomfort noted. Skin warm to and dry. Respiration is even and non-labored. Temperature 98.0, Pulse 62, Respirations 18, Blood Pressure 128/81, Oxygen Saturations 96%. When asked why he eloped from the facility, resident stated that he does not want to stay here and verbalized that he will walk out again. New order given to monitor resident one on one until seen by the psychiatric team. Close monitoring in progress and maintained. A review of the facility's investigation packet dated 04/04/23 lacked documented evidence of the following: -The staff findings when they searched the boiler, storage, and equipment rooms, laundry and kitchen areas, the basement, beneath beds and other furniture, beneath stairways, parked vehicles, shrubbery, parking lot, bus stops, and the neighborhood, as outlined in the Missing Resident policy. - If neglect occurred, the extent and cause of the neglect, as outlined in their Prohibition of Resident Abuse/Abuse Prevention policy. - Interviews of Unit #1's night shift staff (person who might have knowledge of the incident) and Interview of ex-wife and daughter. As outlined in their Prohibition of Resident Abuse/Abuse Prevention policy. It should be noted that the resident got off the elevator on Unit 1 to exit the front door. This showed that facility staff failed to have documented evidence that a thorough investigation was conducted for Resident #192's elopement incident on 04/04/23. During a face-to-face interview on 03/12/24 at approximately 3:00 PM, Employee #2 (DON) reviewed the investigation packet and stated that she did not see that a thorough investigation was conducted by the facility. The employee also stated that she looked through other facility investigative documents and could not find any additional documents related to the investigation for Resident #192's elopement on 04/04/23. Cross reference 483.25 Quality of Care F689 2. The facility staff failed to conduct a thorough investigation into Resident #294's allegation of staff abuse. Resident #294 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Non-Dominant Side, Pressure Ulcer of Sacral Region Stage 2, and Diabetes Mellitus Type 2. Review of Resident #294's medical record revealed the following: An Admission MDS assessment dated [DATE] showed facility staff coded: A Brief Interview for Mental Status (BIMS) summary score of 15 which indicates intact cognition. A Facility Reported Incident (FRI) DC~12177 was submitted to the State Agency on 08/08/23 that documented: - Resident's wife called writer and stated that her husband's head was hit on the wall 3 times during care on the weekend (Sunday) 08/06/2023. - Writer went to resident's room accompanied by the charge nurse that worked with him on the said day. When resident was asked how it happened, he stated, I hit my head on the bed rail 3 times when I was being changed. When asked if he told the nurse about it, he stated, she came and gave me my medications. Charge nurse stated that she came into resident's room, to pass his routine medications which she did after wiping his face because he had some crusts on his eyes. resident nodded his head and said yes she cleaned my eyes and gave me medications. When asked if he told charge nurse at that time about his head, he stated no. Resident went on to say that his aide for that Sunday was a male. A review of the facility's investigation packet, showed no documented evidence that the facility assessed the resident, notified the physician, interviewed all the staff present at the time of the alleged incident, or that they interviewed other residents. During a face-to-face interview conducted on 03/18/24 at approximately 3:30 PM, Employee #2 (Director of Nursing) stated that the facility leadership has changed, and she was not able to locate any additional documentation concerning Resident #294's allegation of abuse. Cross Reference 22B DCMR sec. 3269.1 3. Facility staff failed to thoroughly investigate Resident #244's allegation of a verbal threat of harm by Resident #63. 3A. Resident #63 was admitted to the facility on [DATE] with diagnoses that included: Vascular Dementia, Cognitive Communication Deficit, and Symptoms and Signs Involving Cognitive Functions and Awareness. Review of Resident #63's medical record revealed: A census tracking form showed that Resident #63 resided on unit 1, room [ROOM NUMBER], A bed, since 03/14/2023. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderate cognitive impairment; no potential indicators of psychosis; no behavioral symptoms directed at others; limited assistance for locomotion on the unit; no functional limitations in range of motion in upper/lower extremities; used a walker for mobility; received antianxiety and antidepressant mediations 7 times during the last 7 days. A Facility Reported Incident (FRI), DC~12019, received by the State Agency on 06/09/23 at 8:10 PM documented: - At the dinner area at around 6:15 PM, Resident [#63] made a verbal threat to shoot another resident in room [ROOM NUMBER]A [Resident #244] with a gun, making an attempt to reach for something under her clothing. Immediately, the staff called 911. - Police officers came at 6:30 PM and searched Resident #63 and her belongings. No guns or any related injurious objects found. - The physician was notified and referred to the psychiatrist for review. - Representative aware. - Police officers advise nursing staff to separate the residents and departed at 7:00 PM. 3B. Resident #244 was admitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit, Mild Cognitive Impairment and Muscle Weakness. Review of the resident's medical record revealed the following: A census tracking form showed that Resident #244 resided on unit 1 room [ROOM NUMBER], A bed, since 04/11/23. An Annual MDS assessment dated [DATE] showed facility staff coded: a BIMS summary score of 15, indicating intact cognition; no indicators of psychosis; no behavioral symptoms directed towards others; no functional limitations in range of motion for upper extremities; independent with walking and picking up objects. A FRI, DC~12018, received by the State Agency on 06/09/23 at 7:58 PM documented: - This event occurred at the dinner area at around 6:15 PM. - Resident #244 reported to the charge nurse that another resident in room [ROOM NUMBER] A (Resident #63) told her that she will shoot her with a gun, making attempt to reach for something under her clothing. - Immediately, the staff called 911. - Police officers came at 6:30 PM and searched Resident #63's room and her belongings. No guns or any related injurious objects found. - The physician and representative were made aware. - Police officers advise nursing staff to separate the residents and departed at 7:00 PM. Review of the investigation documents provided to the surveyor on 03/11/24 showed that Resident #244 reported the incident to Employee #3 (Assistant Director of Nursing/ADON). Further review of the investigation documents showed facility staff failed to conduct a thorough investigation as evidenced by no documented interviews or statements from the involved persons (alleged victim and alleged perpetrator) and no interviews from the staff present at the time of the alleged incident. During a face-to-face interview on 03/12/24 at 10:35 AM, Employee #3 acknowledged the finding and stated, When there's an incident on my shift, I do the incident report to Department of Health (DOH), collect statements from the residents and staff. All that gets forwarded to the DON. I can't remember if I got statements from anyone when this incident happened. Cross Reference 22B DCMR Sec. 3232.2

Based on record review and staff interviews, for two (2) of 41 sampled residents, facility staff failed to immediately notify the resident's primary physician or their representative when there was a change in the resident's condition that required physician intervention. Resident #52 and Resident #243. The findings included: 1. Facility staff failed to immediately notify Resident #52's primary physician and their representative of a facility acquired sacral pressure ulcer/wound. Resident #52 was admitted to the facility on [DATE] with diagnoses that included: Adult Failure to Thrive, History of Falling, and Weakness. Review of the resident's medical record revealed the following: A face sheet that showed the resident had a legal guardian as her Responsible Party (RP), substitute decision maker and emergency contact #1. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 07, indicating severe cognitive impairment; at risk for pressure ulcers/injuries; and had no unhealed pressure ulcers/injuries, wounds, or other skin problems. A Wound Care Physician's Note dated 02/28/24 at 8:16 AM documented: Wound rounds; Stage 3 sacral decubitus ulcer; moderate drainage with necrotic tissue and slough. Plan: clean with Dakins solution (used to prevent and treat skin and tissue infections), apply collagenase Santyl ointment (debridement ointment used on dead tissue) and dry dressing daily. A physician's order dated 03/01/24 at 3:32 PM directed, Dakin's 1/2 strength External Solution 0.25 %, cleanse sacral ulcer with Dakin's solution, pat dry, apply Santyl and cover with border gauze daily. A physician's order dated 03/01/24 at 3:38 PM directed, Santyl External Ointment 250 Unit/GM (gram), apply to sacral ulcer topically every day shift for wound care. Review of the medical record from 02/28/24 to 03/01/24, approximately 48 hours, showed that facility staff failed to immediately notify Resident #52's primary care physician of a change in condition (stage 3 pressure ulcer). Additionally, as of 03/06/24 there was no documented evidence that facility staff notified the resident's representative. During a face-to-face interview on 03/06/24 at 11:15 AM, Employee #2 (Director of Nursing/DON) acknowledged the finding and stated, Once a new wound area is observed, the process is to immediately call the resident's [primary] medical doctor and get new orders. The nurse will write a progress note with a description of the wound that includes size, location, drainage, what the surrounding area looks like and then also indicate that the family was notified. 2. Facility staff failed to immediately notify Resident #243's primary physician or their representative of an x-ray result that showed a left hip fracture. Resident #243 was admitted to the facility on [DATE] with diagnoses that included: Muscle Weakness, Other Abnormalities of Gait and Balance and Age-Related Physical Debility. Review of Resident #243's medical record revealed the following: A face sheet that showed the resident had a legal guardian as her RP and emergency contact #1. An Annual MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 12, indicating mild cognitive impairment and had no falls since the prior assessment. A Facility Reported Incident (FRI), DC~11996, received by the State Agency on 05/29/23 at 6:30 PM documented: - At 4:40 PM, the resident got up on her seat to give another resident a hug and she missed her step and fell on her left side. - The physician was called and gave an order for an x-ray of the affected leg. - Resident RP was called and was made aware of the fall accident. A Nursing Progress Note dated 05/29/23 at 7:36 PM documented: - At 4:40 PM, the resident got up on her seat to give another resident a hug and she missed her step and fell on her left side. - The physician was called and gave an order for an x-ray of the affected leg. - Resident RP was called and was made aware of the fall accident. A physician's order dated 05/29/23 directed, Left hip/left knee x-ray. Left knee x-ray results dated 05/30/23 at 1:21 PM documented: - No acute fracture, dislocation or degenerative disease. Left hip x-ray results dated 05/30/23 at 1:21 PM documented: - There is a fracture of the neck of the proximal femur without significant displacement. - Clinical Correlation and follow-up imaging recommended as indicated. A Nursing Progress Note dated 05/30/23 at 2:01 PM written by Employee #7 (Licensed Practical Nurse/LPN) documented: - X-Ray for left hip/knee done this shift, results received: No acute fracture, dislocation, or degenerative disease. - Physician's Assistant (PA) made aware; no new order given. It should be noted that although Employee #7 documented that she received the results of the left knee/hip x-rays, she failed to inform the PA of the left hip fracture. A Night Shift Nursing Progress Note dated 05/31/23 at 6:56 AM documented: - Received results of left hip x-rays with impression of non-displaced fracture of neck of left proximal femur. Clinical correlation and follow-up imaging indicated. Morning shift (day shift, 7:00 AM - 3:30 PM) to follow-up with primary physician. A Night Shift Nursing Supervisor Note dated 05/31/23 at 8:47 AM written by Employee #8 (Night Shift Nursing Supervisor) documented: - Result of left hip x-rays received with impression of non-displaced fracture of neck of left proximal femur. Clinical correlation and follow-up imaging indicated. Please follow-up with primary medical doctor. A Day Shift Nursing Progress Note dated 05/31/23 at 12:22 PM documented: - Status post fall, order given on 05/29/23 as follows: left hip/left knee x-ray to rule out fracture. X-ray result received and indicated a fracture of the neck of the left proximal femur without significant displacement. - [Physician's Name] made aware, new order given to transfer resident to the nearest emergency room for further evaluation. - 911 called at 10:40 AM, resident left at 11:20 AM via stretcher. Representative made aware before and after transfer. The evidence showed that facility staff received Resident #243's left hip and left knee x-ray results on 05/30/23 at 1:20 PM, during the day shift (7:00 AM - 3:30 PM). There is no documented evidence that the assigned day shift nurse, Employee #7, made the resident's physician or representative aware of the left hip x-ray result that showed fracture of the neck of the proximal [left] femur. The evidence also showed that on 05/30/23, the assigned night shift nurse and nursing supervisor both documented that Resident #243's left hip x-ray showed a fracture but neither notified the resident's physician or her representative. It was not until 05/31/23, at approximately 10:30 AM, 21 hours later, that facility staff notified Resident #243's primary care physician and their RP of the left hip x-ray results. During a face-to-face interview conducted on 03/12/24 at 12:20 PM, Employee #7 (Licensed Practical Nurse/LPN) stated, The process for when x-ray results are received is to call the medical doctor with the results. When asked if she received both x-ray results as documented in her progress note on 05/30/23 at 2:01 PM, she replied, I don't remember. I talked about the left knee, not both. So, I don't believe that I had both results at the time. During a telephone interview on 03/13/24 at 8:30 AM, Employee #8 (Night Shift Nursing Supervisor) was asked why there was no notification made to Resident #243's physician or their representative regarding the left hip x-ray result. The employee stated, We don't have an on-call list. Since I have been working here, the instruction has been to not call the medical doctors during the night unless there's an emergency and the patient is at risk of dying. We wait until around 7:00/7:30 AM because most of the doctors get angry when we call them in the middle of the night. During a face-to-face interview on 03/13/24 at 11:25 AM, Employee #6 (Medical Director) stated, There is no on-call schedule for the medical providers at this facility, but I am available 24/7. During off shifts (evening and night), nursing staff are to contact the assigned medical provider and if they can't reach them, then they are to call me. An x-ray result that comes back with a fracture, should not wait until morning, that should be reported immediately. Anything that affects the resident's well-being should be reported immediately. It has not been reported to me that there are any issues with reaching any of the medical providers during the evening or night shifts. During a face-to-face interview conducted on 03/13/24 at 12:25 PM, Employee #2 (Director of Nursing) acknowledged the findings and made no comment.

45102 Based on record reviews and staff interviews for one (1) of 41 sampled residents, facility staff failed to ensure Resident #192 was free from neglect as evidenced by the resident leaving the facility without staff knowledge. The findings included: Review of the policy titled, Missing Resident #99M-010, documented, A resident is considered missing from the facility whenever their whereabouts cannot be ascertained. This situation is an elopement. Resident #192 was admitted to the facility on [DATE] with multiple diagnoses including: Encephalopathy, Seizures, Muscle Weakness and Cirrhosis of the Liver. Review of the medical record revealed the following: A care plan dated 01/01/23 that documented, Problem: [Resident #192] has risk for Elopement related to wandering evidenced by trying to enter the elevator. Goal: Resident will not elope. Approach: Monitor resident's movements closely while out of bed. Encourage resident to verbalize feelings of boredom/loneliness at all times. Encourage resident to participate in group activities of choice. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the following: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating the resident had an intact cognitive status. Additionally, the resident was coded for requiring supervision from staff with activities of daily living. A Facility Reported Incident Intake form (DC~11829) received by the State Agency that was dated 04/04/23 at 10:59 AM documented the following but not limited to: At 6:55 am, resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink (Missing Resident) was initiated and 911 was called at 7:20am and residents detailed information provided to the police. A search team comprising of nursing staff and security were dispatched to search the community area, especially at the bus stops and metro stations. Resident [was] wearing a white sweat pants and white hooded top long sleeve sweater. Temperature outside at the time is 58 degrees at 7:30 am. MD (medical director), DON (Director of Nursing), and the responsible party (ex-wife) was notified. Eventually we got a call from the facility security that the police found resident. Investigation is still in the process. Please note, According to World Weather, the temperature in the District of Columbia on 04/04/23 during the daytime ranged from 55 to 75 degrees (Fahrenheit). https://world-weather.info/forecast/usa/washington_1/april-2023/ A nursing progress note dated 04/04/23 at 11:22 AM documented, Resident was received in bed at 11:00 pm, alert, oriented and verbally responsive. During routine round, Resident was in bed through the night. Breathing even and unlabored. No sign of respiratory distress or shortness of breath noted. No complain of pain or discomfort voiced. Around 5:30 am when I pushed my medication cart down the hall to start from room [ROOM NUMBER] where I normal start. Resident was in his room. When I got to his room at 6:40 am to give him his medication, I could not see him, I checked the bathroom, he was not there, then I alert other staffs and the supervisor, then called the security officer to found out if Resident left the facility. The staffs(sp) begin to search for him all rooms and bathrooms. I left the facility with other staffs in search of him to nearby bus-stops and metro stations. A nursing supervisor note dated 04/04/23 at 12:16 PM documented that, At 6.55 am, I was informed that the resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink was initiated. 911 was called at 7:20am and information about resident given. Search team comprising of nursing staff and security were dispatched to search for him around bus stops and metro stations. The DON was notified. [Responsible party's name] was called, and she said [resident's name] call(ed) her from bus stop around the facility. The search team converged around the community area. Eventually we got a call from the facility security that the police found resident at a bus stop. Upon returning to the facility, resident was found at the parking lot accompanied by the police officer. At this point, resident refused coming into the facility, it took about 40 to 45 minutes to encourage and convince resident to come into the facility. At 8:50am, [Resident's name] returned to the unit after much encouragement. Resident remains alert and verbally responsive, not in acute distress. Head to toe assessment done. Denied pain, no discomfort noted. Skin warm to and dry. Respiration is even and non-labored. Temperature 98.0, Pulse 62, Respirations 18, Blood Pressure 128/81, Oxygen Saturations 96%. When asked why he eloped from the facility, resident stated that he does not want to stay here and verbalized that he will walk out again. New order given to monitor resident one on one until seen by the psychiatric team. Close monitoring in progress and maintained. According to the investigation packet, the following employees wrote statements dated 04/04/23:? Employee #14 (CNA) documented, I [employee's name] worked last night April 3, 2023, and [resident's name] was assigned to me. The last time I saw [resident's name] was at 5:30 AM in his room. We the nurses on the night shift on unit (Unit2) left the floor and went to the street and metro station looking [for him] after he left the facility. We did not find him. Employee #15 (Housekeeping Director) documented, I [employee's name] entered the building at 5:36 AM, after signing in on the covid machine (kiosk) I walked thru the door (left of the security desk) leading to the bird (cage) area and a resident wearing a white sweat suit and carrying a bag was coming off of Unit 1. I asked where he was going, and he stated that his brother was picking him up front up front. He continued to the front desk area where security was sitting. Continued review of the facility's investigation packet showed Employee #16 (Security Guard) wrote an Incident Report dated 04/04/23 that documented, [Resident daughter's name] called [Facility name] at 6:44 AM and confirmed [resident's name] was at the bus stop. I went to go look for [resident's name] at the bus stop and I returned to the nursing home at 7:20 AM. A psychiatric nurse practitioner note dated 04/05/23 at 6:58 PM documented that, Resident seen secondary to elopement on 04/04/23 and review of 1:1 monitoring order. [Resident stated] 'I have been here for too long; I was told at the other facility that I could leave.' Remains on 1:1 monitoring. Alert and oriented to place, person, time, and situation. Does not present with any psychiatric disorder. Pleasant, not confused but appears to make poor and irrational judgement occasionally. Ambulates with steady gait. Continue 1:1 monitoring every shift for now and reassess for elopement risk in 4-5 days. Encourage participation in different activities on unit. A State Survey Agency Complaint Intake (DC~11872) dated 04/10/23 at 3:30PM documented: - It was on April 4, 2023 [Resident #192] called me at 7:00 AM stating that he's out of the nursing home and was at a bus stop and didn't know what bus stop or where. - I called the nursing home asking them was my husband in the facility, because he called and told me that he's at a bus stop. They asked me what bus stop he was at and for his cell phone number. - I called [Resident #192] back, an officer from MPD (Metropolitan Police Department) got on the phone and stated that they were at the Metro Cener train station (approximately 3.1 miles from the facility). - The officer agreed to hold him. My daughter went and picked him up from Metro Center and took him back to the nursing home. - I feel that this is a neglect on the staff that's on the 2nd floor where he's on and security for allowing him to get out. Review of Employee #16's (Security Guard) personnel record showed the employee was hired on 05/16/22. The employee signed his initials on the Training Checklist dated 05/17/22 indicating he received training on Never leaving the front desk unattended. Moreover, the employee signed an Employee Warning Notice dated 04/12/23 that documented that, Date of incident 04/03/23 between 5AM to 5:30 AM. [Employee's name] you [were] supposed (sp) to been (sp) posted at the front desk during this time [resident's name] from room [ROOM NUMBER] walked thru the lobby past the front desk and out of the front door which caused an elopement. On 03/08/24 at approximately 11:00 AM, an observation of the lobby area revealed a security desk located adjacent to the facility's front door. At the time of the observation, a security guard and receptionist were seated at the desk. Behind the security desk, was a closet that's used by security staff. Additionally, there was a three-ring binder labeled Wanders and a security logbook (where security staff write notes about rounds and concerns in the facility) was noted on the desk. The security logbook lacked documented evidence of Resident #192's elopement incident on 04/04/23. During a telephone interview on 03/13/24 at 8:30 AM, Employee #17 (Nursing Supervisor) stated that Resident #192's assigned nurse called and informed her that staff could not locate the resident (on 04/04/23). After Employee #16 (Security Guard), who was posted at the front desk of the lobby, informed her that he did not see the resident leave out the front door, she called a Code Pink and continued looking for the resident with other staff. During a telephone interview on 03/13/24 at 9:30 AM, Employee #16 (Security Guard) stated that he believed when he walked into the closet behind the security desk, the resident exited the facility through the front door. The employee stated that he was wrong for leaving the front desk unattended. He should have called the other security guard to cover the front desk. The employee also stated that he wrote an incident report related to Resident #192's elopement, and he thought he wrote the information in the security logbook. During a face-to-face interview on 03/13/24 at approximately 10:00 AM, Employee #18 (Security Supervisor) stated that Employee #16 (Security Guard) did not follow the company's policy when he left his post at front desk unattended on 04/04/23. He was to call the other security guard in the building to cover his post. Employee #18 reviewed that logbook and stated that she did not see documented evidence that Employee #16 documented Resident #192's elopement incident. When asked if that incident should have been documented in the logbook, Employee #18 replied Yes. Cross reference 483.25 Quality of Care F689

Based on observations, record reviews and resident and staff interviews, for four (4) of 41 sampled residents, facility staff failed to implement its policies and procedures for reporting and investigating allegations or incidents of abuse and neglect. Resident #192, Resident #40, Resident #25 and Resident #294. The findings included: A policy titled Prohibition of Resident Abuse/Abuse Prevention (#99-12) documented the following but not limited to: Each resident has the right to be free from neglect. Neglect- means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A review of the facility's policy titled Resident Abuse reviewed on 08/23/23, documented the following: each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents and Abuse means the willful infliction of injury and resulting in physical harm, pain or mental anguish and Physical abuse includes hitting, slapping, pinching and kicking and Each resident has the right to be free from mistreatment, neglect and This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents. Identification Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. Investigation Investigate different types of incidents; and identify the staff member responsible for initial reporting, investigation of alleged violations and reporting of results to the proper authorities. Protection Protect residents from harm during an investigation. Reporting/Response Anyone who suspects or witnesses an alleged incident of resident abuse is required to report the incident to the Nursing Supervisor or department head immediately. The Nursing Supervisor/department head will immediately initiate and investigation and give an oral report to the Administrator. 1. The facility staff failed to implement its policies and procedures for reporting and investigating allegations or incidents of abuse and neglect for Resident #192. Resident #192 was admitted to the facility on [DATE] with multiple diagnoses including: Encephalopathy, Seizures, Muscle Weakness and Cirrhosis of the Liver. Review of the medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the following: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating the resident had an intact cognitive status. Additionally, the resident was coded for requiring supervision from staff with activities of daily living. A Facility Reported Incident Intake form (DC~11829) received by the State Agency that was dated 04/04/23 at 10:59 AM documented the following but not limited to: At 6:55 am, resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink (Missing Resident) was initiated and 911 was called at 7:20 am and residents detailed information provided to the police. A search team comprising of nursing staff and security were dispatched to search the community area, especially at the bus stops and metro stations. Resident [was] wearing a white sweat pants and white hooded top long sleeve sweater. Temperature outside at the time is 58 degrees at 7:30 am. MD (medical director), DON (Director of Nursing), and the responsible party (ex-wife) was notified. Eventually we got a call from the facility security that the police found resident. Investigation is still in the process. A nursing supervisor note dated 04/04/23 at 12:16 PM documented that, At 6.55 am, I was informed that the resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink was initiated. 911 was called at 7:20am and information about resident given. Search team comprising of nursing staff and security were dispatched to search for him around bus stops and metro stations. The DON was notified. [Responsible party's name] was called, and she said [resident's name] call(ed) her from bus stop around the facility. The search team converged around the community area. Eventually, we got a call from the facility security that the police found resident at a bus stop. Upon returning to the facility, resident was found at the parking lot accompanied by the police officer. At this point, resident refused coming into the facility, it took about 40 to 45 minutes to encourage and convince resident to come into the facility. At 8:50am, [Resident's name] returned to the unit after much encouragement. Resident remains alert and verbally responsive, not in acute distress. Head to toe assessment done. Denied pain, no discomfort noted. Skin warm to and dry. Respiration is even and non-labored. Temperature 98.0, Pulse 62, Respirations 18, Blood Pressure 128/81, Oxygen Saturations 96%. When asked why he eloped from the facility, resident stated that he does not want to stay here and verbalized that he will walk out again. New order given to monitor resident one on one until seen by the psychiatric team. Close monitoring in progress and maintained. A State Survey Agency Complaint Intake (DC~11872) dated 04/10/23 at 3:30PM documented: - It was on April 4, 2023 [Resident #192] called me at 7:00 AM stating that he's out of the nursing home and was at a bus stop and didn't know what bus stop or where. - I called the nursing home asking them was my husband in the facility, because he called and told me that he's at a bus stop. They asked me what bus stop he was at and for his cell phone number. - I called [Resident #192] back, an officer from MPD (Metropolitan Police Department) got on the phone and stated that they were at the Metro Cener train station (approximately 3.1 miles from the facility). - The officer agreed to hold him. My daughter went and picked him up from Metro Center and took him back to the nursing home. - I feel that this is a neglect on the staff that's on the 2nd floor where he's on and security for allowing him to get out. During a face-to-face interview on 03/08/24 at approximately 1:00 PM, Employee #2 (DON) stated that the facility staff failed to implement their prohibition of resident abuse/abuse prevention policy when Resident #192 eloped from the facility without staff knowledge. Cross reference 483.25 Quality of Care F689 2. The facility staff failed to implement its policies and procedures for reporting and investigating allegations or incidents of abuse and neglect for Resident #40 and Resident #25's physical altercation. During an observation on first floor resident day room on 03/05/24 at 3:14 PM, the following was noted by two (2) State Agency Surveyors: Resident #25 was walking into the dayroom toward Resident #40, who was seated in a wheelchair and watching television. Resident #25 was then observed grabbing the push handles of Resident #40's wheelchair and pushing the wheelchair forward. Resident #25 then started hitting Resident #40 on the left side of his body. Resident #40 responded by attempting to raise his arms to block the hits. At this time, three (3) facility staff came running from the nursing station to the day room to separate the 2 residents. The surveyors observed Employee #23 (Registered Nurse) walk away with Resident #25 and another employee rolled Resident #40 to the opposite side of the dayroom. 2A. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses that included: Other Seizures, Anemia, Hypotension, and Personal History of Other Venous Thrombosis and Embolism. Review of Resident #40's medical record revealed the following: A Quarterly MDS assessment dated [DATE], revealed that the facility staff coded that the resident's preferred language is Russia and that the resident needs an interpreter to communicate with a doctor or health care staff; had unclear speech, sometimes makes self-understood, sometimes is able to understand others, impaired vision; Moderately impaired cognitive skills for decision making; dependent on staff for self-care; used a manual wheelchair and had no impairment in the upper extremities. Review of the medical record showed there was no documented evidence of the physical altercation involving Resident #40 and Resident #25 that was observed by the facility's staff on 03/05/24. 2B. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unspecified Dementia, Altered Mental Status, Blindness Right Eye Category 5, Normal Vision in Left Eye, and Cognitive Communication Deficit. Review of Resident #25's medical record revealed the following: A Quarterly Minimum Data Set assessment dated [DATE] showed that the facility staff coded: adequate hearing, clear speech, usually make self-understood, understands others, and had highly impaired vision; severely impaired cognitive skills for daily decision making; behavior symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing rummaging), rejection of care, and wandering, occurred 1 to 3 days; and no impairment on the upper or lower extremities. A nursing progress note dated 03/05/24 at 5:56 PM documented, Resident is alert and verbally responsive with intermittent confusion. Resident kept pacing and wandering around the unit and wandering to other resident's rooms. Resident attempted to leave the unit 2 times during the AM (morning) shift; via the exit door behind and also via the exit door at the dining area. A nursing progress note dated 03/06/24 at 10:28 AM documented, Late entry 3/5/25 [3/5/24] at 18:36 [6:36 PM] [Resident #25] noted with escalating behaviors, redirected by staff to include diversional activities. Resident noted pushing a chair and this writer redirected resident by ambulating with resident around unit for redirection. Review of Resident #25's medical record lacked any documented evidence that the facility staff noted or investigated the observed resident to resident altercation on 03/05/24. On 3/6/2024 at 10:15 AM during an attempt to interview Resident #25; He was observed laying in bed and was non-responsive verbally to the writer's question, Good morning how are you? On 3/6/2024 at 10:30 AM during an attempt to interview Resident #40; He was observed sitting up in bed and unable to verbally respond to the writer's baseline questions such as, Good morning how are you? During a face-to-face interview conducted on 03/07/24 at 10:54 AM, Employee #30 (Certified Nurse Aide) stated, Resident #25 is erratic he goes into other resident's rooms and he has hit people and he has hit me. Employee #30 went on to say that Resident #25 is redirectable. During a face-to-face interview conducted on 03/07/24 at 2:59 PM, Employee #2 stated, I don't know of any incidents that occurred with (Resident #25) and he (Employee #23) should have followed the necessary protocols (report the incident to Administration, notify physician and resident representative, and start an investigation). 3. The facility staff failed to implement its policies and procedures for reporting and investigating allegations or incidents of abuse and neglect for Resident #294's allegation of staff abuse. Resident #294 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Non-Dominant Side, Pressure Ulcer of Sacral Region Stage 2, and Diabetes Mellitus Type 2. Review of Resident #294's medical record revealed the following: An Admission MDS assessment dated [DATE] showed facility staff coded: A Brief Interview for Mental Status (BIMS) summary score of 15 which indicates intact cognition; required extensive assistance of two (2) person physical assist for bed mobility, transfer, dressing, eating, and toilet use; required extensive assistance of one (1) person physical assist for personal hygiene; was dependent on staff for bathing and the resident; and had impairment on both sides in the upper and lower extremities. A care plan focus area of Post-traumatic stress disorder/panic attack initiated on 07/20/23 had the following interventions, Approach resident with caution, explain all procedures to resident, and encourage activity. Report behavior. A Nursing progress note dated 08/06/23 at 10:38 PM, documented Resident remain alert and verbally responsive. And ADL (activities of daily living) cares provided, due medications administered and tolerated well. PO (by mouth) fluids offered. Resident c/o (complained of) pain this shift. A Facility Reported Incident (FRI) DC~12177 was submitted to the State Agency on 08/07/23 that documented: - Resident's wife called writer and stated that her husband's head was hit on the wall 3 times during care on the weekend (Sunday) 08/06/2023. - Writer went to resident's room accompanied by the charge nurse that worked with him on the said day. When resident was asked how it happened, he stated, I hit my head on the bed rail 3 times when I was being changed. When asked if he told the nurse about it, he stated, she came and gave me my medications. Charge nurse stated that she came into resident's room, to pass his routine medications which she did after wiping his face because he had some crusts on his eyes. resident nodded his head and said yes she cleaned my eyes and gave me medications When asked if he told charge nurse at that time about his head, he stated no. Resident went on to say that his aide for that Sunday was a male. A follow-up submission from the facility to the State Agency on 08/17/23 documented the following: Report of investigation into the incident on August 6th (2023). After thorough clinical review with statements from staff, there was no evidence of abuse or neglect related to the resident's complaint. (Resident #294) continues to remain stable, and all due care provided to the resident before discharge to the hospital. It should be noted that the resident's medical record lacked documented of Resident #294's allegation of physical abuse by staff member. A review of the facility's investigation packet related to this incident/allegation, lacked documented evidence that the facility assessed Resident #294, notified the physician of the resident's allegation of abuse, interviewed all the staff that worked the shift on the day of the allegation, and obtained interviews from other residents. During a face-to-face interview conducted on 03/18/24 at approximately 3:00 PM, Employee #2, (Director of Nursing) stated that the facility leadership has changed, and she was not able to locate any additional documentation concerning Resident #294's allegation of abuse. Cross Reference 22B DCMR sec. 3269.1

45102 Based on record reviews and staff interviews, for two (2) of 41 sampled residents, facility staff failed to report the results of their investigations to the State Agency within 5 (five) working days of the incident. Resident #192 and Resident #294. The findings included: A review of a facility policy titled Prohibition of Resident Abuse/Abuse Prevention revised on 12/16/22 documented the following: The facility will designate an Abuse prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect or exploitation to the state survey agency and other officials in accordance with state law and An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation (e.g. (for example) not tampering or destroying evidence); Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations. 1.The facility staff failed to report the results of Resident #192's elopement incident to the State Agency within 5 working days. Resident #192 was admitted to the facility on [DATE] with multiple diagnoses including: Encephalopathy, Seizures, Muscle Weakness and Cirrhosis of the Liver. Review of the medical record revealed the following: A Facility Reported Incident Intake form (DC~11829) received by the State Agency that was dated 04/04/23 at 10:59 AM documented the following but not limited to: At 6:55 am, resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink (Missing Resident) was initiated and 911 was called at 7:20am and residents detailed information provided to the police. A search team comprising of nursing staff and security were dispatched to search the community area, especially at the bus stops and metro stations. Resident [was] wearing a white sweat pants and white hooded top long sleeve sweater. Temperature outside at the time is 58 degrees at 7:30 am. MD (medical director), DON (Director of Nursing), and the responsible party (ex-wife) was notified. Eventually we got a call from the facility security that the police found resident. Investigation is still in the process. A nursing supervisor note dated 04/04/23 at 12:16 PM documented that, At 6.55 am, I was informed that the resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink was initiated. 911 was called at 7:20am and information about resident given. Search team comprising of nursing staff and security were dispatched to search for him around bus stops and metro stations. The DON was notified. [Responsible party's name] was called, and she said [resident's name] call(ed) her from bus stop around the facility. The search team converged around the community area. Eventually we got a call from the facility security that the police found resident at a bus stop. Upon returning to the facility, resident was found at the parking lot accompanied by the police officer. At this point, resident refused coming into the facility, it took about 40 to 45 minutes to encourage and convince resident to come into the facility. At 8:50am, [Resident's name] returned to the unit after much encouragement. Resident remains alert and verbally responsive, not in acute distress. Head to toe assessment done. Denied pain, no discomfort noted. Skin warm to and dry. Respiration is even and non-labored. Temperature 98.0, Pulse 62, Respirations 18, Blood Pressure 128/81, Oxygen Saturations 96%. When asked why he eloped from the facility, resident stated that he does not want to stay here and verbalized that he will walk out again. New order given to monitor resident one on one until seen by the psychiatric team. Close monitoring in progress and maintained. A State Survey Agency 5-day Follow-up Intake Form dated 04/04/23 at 12:11 PM documented, [Resident's name] returned to the unit at around 8:50 am after much encouragement. New order given to monitor resident one on one until seen by the psychiatric team. Close monitoring in progress and maintained. A review of the facility's investigation packet lacked documented evidence describing the results of the investigation for Resident #192's elopement incident on 04/04/23. During a face-to-face interview on 03/12/24 at approximately 3:00 PM, Employee #2 (Director of Nursing/DON) reviewed the investigation packet and stated that she did not see the results of the investigation that was conducted by the facility. Cross reference 483.25 Quality of Care F689 2. The facility staff failed to report the results of their investigation into Resident #294's allegation of staff abuse. Resident #294 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Non-Dominant Side, Pressure Ulcer of Sacral Region Stage 2, and Diabetes Mellitus Type 2. Review of Resident #294's medical record revealed the following: An Admission MDS assessment dated [DATE] showed facility staff coded: A Brief Interview for Mental Status (BIMS) summary score of 15 which indicates intact cognition. A Facility Reported Incident (FRI) DC~12177 was submitted to the State Agency on 08/08/23 that documented: - Resident's wife called writer and stated that her husband's head was hit on the wall 3 times during care on the weekend (Sunday) 08/06/2023. - Writer went to resident's room accompanied by the charge nurse that worked with him on the said day. When resident was asked how it happened, he stated, I hit my head on the bed rail 3 times when I was being changed. When asked if he told the nurse about it, he stated, she came and gave me my medications. Charge nurse stated that she came into resident's room, to pass his routine medications which she did after wiping his face because he had some crusts on his eyes. resident nodded his head and said yes she cleaned my eyes and gave me medications When asked if he told charge nurse at that time about his head, he stated no. Resident went on to say that his aide for that Sunday was a male. A follow-up submission from the facility to the State Agency on 08/17/23 10 days after the initial intake documented the following: Report of investigation into the incident on August 6th (2023). After thorough clinical review with statements from staff, there was no evidence of abuse or neglect related to the resident's complaint. (Resident #294) continues to remain stable, and all due care provided to the resident before discharge to the hospital. During a face-to-face interview conducted on 03/18/24 at approximately 3:00 PM, Employee #2, (Director of Nursing) stated that the facility leadership has changed, and she was not able to locate any additional documentation concerning Resident #294's allegation of abuse. Cross Reference 22B DCMR sec. 3269.1

Based on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to provide Resident #66's representative with written information that specified the duration of the state bed-hold policy before transfer to the hospital. The findings included: Review of the facility's Bed Hold policy, last reviewed on 04/26/23, documented that: - The admissions office will mail out the Bed Hold notification form to each resident/point of contact each time they are out of the facility. - The form will be mailed out the next business day. - The notification shall provide the number of [bed-hold] days remaining. Resident #66 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Hypertension and Hyperlipidemia. Review of the Resident #66's medical record revealed the following: It was noted that the face sheet documented Resident #66's wife as his responsible party and emergency contact. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 03 indicating severely impaired cognitive status. An eInteract Situation Background Assessment Request (SBAR) note dated Sunday, 02/04/24 at 1:48 AM documented: - Situation: fever nausea/vomiting; blood pressure (BP): 87/53, pulse 122. - At about 9:30 PM, writer was notified by charge nurse that resident did vomit after dinner, and supra pubic catheter drainage bag observed with mild blood, bloody discharge from urethra too. - Order given to send resident to nearest emergency room for further evaluation. - Wife notified at 1:30 AM. A Health Status Note dated 02/04/24 at 2:38 PM documented, Telephone call was place by the writer to [Hospital name] and it was confirmed that resident has been admitted . On 03/06/24, the State Surveyor asked facility staff to provide documented evidence of written information given to Resident #66's representative specifying the state bed-hold policy and number of bed-holds available however, they did not have any documentation. During a face-to-face interview on 03/07/24 at 9:29 AM, Employee #4 (Social Services Director) stated that the written notice of bed-hold policy and number of bed-hold days was done by Admissions Department. I am not sure who does that (provide bed-hold policy/days) on the off hours or weekends. A face-to-face interview was conducted on 03/07/24 at 11:05 AM with Employee #12 (Admissions Director) and Employee #13 (Director Sales and Marketing). Employee #12 stated, The process is to review and check the nurse's notes and physician's orders to see what residents were transferred out. The residents who were transferred out are then discussed during stand down meeting (conducted on weekdays), at which time, a 6-108 [Notice of discharge, transfer, relocation] form is generated. I can't answer as to why Resident #66 does not have one for February [2024]. I was told that it was completed, but the ball was dropped on that one. Cross Reference 22B DCMR Sec. 3270.1 (Facility staff failed to discharge Resident #66 in accordance with the Nursing Home and Community Resident's Protection Act of 1985 (District of Columbia Law 6-108)).

Based on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to complete a quarterly (every 3 months) assessment for Resident #72. The findings included: Review of the facility's contracts showed that [Company name], effective on 02/12/24, was responsible for completing the facility's Minimum Data Set (MDS) assessments. The contract documented: - [Company Name] shall provide the facility with ongoing MDS department support, specifically, to organize, review, encode and confirm timely completion of all admission, quarterly, annual and significant change in status MDS assessments. Resident #72 was admitted to the facility on [DATE] with diagnoses that included: Pressure Ulcer of Sacral Region, Stage 3, Dysphagia, Aphasia, Pain, and Cerebral Infarction. Review of Resident #72's MDS transmittal sheet provided to this surveyor on 03/08/24 documented: - Annual MDS assessment - dated 10/03/23 showed Accepted, indicating that it was accepted by Center for Medicare and Medicaid Services (CMS). - Quarterly MDS assessment - with an assessment reference date (ARD) of 02/16/24 showed In progress, indicating that it had not been completed by facility staff. It should be noted that this Quarterly assessment should have been completed within 14 calendar days of the ARD (03/01/24). However, review of Section Z (Assessment Administration) of the Quarterly MDS with an ARD of 02/16/24 documented: Sections A1005 (Ethnicity), A1010 (Race), and A1110 (Language) were not completed until 03/04/24 (3 days late). During a telephone interview on 03/14/24 at 12:36 PM, Employee #21 (Director of MDS Support Systems) stated, There is a 14-day window from the ARD to complete all the information in all sections of the assessment. Anything after that time frame is considered late. If the ARD end date is February 16th, [2024] and the section is signed on March 4th, [2024], per the regulation, yes, that is considered late. The evidence showed that facility staff failed to complete a quarterly MDS assessment every 3 months for Resident #72.

Based on record review and staff interviews for one (1) of 41 sampled residents, facility staff failed to have documented evidence a resident's Admission Minimum Data Set (MDS) Assessment was completed as evidenced by not coding the resident's cognitive patterns in Section C. Resident #89. The findings included: Resident #89 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Infarction and Multiple Sclerosis. Review of Resident #89's medical record revealed: An Annual MDS assessment dated [DATE] documented: Section C - Cognitive Patterns, Should Brief Interview for Mental Status (BIMS) (C0200-C0500) be conducted? 1. Yes. However, there was no documented evidence that facility staff conducted the BIMS, as evidenced by Sections C0200, C0400 and C0500 were blank. Additionally, there was no documented evidence of the resident's BIMS summary score that indicated the resident's cognitive status. During a face-to-face interview conducted on 03/07/24 at 2:07 PM, Employee #4 (Director of Social Services) reviewed the Admission MDS and stated that it was her role to complete section C (Cognitive Patterns) which she completes on the day residents are admitted or the next day. As of the date of this interview (38 days after Resident #89's admission), facility staff had not completed the previously mentioned section of the Admission MDS.

45102 Based on record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to develop a care plan with goals and approaches to address a resident's use of a central intravenous (IV) line and a cholecystectomy tube and failed to implement a resident's care plan intervention for falls. Resident #66 and Resident #71. The findings included: Review of the facility's Interdisciplinary Care Plans policy, last reviewed on 11/10/22, it documented: - An individualized interdisciplinary care plan will be maintained for each resident. - Information recorded on the care plan includes date problems and/or needs first addressed, active problems and current needs of the resident. 1. Facility staff failed to develop care plans with goals and approaches for Resident #66's use of a central intravenous (IV) line and a cholecystectomy tube. Resident #66 was admitted to the facility on [DATE] with multiple diagnoses that included: Retention of Urine, Hypertension and Dementia. Review of the resident's medical record revealed the following: A Health Status Note dated 02/14/24 at 4:21 PM that documented: - Resident was readmitted from [Hospital name] to the facility. - Central line placed on 02/09/24 on the right upper arm. - Resident underwent Cholecystostomy tube placement on 02/04/24. - Right gallbladder drainage bag. Physician's orders dated 02/14/24 directed: -Cholecystectomy tube care (abdomen, right upper), flush with 10 ml (milliliters) of 0.9 Sodium Chloride two times a day; irrigate with 60 CC's (milliliters) of saline every shift. -Peripherally inserted central catheter (PICC), 1 lumen brachial right, for antibiotic treatment; monitor PICC line dressing daily for redness, swelling and drainage every shift; change PICC line dressing every week, every evening shift every on Friday. Review of Resident #66's medical record on 03/07/24, (22 days after readmission) showed no documented evidence that facility staff developed a comprehensive resident-centered care plan with goals and approaches to address the Resident's use of a PICC or the cholecystectomy tube with a drainage bag. During a face-to-face interview on 03/07/24 at 9:21 AM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated, Those care plans should've been started on readmission (02/14/24). 2. Facility staff failed to implement Resident #71's care plan interventions for falls. A Facility Reported Incident (FRI), DC~11512, submitted to the State Agency on 01/17/23, documented the following: Charge Nurse called writer to room [ROOM NUMBER]b to see Resident lying on the floor on her back with a pillow under her head at 5.10 am. When asked what happened Resident stated that two men carried her on the wheelchair to upstairs. Resident is alert and responsive with intermittent confusion. Head to toe assessment was done. A small cut noted on left side of the head with minimal bleeding. Area measured 0.1 cm (centimeters) and no depth. Area was cleansed. Ice pack applied. Resident #71 was admitted to the facility on [DATE], with multiple diagnoses that included: Parkinson's Disease, Cognitive Communication Deficit, and Personal History of Non-[NAME] Lymphomas. During an observation on 03/04/24 at approximately 10:15 AM with Employee #7 (Licensed Practical Nurse/LN), Resident #71 was noted in her room lying in bed with the head of bed raised and bed in lowest position. The following was observed: -The call light device was hanging in a loop, on the wall behind the bed, not within the resident's reach. -The bedside table was noted at the foot of the bed with a thermos cup on top of it not within the resident's reach. -A floor mat was noted on the left side of the bed, however, there was not one on the right side of the bed. Instead, a floor mat was noted rolled up, placed against the wall and covered by a white sheet. At the time of the observation, the State Surveyor asked Resident #71 if she was able to press the call light for assistance and the resident stated she does not know where the call light is. A review of Resident #71's medical record revealed the following: A physician's order dated 01/17/23 directed, Floor mats (left and right) to bedside when resident is in bed every shift for safety. A Quarterly MDS assessment dated [DATE] showed that the facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 10 indicating moderate cognitive impairment; was totally dependent on staff for toileting, bathing and dressing; and had 2 falls since the last MDS assessment. A care plan dated 01/09/24 documented, Focus Area: Falls- [Resident #71] had an alleged fall on 1/8/2024. Interventions included: Continue to monitor resident. Continue to educate resident on the use of call light. Encourage resident to call for help when needed, Call light within reach and Floor Mats at bedside when resident is in bed for safety q (every) shift. The evidence showed that facility staff failed to implement the following interventions of Resident #71's care plan: call light within reach and floor mat at the bedside. During a face-to-face interview at the time of the observation, Employee #7 acknowledged the findings, placed the call light and bedside table within the resident's reach, and placed the floor mat bedside the resident's bed. Cross Reference 22B DCMR Sec. 3210.4

Based on observation, record reviews, staff interviews, and a family interview, for one (1) of 41 sampled residents, the facility's staff failed to provide adequate supervision for a resident. As a result, the resident left the facility without staff knowledge (Resident #192). The findings included: Review of the policy titled, Missing Resident #99M-010, documented, A resident is considered missing from the facility whenever their whereabouts cannot be ascertained. This situation is an elopement. Resident #192 was admitted to the facility on [DATE] with multiple diagnoses including: Encephalopathy, Seizures, Muscle Weakness and Cirrhosis of the Liver. Review of the medical record revealed the following: A care plan dated 01/01/23 that documented, Problem: [Resident #192] has risk for Elopement related to wandering evidenced by trying to enter the elevator. Goal: Resident will not elope. Approach: Monitor resident's movements closely while out of bed. Encourage resident to verbalize feelings of boredom/loneliness at all times. Encourage resident to participate in group activities of choice. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the following: a Brief Interview for Mental Status (BIMS) summary score of 14, indicating the resident had an intact cognitive status. Additionally, the resident was coded for requiring supervision from staff with activities of daily living. A Facility Reported Incident Intake form (DC~11829) received by the State Agency that was dated 04/04/23 at 10:59 AM documented the following but not limited to: At 6:55 am, resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink (Missing Resident) was initiated and 911 was called at 7:20am and residents detailed information provided to the police. A search team comprising of nursing staff and security were dispatched to search the community area, especially at the bus stops and metro stations. Resident [was] wearing a white sweat pants and white hooded top long sleeve sweater. Temperature outside at the time is 58 degrees at 7:30 am. MD (medical director), DON (Director of Nursing), and the responsible party (ex-wife) was notified. Eventually we got a call from the facility security that the police found resident. Investigation is still in the process. Please note, According to World Weather, the temperature in the District of Columbia on 04/04/23 during the daytime ranged from 55 to 75 degrees (Fahrenheit). https://world-weather.info/forecast/usa/washington_1/april-2023/ A nursing progress note dated 04/04/23 at 11:22 AM documented, Resident was received in bed at 11:00 pm, alert, oriented and verbally responsive. During routine round, Resident was in bed through the night. Breathing even and unlabored. No sign of respiratory distress or shortness of breath noted. No complain of pain or discomfort voiced. Around 5:30 am when I pushed my medication cart down the hall to start from room [ROOM NUMBER] where I normal start. Resident was in his room. When I got to his room at 6:40 am to give him his medication, I could not see him, I checked the bathroom, he was not there, then I alert other staffs and the supervisor, then called the security officer to found out if Resident left the facility. The staffs(sp) begin to search for him all rooms and bathrooms. I left the facility with other staffs in search of him to nearby bus-stops and metro stations. A nursing supervisor note dated 04/04/23 at 12:16 PM documented that, At 6.55 am, I was informed that the resident in room [ROOM NUMBER]B was not in his room. The security was alerted, all the rooms were searched. Code pink was initiated. 911 was called at 7:20am and information about resident given. Search team comprising of nursing staff and security were dispatched to search for him around bus stops and metro stations. The DON was notified. [Responsible party's name] was called, and she said [resident's name] call(ed) her from bus stop around the facility. The search team converged around the community area. Eventually we got a call from the facility security that the police found resident at a bus stop. Upon returning to the facility, resident was found at the parking lot accompanied by the police officer. At this point, resident refused coming into the facility, it took about 40 to 45 minutes to encourage and convince resident to come into the facility. At 8:50am, [Resident's name] returned to the unit after much encouragement. Resident remains alert and verbally responsive, not in acute distress. Head to toe assessment done. Denied pain, no discomfort noted. Skin warm to and dry. Respiration is even and non-labored. Temperature 98.0, Pulse 62, Respirations 18, Blood Pressure 128/81, Oxygen Saturations 96%. When asked why he eloped from the facility, resident stated that he does not want to stay here and verbalized that he will walk out again. New order given to monitor resident one on one until seen by the psychiatric team. Close monitoring in progress and maintained. According to the investigation packet, the following employees wrote statements dated 04/04/23:? Employee #14 (CNA) documented, I [employee's name] worked last night April 3, 2023, and [resident's name] was assigned to me. The last time I saw [resident's name] was at 5:30 AM in his room. We the nurses on the night shift on unit (Unit2) left the floor and went to the street and metro station looking [for him] after he left the facility. We did not find him. Employee #15 (Housekeeping Director) documented, I [employee's name] entered the building at 5:36 AM, after signing in on the covid machine (kiosk) I walked thru the door (left of the security desk) leading to the bird (cage) area and a resident wearing a white sweat suit and carrying a bag was coming off of Unit 1. I asked where he was going, and he stated that his brother was picking him up front up front. He continued to the front desk area where security was sitting. Continued review of the facility's investigation packet showed Employee #16 (Security Guard) wrote an Incident Report dated 04/04/23 that documented, [Resident daughter's name] called [Facility name] at 6:44 AM and confirmed [resident's name] was at the bus stop. I went to go look for [resident's name] at the bus stop and I returned to the nursing home at 7:20 AM. A psychiatric nurse practitioner note dated 04/05/23 at 6:58 PM documented that, Resident seen secondary to elopement on 04/04/23 and review of 1:1 monitoring order. [Resident stated] 'I have been here for too long; I was told at the other facility that I could leave.' Remains on 1:1 monitoring. Alert and oriented to place, person, time, and situation. Does not present with any psychiatric disorder. Pleasant, not confused but appears to make poor and irrational judgement occasionally. Ambulates with steady gait. Continue 1:1 monitoring every shift for now and reassess for elopement risk in 4-5 days. Encourage participation in different activities on unit. A State Survey Agency Complaint Intake (DC~11872) dated 04/10/23 at 3:30PM documented: - It was on April 4, 2023 [Resident #192] called me at 7:00 AM stating that he's out of the nursing home and was at a bus stop and didn't know what bus stop or where. - I called the nursing home asking them was my husband in the facility, because he called and told me that he's at a bus stop. They asked me what bus stop he was at and for his cell phone number. - I called [Resident #192] back, an officer from MPD (Metropolitan Police Department) got on the phone and stated that they were at the Metro Cener train station (approximately 3.1 miles from the facility). - The officer agreed to hold him. My daughter went and picked him up from Metro Center and took him back to the nursing home. - I feel that this is a neglect on the staff that's on the 2nd floor where he's on and security for allowing him to get out. Review of Employee #16's (Security Guard) personnel record showed the employee was hired on 05/16/22. The employee signed his initials on the Training Checklist dated 05/17/22 indicating he received training on Never leaving the front desk unattended. Moreover, the employee signed an Employee Warning Notice dated 04/12/23 that documented that, Date of incident 04/03/23 between 5AM to 5:30 AM. [Employee's name] you [were] supposed (sp) to been (sp) posted at the front desk during this time [resident's name] from room [ROOM NUMBER] walked thru the lobby past the front desk and out of the front door which caused an elopement. On 03/08/24 at approximately 11:00 AM, an observation of the lobby area revealed a security desk located adjacent to the facility's front door. At the time of the observation, a security guard and receptionist were seated at the desk. Behind the security desk, was a closet that's used by security staff. Additionally, there was a three-ring binder labeled Wanders and a security logbook (where security staff write notes about rounds and concerns in the facility) was noted on the desk. The security logbook lacked documented evidence of Resident #192's elopement incident on 04/04/23. During a telephone interview on 03/13/24 at 8:30 AM, Employee #17 (Nursing Supervisor) stated that Resident #192's assigned nurse called and informed her that staff could not locate the resident (on 04/04/23). After Employee #16 (Security Guard), who was posted at the front desk of the lobby, informed her that he did not see the resident leave out the front door, she called a Code Pink and continued looking for the resident with other staff. During a telephone interview on 03/13/24 at 9:30 AM, Employee #16 (Security Guard) stated that he believed when he walked into the closet behind the security desk, the resident exited the facility through the front door. The employee stated that he was wrong for leaving the front desk unattended. He should have called the other security guard to cover the front desk. The employee also stated that he wrote an incident report related to Resident #192's elopement, and he thought he wrote the information in the security logbook. During a face-to-face interview on 03/13/24 at approximately 10:00 AM, Employee #18 (Security Supervisor) stated that Employee #16 (Security Guard) did not follow the company's policy when he left his post at front desk unattended on 04/04/23. He was to call the other security guard in the building to cover his post. Employee #18 reviewed that logbook and stated that she did not see documented evidence that Employee #16 documented Resident #192's elopement incident. When asked if that incident should have been documented in the logbook, Employee #18 replied Yes.

Based on observation, record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to follow the physician's order to change Resident #66's peripherally inserted central catheter (PICC) line dressing every Friday. The findings included: Review of the facility's PICC/Midline/CVAD (central venous access device) Dressing Change policy dated 10/05/22, it documented: - It is the policy of this facility to change PICC, midline or CVAD dressing weekly or if soiled, in a manner to decrease potential for infection. - Physician's orders will specify type of dressing and frequency of change. Resident #66 was admitted to the facility on [DATE] with multiple diagnoses that included: Retention of Urine, Hypertension and Dementia. Review of Resident #66's medical record revealed: A Significant Change Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) Summary Score of 03, indicating severely impaired cognitive status. A Health Status Note dated 02/14/24 at 4:21 PM that documented: - Resident was readmitted from [Hospital name] to the facility. - Central line placed on 02/09/24 on the right upper arm. Physician's order dated 02/14/24 directed, - PICC, 1 Lumen brachial right, for antibiotic treatment, monitor PICC line dressing daily for redness, swelling and drainage every shift. - Change PICC line dressing every week, every evening shift, on Friday. Review of the Treatment Administration Record (TAR) for February 2024 showed facility staff documented a check mark and their initials to indicate that the central line dressing change was completed on Friday, 02/16/24, Friday, 02/23/24 and on Friday, 03/01/24 and that they were monitoring the dressing site every shift. During an observation on 03/04/24 at 10:30 AM with Employee #5 (Licensed Practical Nurse/LPN), Resident #66 was observed with a single lumen PICC to his right upper arm with a dressing that was dated, 2/9/24. When asked why the resident's central line dressing had not been changed since 02/09/24, the employee stated, The dressing does not get changed on my shift (day shift, 7:00 AM - 3:30 PM) and only a Registered Nurse (RN) is allowed to change the dressing. I will get an RN to come and change the dressing now. The evidence showed that from 02/14/24 to 03/04/24, facility staff failed to follow the physician's order to change Resident #66's central line dressing. It should be noted that the last documented central line dressing change was performed by hospital staff on 02/09/24. The first-time facility staff changed Resident #66's central line dressing was on 03/04/24 (24 days after the resident's readmission). During a face-to-face interview on 03/07/24 at 9:21 AM, Employee #2 (Director of Nursing/DON) acknowledged the finding and stated, The physician's order was not followed and the nurses documented that they did something they in fact did not complete. Cross Reference 22B DCMR Sec. 3211.1 (Facility staff failed to ensure that sufficient time was given ensure that Resident #66's central line dressing was changed as ordered by the physician.)

Based on observations and staff interviews, for two (2) of two (2) oxygen storage rooms, facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks intended for patient use. The findings included: According to the Joint Commission: - Storing oxygen cylinders, as per the National Fire Protection Association (NFPA) 99-2012, 11.6. 5.2, is about ensuring full and empty cylinders are not comingled. - Those cylinders defined as 'empty' by the organization shall be segregated from all other cylinders that are intended for patient care use. https://www.jointcommission.org/standards/standard-faqs/home-care/environment-of-care-ec/000001261/#:~:text=Storing%20oxygen%20cylinders%2C%20as%20per,intended%20for%20patient%20care%20use. 1. An observation on 03/05/24 at 10:09 AM of the 2nd floor oxygen storage room, with Employee #22 (Licensed Practical Nurse/LPN) showed, one (1) empty oxygen tank was stored in the same area with four (4) full oxygen tanks that were stored for resident use. At the time of the observation, Employee #22 stated, I'm not sure who checks the oxygen tanks in the supply room, but a nurse is supposed to look and check the tank before taking it out to use for a patient (resident), which means they shouldn't grab one if it's empty. Empty tanks are kept in the basement for pickup. 2. An observation on 03/05/24 at 10:47 AM of the 1st floor oxygen storage room with Employee #7 (LPN) showed two (2) empty oxygen tanks were stored in the same area with three (3) full oxygen tanks. At the time of the observation, Employee #7 stated, Empty [oxygen] tanks are stored downstairs. I would have to refer you to my DON (Director of Nursing) about whether empty and full oxygen tanks can be stored together. I will remove the empty oxygen tanks and bring them downstairs. During a face-to-face interview conducted on 03/05/24 at 10:56 AM, Employee #2 (DON) acknowledged the findings and stated, The facility did not have a policy or procedure for storage of oxygen tanks. Best practice is for whoever checks the code carts to also ensure that there are only full tanks in the oxygen storage room. Cross Reference 22B DCMR Sec. 3215.4(f) (Facility staff failed to ensure the effective and safe storage of equipment for administering oxygen.)

Based on observation, record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to ensure that Resident #26 received timely treatment and care in accordance with professional standards of practice and the physician's orders for her right foot; and facility staff failed to assess Resident #32's skin every shift per the care plan. Subsequently, the resident was observed with cellulitis of left lower limb with edema. These failures resulted in actual harm to Resident #26 when it was determined that the resident's reddened right big toe (first observed on 07/14/22) further declined and resulted in amputation on 10/26/22. The findings included: Review of the policy Documentation Criteria last reviewed on 07/22/22 directed, Clinical notes are written by a licensed nurse in the medical record. Clinical notes are randomly audited by registered nurse quarterly. Finding of audit are reported to QI (Quality Improvement) team with scheduled meeting . Clinical notes for decubitus/open wound include description of the area, size, drainage, presence of necrotic tissue, and condition of skin around the area . treatment was done as ordered . skin: note condition of feet even if no open areas exist .note for evidence of infection . Review of the 1st floor shower book showed a document titled, Skin Monitoring: CNA (Certified Nurse Aide) Shower Report that directed, perform a visual assessment or a resident's skin when giving the resident a shower. Report any abnormal looking skin to the charge nurse immediately . The form also had an area that directed, Charge nurse assessment followed by a designated space for the CNA's signature as well as the charge nurse's signature. 1. Facility staff failed to ensure that Resident #26 received timely treatment and care in accordance with professional standards of practice and the physician's orders for her right foot. Resident #26 was admitted to the facility on [DATE] with diagnoses that included: Idiopathic Peripheral Autonomic Neuropathy, Type 2 Diabetes Mellitus and Muscle Weakness. Review of Resident #26's medical record revealed the following: 05/10/19 [physician's order] Monitor for bruising/bleeding every shift 05/10/19 [physician's order] Turn and repositioning Q (every) 2 hrs (hours) every shift Care plan focus area, [Resident #26] is at risk for skin impairment r/t (related to) decreased mobility, incontinence, underweight initiated on 09/10/19 had the following approaches, Report any signs of skin breakdown (sore, tender, red, or broken areas). Provide diet and supplement as ordered. Dietary consult PRN (as needed) .Keep clean and dry as possible. Minimize skin exposure to moisture. The Annual Minimum Data Set (MDS) dated [DATE] showed facility staff coded the resident as: usually makes self understood; usually understands others; severe cognitive impairment; no behavior issues or refusal of care; required extensive assistance with two persons physical assist for bed mobility; required extensive assistance with one person physical assist for transfers, toilet use and personal hygiene; no functional limitations in range of motion; at risk for pressure ulcers; and no unhealed pressure ulcers or any other skin conditions. 06/27/22 Monthly Summary .No skin breakdown . no new skin issues noted . 07/14/22 at 11:48 AM [Physician's Assistant Note] .Pt's (patient's) nurse reported that pt complained of big toe pain and redness [right toe] .Pt admits to doing well and admits to pain to the foot .Plan: .Order Colchicine (decreases swelling) 0.6mg (milligrams) tablet, give 2 tablet x 1, then 1 tablet 1 hour later for [NAME] exacerbation. 07/14/22 at 10:55 PM [Nursing Note] .MD (medical doctor) in house, made aware of RT (right) great toe swollen, new order given for Colchicine 0.6mg tab (tablet), give 2 tabs x1, then 1 tab 1 hour later for [NAME] exacerbation. Order faxed, awaiting delivery .Will continue with POC (plan of care). 07/15/22 [physician's order] Colchicine tablet; 0.6 mg; amt (amount): 2 tabs x1; oral Special Instructions: give 2 tablet x 1, then 1 tablet 1 hour later for [NAME] exacerbation once - one time It should be noted the order for Resident #26 to receive Colchicine was written one day after she was assessed for the pain and redness of her right foot. A review of the 1st Floor Assignment sheet was conducted and showed that Resident #26 was scheduled to receive a shower every Monday and Thursday evening shift (3:00 PM - 11:00 PM). CNA documentation showed that on 07/17/22, evening shift, Resident #26 received a shower. However, there was no evidence that a skin report sheet was completed to show that a skin assessment was performed. Furthermore, as of 11/09/22, facility staff was unable to provide documented evidence that a shower report sheet had been completed on Resident #26 for any of her scheduled shower days from January 2022 to present. Treatment Administration Record (TAR) showed that from 07/15/22 to 07/22/22, facility staff documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. From 07/15/22 to 07/22/22 (8 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. 07/23/22 at 8:58 PM [Physician's Note] .Patient seen at the request of nursing for ischemic [necrotic] foot and toe with surrounding cellulitis .Dark big toe dry and cellulitis .Begin Keflex (antibiotic) . 07/23/22 at 11:05 PM [Nursing Note] .New order given (1) Keflex 500mg po (by mouth) TID (three times a day) X 7 days for cellulitis of foot .and Gangrene [Dead tissue caused by an infection or lack of blood flow]. 07/26/22 [physician's order] Uric Acid [laboratory test that measures waste product found in blood ] 07/26/22 at 5:57 PM [American Health Associates] .Uric Acid . 3.9 . Reference range 2.3 - 6.6 mg/dL (deciliter) . 07/28/22 at 8:11 AM [Physician's Assistant Note] .MSc (musculoskeletal): Normal ROM (range of motion) to lower extremities, hyper pigmented discoloration of the foot, and no pedal edema .Plan 1. Continue with current treatment plan and level of care .Continue with Cellulitis medication regimen and treatment. 07/31/22 [Monthly Summary] . Resident recently completed antibiotic .for right foot cellulitis . 08/01/22 at 10:06 PM [Nursing Note] . [resident's] RT foot remains swollen, denies pain. 08/06/22 at 7:34 PM [Physician's Note] Follow up done regarding PVD (Peripheral Vascular Disease) with dry gangrene. Hyperpigmentation persists with skin warm to touch and dry . Continue current treatment . A Quarterly MDS dated [DATE] showed facility staff coded: required extensive assistance with two persons physical assist for bed mobility; required extensive assistance with one person physical assist for personal hygiene; at risk for pressure ulcers; and 1 venous/arterial ulcer present. It should be noted that the MDS is coded as the Resident having 1 venous/arterial ulcer present. However, there are no documented skin assessments/clinical notes for any open wound/ulcer for this time period. Care plan focus area, [Resident #26] is at risk for skin impairment r/t (related to) decreased mobility underweight showed it was revised on 08/16/22. However, there was no evidence that when facility staff first noted the change in the condition to the resident's right foot, that the care plan was updated to include person-centered care goals and approaches that addressed actions, treatments, procedures, or activities for the care of Resident #26's right foot. From 08/09/22 [date the MDS was coded for Resident #26 having one venous/arterial ulcer] to 08/23/22 (15 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. The August 2022 TAR showed that from 08/09/22 to 08/23/22 (15 days), facility staff documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. 08/24/22 at 9:56 PM [Nursing Note] .Vascular Consult for RT lower extremity. [Duplex (test examines the blood flow in the major arteries and veins in the arms and legs)] for diagnosis follow up. DX (diagnosis) (1) Toe pain great toe (2) Wound great toe RT nacrotic (sp). (2) Wound care cleansing RT great toe and light dressing pending vascular consult. 08/24/22 [physician's order] Vascular consult for rt lower extremity [Duplex] for diagnosis and follow up . 08/24/22 [physician's order] Wound care cleansing RT great toe and light dressing pending vascular consult - once a day 09/03/22 at 1:00 PM [Nursing Note] .Seen today by wound doctor . 09/03/22 [physician's order] Bacitracin (topical antibacterial) ointment; 500 unit/gram; ribbon size; apply ointment to right toe once daily. Leave open to air dry . 09/08/22 at 11:02 AM [Physician's Assistant Note] Pt seen at bedside on routine visit appears alert and stable Pt appears to be doing well and denies to pain to the foot MSc: Normal ROM to lower extremities, hyperpigmented discoloration of the foot, and no pedal edema .continue with current treatment and level of care . From 09/09/22 to 09/21/22 (13 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. September 2022 TAR showed that from 09/09/22 to 09/21/22, facility staff initialed in the area that directed, Bacitracin .apply ointment to right toe once daily. Leave open to air dry . indicating that the task was completed and documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. 09/22/22 at 7:34 PM [Physician's Assistant Note] Pt's nurse reported that pt's right foot toes are changing color with gangrene . Pt was communicated through phone translator . Order bilateral duplex arterial/venous US (ultrasound) to rule out occlusion. 09/23/22 [physician's order] Duplex Doppler arterial\venous right leg and left leg . 09/23/22 at 11:24 PM [Nursing Note] Dynamic mobile called that Doppler will be done tomorrow and not today, to be done on 09/24/22 . 09/24/22 at 9:20 PM Dynamic Mobile Imaging . procedure: venous Doppler bilateral . findings: the venous ultrasound is normal .no evidence of venous clot . 09/26/22 at 2:54 PM [Nursing Note] [Resident #26] was seen today by .wound specialist and the wound team in house for dry gangrene perfusing (sp) right toes ischemic 1st, 4th and 5th toe continue Bacitracin ointment and leave open to air . No new order at this time. 09/29/22 at 6:35 PM [Physician's Assistant Note] Pt's nurse reported that pt had Doppler Scan results that need to be reviewed and addressed . Imaging: Venous Doppler bilateral LE (lower extremities) shows no evidence of venous clots .Plan Continue with current treatment plan and level of care . 10/01/22 [physician's order] Bilateral lower extremities arterial Doppler . 10/01/22 at 10:00 PM [Nursing Note] .Total care provided, turned and repositioned [every] 2 hours . Bilateral lower extremities arterial Doppler done this shift, result pending . 10/02/22 at 1:06 AM [Dynamic Mobile Imaging] . procedure: arterial legs bilateral venous . findings: right: moderate plaque is noted within visualized arteries . Findings consistent with moderate PVD without occlusion, right lower extremity .Moderate stenosis between right proximal femoral artery and mid SFA (superficial femoral artery). Moderate stenosis of the right distal SFA . It should be noted that the duplex test was first ordered on 08/24/22. A venous duplex test was not completed until 09/24/22 (31 days later), that showed no evidence of venous clots. Within this timeframe), Resident #26 had additional toes that became ischemic (4th and 5th toes). An arterial duplex was then done on 10/01/22 that showed PVD with moderate stenosis of the right lower extremity. The October 2022 TAR showed that from 10/02/22 to 10/16/22, facility staff initialed in the area that directed, Bacitracin .apply ointment to right toe once daily. Leave open to air dry . indicating that the task was completed and documented: 0 or none noted in the area that directed, Monitor for bruising/bleeding every shift; and that Resident #26 was turned and repositioned q (every) 2 hours. From 10/02/22 to 10/16/22, (15 days), there was no documented evidence that facility staff performed an assessment (skin color, temperature, pain and swelling) of Resident #26's right foot. 10/17/22 at 1:47 PM [Nursing Note] [Resident #26] was seen today by .wound specialist and the wound team in house for dry gangrene perfusing right toes ischemic 1st, 4th and 5th to continue Bacitracin ointment and leave open to air. 10/22/22 at 5:37 PM [Nursing Note] Resident .seen by PCP (primary care physician) .on shift. Orders given to send resident to the hospital for progressive gangrene, needs revascularization vs (versus) amputation . 10/23/22 [Hospital Discharge Summary] .presenting to the ED (emergency department) with dry gangrene of [right] foot . Per vascular surgery, no urgent surgical intervention is warranted at this time . recommended Betadine and dry dressing for patient's wounds . 10/23/22 at 10:27 PM [Nursing Note] Resident back on the unit from ER (emergency room ) visit at 3:45pm . Resident discharged from ER with recommendation for right foot gangrene treatment with Betadine daily and to follow up with . wound center and scheduled vascular surgery appointment on 10/26/22 . 10/23/22 [physician's order] Cleanse right foot gangrene with Betadine and leave open to air daily once a day 10/26/22 at 1:15 PM [Vascular Consult Note] . presents with gangrene of the right foot . extending to the midfoot . no realistic chance of healing . The only choice her would be below-knee amputation . The patient and family do not wish to have major amputation . During a tour of the 1st floor on 10/31/22 at 12:15 PM, Resident #26 was observed in bed, covered with a sheet, with both her feet exposed. The right foot was observed to be necrotic from midway of the foot, extending to all five of her toes. Review of Resident #26's comprehensive care plan showed that from 07/14/22 to 11/03/22 there was no evidence that facility staff developed a patient-centered care plan with goals, approaches to address care of Resident #26's right foot. There was no evidence that facility staff provided Resident #26 with the necessary care and required services to meet the resident's needs as evidenced by: A. Failure to develop a patient-centered care plan to address care of Resident #26's right foot B. Failure to conduct ongoing skin assessments as directed by the facility's policies and Skin Monitoring Shower Report C. Failure to assess and document skin color, temperature, pain and swelling of Resident #26's right foot in order report any changes and deterioration in the residents condition to the physician from 07/15/22 to 07/22/22 (8 days), 08/09/22 to 08/23/22 (15 days), 09/09/22 to 09/21/22 (13 days) and 10/02/22 to 10/16/22 (15 days) D. Failure to obtain ordered duplex and vascular consult in a timely manner. Duplex and Vascular consult were ordered on 08/24/22. A venous duplex test was not completed until 09/24/22 (totaling 31 days later), that showed no evidence of venous clots. Within this timeframe (31 days), Resident #26 had additional toes that became ischemic (1st, 4th and 5th toes). An arterial duplex was then done on 10/01/22 that showed PVD with moderate stenosis of the right lower extremity. The vascular consult was completed on 10/26/22 (totaling 63 days later) where it was documented, gangrene of the right foot . extending to the midfoot . no realistic chance of healing .The only choice [for] her would be below-knee amputation . During a face-to-face interview on 11/04/22 at 12:21 PM, Employee #10 (1st Floor Charge Nurse) reviewed Resident #26's comprehensive care plan, acknowledged the findings, and made no further comments. During a face-to-face interview conducted on 11/07/22 at 12:09 PM, Employee #10 stated, When the doctor's order a consult, the nurse reviews it and lets the unit secretary know so it can be scheduled. Once it is scheduled, arrangements are made for transportation and the consult date is documented. When asked why Resident #26's vascular consult was never scheduled as ordered, the employee stated, I don't know. A face-to-face interview was conducted on 11/07/22 at 3:30 PM with Employees #2 (Director of Nursing/DON) and #11 (Clinical Educator). Employee #11 stated, Nurses are supposed to do a weekly skin assessment on all residents whether they have wounds or not. When the CNA's give a shower, they look for any new areas and report that to the nurse. The nurse then documents it in Matrix Care (facility's electronic health record system) and makes the doctor aware. There's a shower sheet that both the CNA and nurse have to sign off on. The shower sheets are kept in a binder. There's one for every unit. When asked who audits the shower sheets or Matrix Care to ensure compliance with resident skin assessments, Employee #11 stated, I can't answer that question. Employee #2 stated, Unit Managers are supposed to check that the shower sheets and weekly skin assessments are being done and report back to me. There have not been any audits done lately on whether the skin assessments are being completed and I have not audited or reviewed to make sure that the forms [shower report] are getting completed. When asked about the care plans either not getting developed or not being patient-centered, Employee #2 stated, Only the RNs (registered nurses) can start or revise care plans. That's the charge nurses, evening and night supervisors and myself. Employee #2 acknowledged that licensed staff have not been developing or revising the care plans with patient-centered goals and approaches. When asked about the facility's process is for when the physician orders laboratory (lab) or any other test. Employee #2 stated, If the doctor orders a test, we call the lab or the x-ray and tell them. Once the results are in, we call the doctor and make him aware of the results. The nurse then signs and dates the form and puts it in the doctor's binder for them to sign when they come in. The night shift is supposed to check to see if tests that were ordered were obtained, if the results are back and if they were reported to the physician. When asked about the delay of Resident #26's ordered duplex test, Employee #2 stated that he doesn't know how it was missed the first time [08/24/22]. During a face-to-face interview conducted on 11/09/22 at 11:08 AM, Employee #2, #11, and #12 (Director of Quality Improvement) were made aware of the findings that Resident #26 did not receive the necessary care and required services for her right foot, causing a negative outcome. They all acknowledged the findings. 2. Facility staff failed to assess Resident #32's skin every shift per the care plan. Subsequently, the resident was observed with cellulitis of left lower limb with edema. During an observation and interview on 11/01/22 at 3:41 PM, Resident #32 stated that her left leg had started to swell and would sometimes leak. She said she had compression stockings at one time but believed they were taken with her laundry to be cleaned and never replaced. The surveyor noted that the resident's left leg was edematous from the knee to the ankle. The skin on the resident's leg appeared dark with light pink areas at the outer knee. The resident also stated that no facility staff had looked at her leg because she had not mentioned her concern to them. Resident #32 was admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease, Cellulitis of the Left Lower Limb, Diabetes Mellitus, and Absence of Right Leg below the Knee. Review of Resident #32's medical record revealed: 06/17/21 at 5:42 PM [physician's order]: Monitor for Bruising/Bleeding every shift. 06/17/21 at 8:46 PM: [physician's order]: Emollient topical lotion, apply 2x/day as needed for dry skin. Care plan initiated on 01/10/22: Category: Skin integrity .[Resident #32] is at risk for skin breakdown r/t (related to) lower extremity cellulitis .Approach: Assess Resident for the presence of risk factors .Keep clean and dry as possible .Report any signs of skin breakdown (sore, tender, red or broken areas), skin every shift . 05/14/22 at 2:55 PM [physician's order]: Leg wrap with non-stretch leg wrap daily to left leg for venous insufficiency. A Quarterly MDS dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS)Summary Score of 15, indicating intact cognition; required extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, bathing; functional impairment on one side for lower extremity; and was at risk for developing pressure ulcers. 09/19/22 at 1:45 PM [Nursing Progress Note]: .Complaint of dryness and scaling of the left leg .ordered Furosemide 40 mg (milligrams) and Spironolactone 25 mg once a day (to reduce edema caused by fluid accumulation). Also advised to continue the use of Cetaphil (emollient topical lotion) for dryness of the leg . Care plan initiated on 09/19/22 Category: Skin integrity .[Resident #32] has dryness/scaling/discoloration to left leg .Approach: Assess skin every shift . From 09/20/22 to 11/03/22, Resident #32's Treatment Administration Record (TAR) showed that facility staff initialed to attest that they Monitor[ed] for bruising/bleeding every shift and applied leg wrap with non-stretch leg wrap daily to left leg for venous insufficiency. From 09/20/22 to 11/03/22, Resident #32's Medication Administration Record (MAR) showed that facility staff initialed to attest that they applied emollient topical lotion 2x/day for dry skin. From 09/20/22 to 11/03/22 (45 days), there was no evidence that facility staff implemented a daily assessment and the condition of Resident #32's left lower extremity to include color, temperature, pain and swelling in order to identify and report changes and deterioration. During a face-to-face interview conducted on 11/07/22 at 1:10 PM, Employee #2 (Director of Nursing/DON) acknowledged the finding and made no further comments. During a face-to-face interview on 11/07/22 at 3:30 PM, Employee #11 (Clinical Educator) reviewed the findings for Resident #32 and stated that when the licensed nurses do the skin assessments, they should document the any new skin areas and the condition of the other existing areas. During a face-to-face interview conducted on 11/09/22 at 11:08 AM, Employee #2, #11, and #12 (Director of Quality Improvement) were made aware of the findings that facility staff failed to assess Resident #32's left leg daily per the resident's comprehensive care plan and they all acknowledged the findings. Cross reference: DCMR 3211.1

Based on record review and staff interview for three (2) of three (3) sampled residents, it was determined that facility staff failed to consistently promote the healing of two (2) ulcers for one (1) resident; and failed to consistently monitor and assess the progress of wounds for one (1) resident. Residents #95 and 169. The findings include: 1. Facility staff failed to consistently promote the healing of two (2) ulcers for Resident #95. The annual Minimum Data Set (MDS) dated [DATE] and the quarterly MDS dated September 27, 2011 coded Resident #95 as follows: Section G0110 (Functional Status) the totally dependent with one person physical assistance in bed mobility, dressing, eating and personal hygiene, and totally dependent with two persons assistance in transfer and toilet use; G0300 (Balance During Transitions and Walking)- The resident had impairment on one side upper extremity and impairment both sides lower extremity; H0300/H0400 (Urinary and Bowel Incontinent) always incontinent; Section O0500 (Restorative Nursing Program) the resident received six(6) days passive range of motion (rom). Additionally, the annual MDS dated [DATE] coded Section M (Skin Condition) as the resident having no skin impairment. The quarterly MDS dated [DATE] coded Section M as the resident having two unstageable ulcers that were not present upon admission. Resident #95 has [DIAGNOSES REDACTED]. A review of the laboratory report dated October 25, 2011 revealed the following: [MEDICATION NAME] level of 2.8, low (range 3.5 to 4.7); Hemoglobin 8.7, low (range 11.6-15.1) hematocrit 29.5, low (range 34.0-45.0). The Braden Scale for Predicating Pressure Sore Risk was 13 (moderate risk) on September 13, 2011 and June 13, 2011. The Wound Assessment Sheet dated September 14, 2011 revealed that the right heel was first observed and assessed as follows: the type of wound was a vascular leg ulcer. The stage was described as unstaged. The area measured as Length 3.0 cm x Width 3.5 cm x Depth 0, the characteristic was black, the treatment was to monitor closely and turn every 2 hours and an air mattress with pump. Additionally, the facility staff documented that the right heel was an " Old closed wound with discoloration at the site. " The Wound Assessment Sheet dated September 14, 2011 revealed that the right lateral foot was first observed and assessed as follows: the type of wound was a vascular leg ulcer. The stage was described as unstaged. The area measured as Length 2.0 cm x Width 2.0 cm x Depth 0, the characteristic was black, the treatment was to monitor close with pillows and turn every 2 hours. Additionally, the facility staff documented that the right lateral foot was an " Old closed area of discoloration. Diagnosis: [REDACTED]. According to the wound sheet documentation for September 14, 2011 the right heel and the right lateral foot " Wound Type " were identified vascular leg ulcers. On September 14, 2011 the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" . September 14, 2011 (no time indicated) nurses initials were placed in the designated box indicating adherence to the aforementioned entry, however there were no additional initials/entries to indicate that additional monitoring was done between September 15 through 19, 2011. A review of the record was conduct and found that there were no physician's order [REDACTED]. A review of the nursing notes and the " 24 Hour " report on September 14-18, 2011 was conducted. There was no evidence that facility staff notified the attending physician or the responsible party that Resident #95 was observed with unstageable ulcers/discoloration to the right heel and foot. There was no evidence that consistent monitoring was done, and the physician and responsible party were notified when Resident #95 was first observed with unstageable areas on the right heel and foot. The nursing note dated September 18, 2011 at 3:22 PM revealed..."Resident was noted with open area to right heel with a slough tissue and right outer aspect with a (eschar) tissue, no drain/odor noted, are unstageable, NP (nurse practitioner) in the house gave order for Santyl ointment to be applied to areas bid. R/p (responsible party) made aware. No s/s (signs and symptoms) of distress or discomfort noted. " The Wound Assessment Sheet dated September 19, 2011 revealed that the right heel was observed and assessed as follows: the type of wound was a vascular leg ulcer. The stage was described as unstaged. The area measured as Length 5.0 cm x Width 5.0 cm x Depth 0, the characteristics were pink/red and black; the treatment was Enzymatic Debridement and an air mattress with a pump. Additionally, the facility staff documented that the right heel was a " Closed wound now opened. " The Wound Assessment Sheet dated September 19, 2011 revealed that the right lateral foot was observed and assessed as follows: the type of wound was a vascular leg ulcer. The stage was described as unstaged. The area measured as Length 3.0 x Width 4.0 x Depth 0, the characteristics were pink/red, yellow and black, small amount. The treatment was Enzymatic debridement/Santyl and turn every 2 hours and an air mattress. Additionally, the facility staff documented that the right lateral foot was not improving " [MEDICAL CONDITION] " . According to the wound sheet documentation for September 19, 2011 the right heel and the right lateral foot " Wound Type " were identified vascular leg ulcers. The physician orders [REDACTED]. " According to the September 2011 Treatment Administration Record the treatments to the right heel and right (outer) lateral areas were signed as being completed on September 20, 2011 AM, one day after the Nurse Practitioner gave orders to treat the now open areas to Resident #95 ' s right heel and foot, and two days after open areas were observed. The 24 hour report revealed the following: On September 18, 2011-evening shift documentation/remarks- "Md (medical doctor) call for re-open area on rt (right) heel. Waiting for return." There was no night shift entry (September 18 -19, 2011) related to Resident #95 ' s open area. On September 19, 2011 Day Shift entry: NP (name) in the house notified of wounds to the rt heel and rt outer aspect, evaluated resident gave order for Sanytl oint (ointment) to be applied to areas bid. r/p (responsible party) notified." A review of the Progress notes revealed that the Nurse Practitioner was in to visit Resident #95 on September 14 and 16, 2011. There was no evidence that he/she included the resident ' s skin impairment in the reviews. A face-to-face interview was conducted with Employee# 4 on November 1, 2011 at 2:10 PM to review the findings. He/she reviewed the record and said " Okay. " ? Air Mattress: The care plan (last updated July 14, 2011) NSG39-Potential for skin impairment related to decreased mobility due to weakness, Related to pain due to....Potential skin impairment related to incontinent of bladder and bowel. Interventions: Turn every 2 hours, give pain med as ordered for comfort, air mattress to bed...keep pads and sheets wrinkled free...monitor skin for breakdown frequently. On October 24, 25, 27, 28 and 31, 2011, at various times, Resident #95 was observed without an air mattress in place. There was no evidence that facility staff followed the care plan intervention to keep an air mattress in place for Resident # 95. A face-to-face interview was conducted on November 1, 2011 at 11:58 AM with Employee #4. He/she stated the air mattress stopped working over the weekend (October 22, 2011). (The state agency) came on Monday and the process stopped. We put the air mattress back on the bed (November 1, 2011)." Through observations, record review and staff interview, there was no evidence that facility staff: notified the attending physician and the responsible party of the unstageable areas to the right foot and heel; consistently monitored the unstageable areas for four days prior to the wound opening; there was no evidence that treatment was conducted for 48 hours after the wound was observed open. Additionally, the wound unstageable right foot and heel ulcers were documented as vascular leg ulcers and for five days the air mattress was not observed on the resident ' s bed as per the plan of care. The record was reviewed on November 1, 2011. 2. Facility staff failed to consistently monitor and assess the progress of wounds for Resident #169. According to the history and physical examination [REDACTED]. " According to an admission Minimum Data Set (MDS) signed May 19, 2011; with an ARD (Assessment Reference Date) of May 13, 2011, Resident #169 was coded under Section M (Skin Conditions) as having three (3) unstageable pressure ulcers. A review of the admission nurses ' notes dated May 6, 2011 at 10:42 PM revealed: " General Skin Condition: Skin Problems: Has infection of the foot-eg. [MEDICAL CONDITION], purulent drainage. Location: Left great toe and Right 5th digit. " A review of the " Resident Assessment- Data Collection Form " dated May 6, 2011 revealed a posterior anatomical diagram with a " necrotic tissue left heel (measuring) (7cm/5cm). " The clinical record revealed a document entitled, skin " assessment sheet " that included the following: "Date: 5/6/11 - location: right 5th digit, Stage III, treatment: cleanse (right) digit with normal saline solution and apply [MEDICATION NAME] ointment every shift, "Date: 6/1/11 - location: (left) great toe, Stage III, characteristic: gray/black, treatment: cleanse left great toe with NSS (normal saline solution) and apply [MEDICATION NAME] ointment (every) shift, date: 5/6/11; location: right 5th digit, Stage III, treatment: cleanse (right) digit with normal saline solution and apply [MEDICATION NAME] ointment every shift, "Date 6/1/2011: comments: (first time seen).: location - left heel, other: (history of [MEDICAL CONDITIONS], stage: Unstaged, size: length: 3 cm, width: 3cm, Depth: (no depth), characteristic: gray/black, no drainage, no odor, treatment: turn every 2 hours, OOB (out of bed in chair), granule spray, date: 6/1/11. " According to the facility ' s policy " Pressure Ulcers, Prevention and Care, Policy No: 99P-014. " Under required documentation, Step 2 stipulates: " the licensed nurse documents on all pressure ulcers every seven days on the Pressure Ulcer Weekly Skin Assessment Sheet. Each form may be used for three separate sites. Weekly assessments must include but not limited to: a. complete information listed for this site, b. Location and origin of pressure ulcers ... c. date, state, size, depth, drainage, odor and all other descriptive information. #6. The nurse designated to do treatments writes a weekly descriptive note of the pressure ulcers to include but not limited to stage, size, characteristics, treatment, pressure relieving device on the skin sheet. " The record lacked that consistent monitoring and assessments was done for the progress of wounds. A face-to-face interview was conducted with Employees #3 and #6 on November 1, 2011 at approximately 1:00 PM. Both stated that documentation was missing from the closed record. At the time of the interview, additional assessment sheets were given to the surveyor. Facility staff ailed to consistently assess and monitor Resident #178 ' s pressure ulcers. The record was reviewed November 1, 2011.

Based on record review and staff interview for six (6) of 24 sampled resident and two (2) of 13 supplemental residents, it was determined that facility staff failed to follow up with one (1)resident's weight loss, failed to consistently obtain monthly weights for one (1) resident in accordance with physician orders [REDACTED]. [REDACTED]. and failed to allow sufficient nursing time to obtain weights in accordance with the facility's policy for one (1) resident on isolation. Residents # 6, 1, 7, 10, 11, 16, F1 and F5. The findings include: 1. Facility staff failed to follow-up with Resident #6's weight loss. A review of the Treatment Administration Record for Resident #6 revealed the following daily weights. Date Weight October 20, 2010 171 pounds October 21, 2010 172 pounds October 22, 2010 164.5 pounds October 23, 2010 164 pounds October 24, 2010 162 pounds October 25, 2010 160 pounds October 26, 2010 160 pounds October 27, 2010 160.5 pounds October 28, 2010 159 pounds October 29, 2010 159.4 pounds October 30, 2010 158 pounds October 31, 2010 159.5 pounds According to the documentation of weights on the Treatment Administration Record (TAR) the resident lost 7.5 pounds between October 21 and 22, 2010 and an additional 5 pounds between October 22 and 31, 2010 (total of 12.5 pounds). Review of the resident's clinical record failed to reveal any documentation that addressed the resident's weight loss of 12.5 pounds. The facility has no policy for daily weight. The facility's "Monthly Weight" Policy was last reviewed on November 15, 2002. Under the headings of Procedure and Nursing: Item #1 stated, "Residents will be weighed monthly, unless more frequent monitoring is requested." Review of the record revealed that the resident returned to the facility with the following order on October 19, 2010, "Daily weight till the next [MEDICAL CONDITIONS] appointment. Send weight record with resident for the next [MEDICAL CONDITION] appointment." Per the documentation in the nurses' notes the physician was notified and confirmed all transfer orders at 8:00 PM on October 23, 2010. A Dietary Note dated October 20, 2010 identified the resident ' s weight at 173 lbs. according to the weight sheet the resident's weight was 171 lbs. At 1:40PM on October 20, 2010 the dietician documented, "PO (oral) intake 100-75%. Weight increased which is beneficial. Good appetite. " The weight documented by the dietician was not the same as the resident ' s monthly weight as recorded in the unit's weight book. The resident's weight as documented in the monthly weight book was 174.2 lbs in September and 172.8 lbs in October, 2010. The weight documented in the dietician's note dated October 27, 2010 was reported to be 171.0 lbs. The weight on the MAR (Medication Administration Record) was recorded as 160.5 lbs. A face-to-face interview was conducted with the dietician at approximately 10:50AM on November 1, 2010. During the interview he/she stated, "I was not aware that the resident was on daily weights or that he/she lost weight. No one told me. The weight I used in my documentation came from nursing. They always give me the weights." Item #10 of the policy stated, " The licensed staff will compare the current weight with the prior month's weight. If there is 5 or more pounds difference from the prior month's weight to the current weight a reweigh is indicated." A weight loss of greater than five (5) pounds was recorded for the resident within eleven (11) days. On October 21, 2010 the resident's weight was 172 pounds and he/she weighed 159.5 pounds on October 31, 2010. There was no evidence on the record that the weight loss of 12.5 pounds in 11 days was addressed by the facility's staff. A face-to-face interview was conducted with Employee #6 at approximately 11:00AM on November 1, 2010. He/she stated that the resident's weight was done according to the "Weight Team" policy no: 09-19 last reviewed and signed May 2003 bullet number (5) which indicated, "The new admissions and re-admissions resident weights must be documented on the Admission Nursing Database Form, the Nursing Progress notes and in the Unit Weight Book. The CNAs on the Weight Team will validate the new admissions and re-admissions weights within four (4) days of their admission." The facility's staff failed to follow its policy to validate the resident's readmission weight within five days of his/her admission. Employee #6 acknowledged that the resident was not reweighed and no other actions were taken to address the resident's weight loss. The employee also acknowledged that neither the dietician nor the physician was notified of the resident's weight loss. The employee added, "We usually reweigh the residents within five (5) days whenever weight loss is evident. However, there was no reason to reweigh the resident because he/she was being weighed every day. The resident is also scheduled to return to the cardiologist in a few days and I thought the weight would be addressed then." The facility staff failed to follow-up on the resident's weight loss. Subsequently, the resident was transfered from the facility on November 2, 2010 via 911 transport to the nearest emergency room for evaluation of a heart rate of "135". The record was reviewed on October 29, 2010. 2. Facility staff failed to consistently obtain monthly weights on Resident #1 per physician's order [REDACTED]. According to the " Admitting Evaluation and History (History and Physical), " Resident #1 was admitted to the facility on [DATE]. Chief Complaint: ..[MEDICAL CONDITIONS], Dementia, Stage IV Sacrum (Decubitus); Physical Examination: Weight was " 110 1bs (pounds)." A review of Resident # 1's record revealed physician's order [REDACTED]." A nurse ' s progress note dated April 16, 2010 at 10:45 PM revealed, " Weight 110 lbs. Pt (patient) stable." The " Nursing Monthly Summary " reports revealed the following weights: April 20, 2010 --- 110 (pounds) May 20, 2010 --- Wt (weight) ... Isolation June 20, 2010 ---- Wt ... Isolation July 26, 2010 --- Wt ... Isolation August, 2010- no weight documented September 2010 - no weight documented According to the monthly weight log sheet the following was revealed: April------ no weight documented May --- Isolation June --- no weight documented July --- no weight documented August, 2010- no weight documented September 2010 - no weight documented There was no evidence in the record that the resident had monthly weights consistently obtained from April to September 2010 as directed by the physician's orders [REDACTED]. A " Nutrition Risk Assessment " dated April 22, 2010 revealed, "Weight: 110 lbs " . Dietary progress notes dated May 26, 2010 revealed, " Resident on contact isolation, so no (weight) obtained. " The " Nutrition Progress/Quarterly Review " signed and dated July 7, 2010 revealed, " Weight: isolation ... no weight. " An attending physician note dated August 17, 2010 revealed, " He/she has improved significantly since admission and since he/she gets adequate nutrition; we are unable to weigh him/her but he/she appears to be improving. " There was no evidence that facility staff weighed Resident #1 in accordance with the physician's orders [REDACTED]. A face-to-face interview was conducted with Employee #6 on October 29, 2010 at 10:05 AM. He/she stated, "the resident did not have monthly weights consistently done because we don't weigh residents who are in isolation." The record was reviewed on October 28, 2010. 3. Facility staff failed to obtain a resident ' s pacemaker check in accordance with the physician's order [REDACTED]. A review of resident #7 ' s record revealed a physician ' s telephone order on the " Interim order form " dated September 9, 2010 at 6:00 PM that directed, " Pacemaker check every three (3) months September, December, March, June..." A review of the resident ' s record revealed a (Clinic name) visit on March 3, 2010 at ... for pacemaker check. The record lacked evidence that the pacemaker check was performed as per physician's order [REDACTED]. A face-to-face interview was conducted with Employee #19 on October 29, 2010 at 11:30 AM. In response to a query regarding the status of Resident #10's pacemaker check; he/she acknowledged after reviewing the chart that the pacemaker check was not done since March 2010 and added that he/she had called and scheduled an appointment for November 1, 2010. The record was reviewed October 29, 2010. 4. Facility staff failed to obtain resident readmission weight in accordance to physician orders [REDACTED]. The "New Admissions physician's orders [REDACTED]." . The "Resident's Monthly Weight Record" for October, 2010 revealed, 151 pounds for October. There was no weight recorded for November. "ISOLA" (isolation) was written in the area designated for the weight. The "Resident's Monthly Weight Record" lacked evidence of a weight for November, 2010. A face-to-face interview was conducted on November 2, 2010 at 10:25 AM with Employee #19. He/she acknowledged that the weight for November was not done because, " We do not take weights on residents on isolation. " Another face-to-face interview was conducted on November 2, 2010 at 4:25 PM with Employee #3. He/she acknowledged that the weight was not done after reviewing the record and agreed that the facility staff know that weights should be done on residents on isolation. The record was reviewed on November 2, 2010. 5. Facility staff failed to assess and measure the pain intensity prior to the administration of Tylenol for Resident #11. A medication pass of Employee #18 was conducted on October 27, 2010 at approximately 10:00 AM. Employee #18 failed to assess and measure the pain intensity prior to the administration of Tylenol. Resident #11 was in his/her room sitting in a wheelchair. Employee #18 indicated that he/she would administer medications to Resident #11. After the administration of the routine medications, Resident #11 stated, " You did not give me my pain medications " Employee #18 proceeded to obtain 2 tabs of Tylenol from the medication cart and administered the medication to Resident #11 without first assessing and measuring the pain intensity. " Review of Residents' #11 "Physicians Orders" dated and signed October 19, 2010 directed " [MEDICATION NAME] 325 mg tab ( ...Tylenol) Give 2 tabs (650mg) by mouth every four hours as needed for joint pain ... " A face-to-face interview was conducted with Employee #5 on November 2, 2010 at 9:30 AM. After review of the Medcation Administration Record and the clinical record Employee #5 was informed of the medication pass observation he/she acknowledged the findings. The observation was made on October 27, 2010. 6. The facility staff failed to clarify/follow up on the documented post [MEDICAL TREATMENT] weight for Resident #16. A review of the resident ' s " [MEDICAL TREATMENT] Information Sheet " revealed that the record of the resident ' s weight was inconsistent. A listing of the resident ' s pre-[MEDICAL TREATMENT] and post [MEDICAL TREATMENT] weights as documented on the [MEDICAL TREATMENT] Information Sheet is outlined below. Pre-[MEDICAL TREATMENT] Weight Post [MEDICAL TREATMENT] Weight October 8, 2010 138 lb 105.2 Kg (231.44 lb) October 12, 2010 136.8 lb 96.4 Kg (212.08 lb) October 14, 2010 141.2 lb 96.6 Kg (212.52 Lb) October 16, 2010 142.8 lb 30.6 Kg (67.32 lb) October 26, 2010 134.4 lb 134 lb October 28, 2010 135.8 lb 134 lb October 30, 2010 139.6 lb 67.4 Kg (148.28 lb) A review of the weights as outlined above revealed that five (5) of seven (7) of the post [MEDICAL TREATMENT] weights were documented in kilograms (kg) and only two (2) of seven (7) were documented in pounds from October 8 through 30, 2010. On October 8, 2010 the difference between the post [MEDICAL TREATMENT] weight and the pre [MEDICAL TREATMENT] weight as recorded was 93.44 lb. The difference between the pre and post weights on October 12, 2010 was 76 lb. On October 14 the difference between the pre and post [MEDICAL TREATMENT] weight was 71.32 lb. The aforementioned post [MEDICAL TREATMENT] weights were documented as weight gains. On October 16, 2010 the post [MEDICAL TREATMENT] weight was documented as a weight loss of 75.48 lb and on October 30, 2010 the post [MEDICAL TREATMENT] weight was documented as a gain of 8.68 lb. on October 26 and 28, 2010 the pre and post [MEDICAL TREATMENT] weights were consistent. On October 26, 2010 the post [MEDICAL TREATMENT] weight was 0.4lb less than the pre weight and on October 28, 2010 the post [MEDICAL TREATMENT] weight documented on the [MEDICAL TREATMENT] sheet indicated a weight loss of 1.8 lb. A face-to-face interview was conducted with Employees #1, 2 and 3 at approximately 4:15 PM on November 2, 2010. The employees acknowledged that they could not determine whether the resident sustained [REDACTED]. The facility staff failed to clarify/follow up on the documented post [MEDICAL TREATMENT] weight and could not determine whether the resident sustained [REDACTED]. 7. The facility staff failed to allow sufficient nursing time to obtain weights in accordance with the physician's orders [REDACTED]. A review of the weight log last updated November 2010, revealed that " Isola " (isolation) was recorded as the September 2010 weight for Resident F1. A review of the physician's order [REDACTED]. August 20, 2010 at 9:30 PM, " Contact Precaution [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) in left foot open area. " " September 28, 2010 at 4:00 (AM/PM not indicated), " D/C (discontinue) Contact Precautions [MEDICAL CONDITION] " . A face-to-face interview was conducted with Employees # 3 and 41 on November 3, 2010 at 10:07 AM. They stated that we (the facility) don ' t do weights on isolation residents. When the DON came we started doing them (obtaining weights) again and we do them last (obtain the weights last). We started in October 2010. Additionally, they acknowledged that the weights were not obtained for residents on isolation. 8. The facility staff failed to allow sufficient nursing time to obtain weights in accordance with the facility policy for Resident F5 who was on isolation. A review of the weight log last updated November 2010, revealed that " Isola " (isolation) was recorded as the September 2010 weight for Resident F5. A review of the physician's order [REDACTED]. " August 30, 2010 at 8:00 AM, " D/C Contact Isolation " . According to the aforementioned physician's order [REDACTED]. A face-to-face interview was conducted with Employees # 3 and 41 on November 3, 2010 at 10:07 AM. They stated that we (the facility) don' t do weights on isolation residents. When the DON came we started doing them (obtaining weights) again and we weight the isolation residents last. We started in October 2010. Additionally, they acknowledged that the weights were not obtained for residents on isolation.