Every finding on record at The HSC Pediatric Skilled Nursing Facility

Facility staff failed to implement its written policies and procedures for abuse that included staff training after an alleged incident of staff-to-resident sexual abuse for one (1) resident. ([NAME]) Based on observation record review and staff interviews, for one of eleven (11) sampled residents, facility staff failed to implement its written policies and procedures for abuse that included staff training after an incident of alleged staff-to-resident sexual abuse for one (1) resident. Resident #2The findings included:A facility policy entitled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property (effective date 02/06/2020) .Prevention. 1. Procedures must be in place to provide the resident with a safe, protected environment during the investigation. 2. Other measures as deemed appropriate and by existing safety policies and procedures.i. Education will be provided as needed to all parties involved.Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Lesch Nyhan Syndrome, Expressive Language Disorder, Self-Injurious Behavior, Aggressive Behaviors, and Global Developmental Delay.A review of Resident #2's medical record revealed the following:A comprehensive minimum data set (MDS) assessment dated [DATE] which documented that the resident: had a Brief Interview for Mental Status Summary Score of,12 indicating moderately impaired cognition; had displayed physical behaviors towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually; had displayed verbal behaviors towards others threatening others, screaming at others, cursing at others) for one to three days during the assessment; had upper and lower extremity impairments on both sides; required substantial of maximal assistance with rolling from side to side while in bed; was dependent on staff for all ADLs (activities of daily living-bathing personal hygiene getting dressed, transfers, eating, incontinent care) and used a manual or electrical wheelchair for mobility. A facility reported incident (FRI), Intake Number DC00013832, submitted online on 7/10/25 at 1:51 pm, that documented: Summary of Allegation: On [Insert Date], our facility was notified by [Name of Resident #2]'s educational team regarding a disclosure he made at school. According to the report, [First Name of Resident #2] told his classroom staff and a school representative that he had been touched on his [expletive] (his words) by a female staff member at our facility earlier that morning. He also reported that the staff member was wearing blue. The school representative noted that [First Name of Resident #2] was visibly upset, and his physical demeanor indicated discomfort. They reported the incident to the Child and Family Services Hotline and are awaiting follow-up. Resident Background: [Name and age of Resident #2] Diagnosis: Lesch Nyhan Syndrome, Expressive Language Disorder, Self-Injurious Behavior, Aggressive Behaviors, Global Developmental Delay Communication Ability: Communicates primarily using one to two-word responses. Immediate Actions Taken by Facility: Notification: The allegation was reported to facility leadership, and the appropriate internal reporting protocols were initiated. FUP [Follow-up report] received on 07/15/25 at 5:38 PM: Situation: This correspondence serves as the required five-day follow-up regarding the abuse allegation reported on July 10, 2025, involving resident [Name of Resident #2] at [Name of Facility]. Background: As previously shared, after being notified of the allegation, we promptly notified and fully cooperated with the Metropolitan Police Department (Report #2510407) and the Child and Family Services Investigative Social Worker. Following the initial report, an extensive internal investigation was conducted. Based on the specifics of the resident's allegation (a female dressed in blue), one staff member was placed on administrative leave per our standard process pending the outcome of the investigation .A thorough review, including but not limited to the individual's HR (Human Resources) file and a background check, revealed no findings of concern. Assessment: After interviewing all relevant personnel and reviewing available documentation, we found no evidence to substantiate the claim.Although the allegation could not be substantiated, we will collaborate with our Medical Director and education team to provide further training focused on caring for pubescent residents. A review of the education and training files for nursing staff who provided care for Resident #2, both the night before and the morning of the alleged incident, showed no evidence of education and training for abuse from 07/10/25 to 07/24/25.During a telephone interview on 07/24/25 at 3:40 PM, Employee #3 (Certified Nurse Aide/ CNA) stated that she was assigned to Resident #2 during the evening shift (3:00 PM-11:00 PM). The Employee stated that she recalled being interviewed about the statement, but she did not receive any recent education or training on abuse after the incident.During a telephone interview on 07/25/25 at 12:41 PM, Employee #4 (Certified Nurse Aide/ CNA) stated that she received abuse education and training when she was first hired approximately two years ago and annually thereafter. She stated further that she worked from 11:00 PM on 07/09/25 to 7:30 AM on 07/10/25, and she was the CNA who bathed Resident #2 and got the resident dressed for school on 07/10/25. She added that after her shift on 07/10/25, Employee #2 (Director of Nursing) called to inform her that the facility had initiated an investigation, and she was being placed on administrative leave until the investigation was resolved. Employee #4 further stated that she was contacted by Employee #2 and was informed that she could return to work on 07/15/25; however, she did not return until 07/16/25. She added that she was informed both verbally and via email from Employee # 2 that two staff members had to be present when providing care for Resident #2. She added that she had not been assigned to the Resident since the alleged incident, and she had not received or completed any additional training on abuse upon her return on 07/16/25.Of note, the assigned nurse was not available for interview during the survey.During a face-to-face interview at 1:15 PM [Employee #2/ Director of Nursing/DON], when asked if any additional abuse education or training was provided to all parties (staff) involved in the alleged incident on 07/10/25, per the facility's policy, the Employee stated, No, there was no addition education or training provided after the incident. Additional education and training is provided by me or the nurse educator on an as-needed basis after a reported or alleged incident, depending on the incident itself and the staff involved. After the incident on 07/10/25 with Resident #2, I sent an email (return receipt requested) to the nursing staff, informing them that two staff were required when providing care for the Resident; however, I didn't provide an additional educational or training in-service on abuse. The Employee then acknowledged the finding.

Facility staff failed to develop and implement a comprehensive person-centered care plan that included new interventions for one (1) resident following an alleged incident of injury of unknown origin and an alleged incident of staff-to-resident sexual abuse. Based on observation record review and staff interviews, for one of eleven (11) sampled residents, facility staff failed to develop and implement comprehensive person-centered care plans for a resident following: 1) an incident of injury of unknown origin and 2) an alleged incident of sexual abuse by facility staff. Resident #2The findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Lesch Nyhan Syndrome, Expressive Language Disorder, Self-Injurious Behavior, Aggressive Behaviors, and Global Developmental Delay.A review of Resident #2's medical record revealed the following:A quarterly minimum data set (MDS) assessment dated [DATE] which documented that the resident: had a Brief Interview for Mental Status (BIMS) Summary Score of,12 indicating moderately impaired cognition; had displayed physical behaviors towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually; had displayed verbal behaviors towards others threatening others, screaming at others, cursing at others) for one to three days during the assessment; had upper and lower extremity impairments on both sides; required substantial of maximal assistance with rolling from side to side while in bed; was dependent on staff for all ADLs (activities of daily living-bathing personal hygiene getting dressed, transfers, eating, incontinent care) and used a manual or electrical wheelchair for mobility. 1. Incident #1 -Injury of Unknown Origin on 06/17/25A State Agency Complaint Incident Report Form dated 06/17/25 at 3:48 PM that documented: 6/16/25 [Name of Resident #2] was observed with a bruise under his eye, which appears to have occurred overnight and was unwitnessed. At this time, we believe the injury may have happened while he was in bed. [First Name of Resident #2] has a medical diagnosis of [NAME]-[NAME] syndrome, a condition that includes involuntary limb movements and self-injurious behaviors. Due to this, he wears arm immobilizers at all times. It is possible that despite these precautions, he may have inadvertently injured himself during sleep. In response: Medical providers have been notified and have assessed the resident. A State Agency Complaint Incident Report Form dated 06/23/25 at 4:53 PM that documented: This is the follow-up from the 6/17/25 incident report. Injury of unknown origin. After investigation, the resident's helmet needed readjustment along with his neck brace. It appears the injury came from his helmet that slipped down over his eye and cheek. Our therapy tea[m] has assessed the helmet and made adjustments to the neck brace. We have ordered material to fix the ill-fitting helmet. The resident is doing well with no complaints of pain or discomfort.A Case Management Narrative Note dated 06/27/25 at 10:31 AM that documented: Comment: Tuesday weekly Shared Nursing Facility (SNF) Rounds: late entry-->pt (patient) is going through a growth spurt--> home from school due to damage to helmet that might have been loose and smashed when fell off; prefer he doesn't go back until helmet is replaced; also making adjustments to helmet; school aware of what is happening.A review of Resident #2's comprehensive person-centered care plan showed no documented evidence that facility staff developed or implemented a care plan to include a focus, goals, or interventions to prevent further injury to the resident, after the resident's injury of unknown origin was observed by facility staff on 06/17/25.2. Incident #2- Alleged Incident of Staff-to-Resident Sexual Abuse on 07/10/25A comprehensive MDS assessment dated [DATE] which documented that the resident: had a BIMS score of,08 indicating moderately impaired cognition; had displayed physical behaviors towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually; had displayed verbal behaviors towards others threatening others, screaming at others, cursing at others) for one to three days during the assessment; had upper and lower extremity impairments on both sides; required substantial of maximal assistance with rolling from side to side while in bed; was dependent on staff for all ADLs (activities of daily living-bathing personal hygiene getting dressed, transfers, eating, incontinent care) and used a manual or electrical wheelchair for mobility. A facility reported incident (FRI), Intake Number DC00013832, submitted online on 7/10/25 at 1:51 PM, that documented: Summary of Allegation: On [Insert Date], our facility was notified by [Name of Resident #2]'s educational team regarding a disclosure he made at school. According to the report, [First Name of Resident #2] told his classroom staff and a school representative that he had been touched on his [expletive] (his words) by a female staff member at our facility earlier that morning. He also reported that the staff member was wearing blue. The school representative noted that [First Name of Resident #2] was visibly upset, and his physical demeanor indicated discomfort. They reported the incident to the Child and Family Services Hotline and are awaiting follow-up. Resident Background: [ Name and age of Resident #2] Diagnosis: Lesch Nyhan Syndrome, Expressive Language Disorder, Self-Injurious Behavior, Aggressive Behaviors, Global Developmental Delay Communication Ability: Communicates primarily using one to two-word responses. Immediate Actions Taken by Facility: Notification: The allegation was reported to facility leadership, and the appropriate internal reporting protocols were initiated. FUP [Follow-up report] received on 07/15/25 at 5:38 PM: Situation: This correspondence serves as the required five-day follow-up regarding the abuse allegation reported on July 10, 2025, involving resident [Name of Resident #2] at [Name of Facility]. Background: As previously shared, after being notified of the allegation, we promptly notified and fully cooperated with the Metropolitan Police Department (Report #2510407) and with the Child and Family Services Investigative Social Worker, . Following the initial report, an extensive internal investigation was conducted.Based on the specifics of the resident's allegation (a female dressed in blue), one staff member was placed on administrative leave per our standard process pending the outcome of the investigation .A thorough review, including but not limited to the individual's HR (Human Resources) file and a background check, revealed no findings of concern. Assessment: After interviewing all relevant personnel and reviewing available documentation, we found no evidence to substantiate the claim.Although the allegation could not be substantiated, we will collaborate with our Medical Director and education team to provide further training focused on caring for pubescent residents.Of note, a review of Resident #2's comprehensive person-centered care plan showed no documented evidence that facility staff developed or implemented a care plan to include a focus, goals, or interventions to prevent the resident from staff abuse after the alleged incident of staff-to-resident sexual abuse was reported on 07/10/25. During a face-to-face interview on 07/25/25 at 2:30 PM, Employee #2, Director of Nursing DON stated that care plans are implemented upon admission, quarterly, and as needed. When asked if care plans are developed and implemented after incidents of abuse or injuries of unknown origin, she acknowledged that they should be developed by the nurse or by herself (DON). After review of Resident#2's care plan. The Employee then acknowledged that the care plans for Resident #2 should have been developed and implemented after the observation of the resident's skin(/injury of unknown origin) reported on 06/17/25 and after the alleged incident of sexual abuse by staff reported on 07/10/25.

The facility failed to ensure: (1) food was not stored past its expiration date for seven (7) of 7 packages of green beans (baby food); and (2) sanitizer solution concentration for cleaning the service line area meet professional standards for one (1) of 1 sanitizer solution buckets.Based on an observations, record review, and staff interviews, the facility failed to ensure: (1) food was not stored past its expiration date for seven (7) of 7 packages of green beans (baby food); and (2) sanitizer solution concentration for cleaning the service line area meet professional standards for one (1) of 1 sanitizer solution buckets. The findings included: An observation of the kitchen's dry storage area on 07/23/25 starting at 10:01AM revealed one (1) of 1 package of green beans (baby food) with an expiration date 05/31/25 and six (6) of 6 packages of green beans (baby food) with expiration dates 06/30/25. During a face-to-face interview on 07/23/25 at 10:05 AM, Employee #5 (Director of Nutrition) stated that the porters check the dry storage area daily for expired food. The employee said that the porters document their finding on the Associate Cleaning Responsibilities form daily. At the time of the interview, the employee stated that the dry storage room had not yet been checked for expired food for 07/23/25. Additionally, the employee was unable to provide documented evidence that the dry storage area was checked for expired foods on 07/22/25. During a face-to-face interview on 07/24/25 at approximately 9:00 AM, Employee #8 (Porter/Nutrition Service Aide) stated, I check for expired food most days, but I don't always check every day. At the time of the observation, the employee reviewed a blank Associate Cleaning Responsibilities and stated that he has never seen the form before and he doesn't document when he checks for expired foods. 2. An observation of the service line on 07/23/25 at approximately 10:30 AM revealed that one (1) of 1 sanitizer bucket. The bucket contained quaternary ammonium sanitizer solution with a concentration level that tested above 400 Parts Per Million (ppm). According to FDA Food Code 7-204.11 and Title 25-A DCMR 1813.4, sanitizer solution shall be prepared according to the manufacturer's use directions. The Quaternary ammonium sanitizing chemical manufacturer directs the concentration of the sanitizer solution to be in the range of 200 to 400 Parts Per Million (ppm) for sanitizing food contact surfaces. FDA-FoodCode2022-FullDocument-01182023_0 (3).pdf Cleaning and Sanitizing in Commercial Kitchens | Clatsop County OR During a face-to-face interview on 07/23/25 at approximately 8:30 AM, Employee #9 (Food Production Lead) said The employee who prepared the sanitizer solution added too much sanitizing chemical to the bucket. At the time of the survey, this was corrected on-site. Cross Reference 22B DCMR Sec. 3219.1

The facility staff failed to maintain one (1) of 1 walk-in freezer and one (1) of 1 ice making machine in safe operating conditions. Based on observations and staff interviews, the facility failed to maintain one (1) of 1 walk-in freezer and one (1) of 1 ice making machine in safe operating conditions. The findings included: An observation on 07/23/25 starting at approximately 8:15 AM showed the following: 1.A walk-in freezer with ice built-up from a leaking condensation pipe. Also, noted was sheet pans placed on top shelf under air condenser from a leaking condensate pipe. 2. An ice-making machine with leaking water onto a soiled blanket lying on the floor under the machine. Also, noted was duct tape on the edges of ice machine to stop the water leak for one (1) of 1. At the time of the observations, Employee #5 (Director of Nutrition) acknowledged the findings. During a face-to-face interview on 07/23/25 at approximately 11:00 AM, Employee #7 (Facility Operation Manager) stated that the walk-in freezer and ice machine were old, and they require frequent maintenance. Cross Reference 22 B DCMR Sec. 3258.13

The facility staff failed to maintain an effective pest control program so that it remains free of pests (mice).Based on observations, record reviews and staff interviews, the facility failed to maintain an effective pest control program so that it remains free of pests and rodents. The findings includedAn observation of the kitchen floor at cookline and dry storage areas on 07/23/25 starting at 8:15 AM revealed rodent droppings and dead two dead mice on glue boards. A review of a Pest Elimination Service Report dated 07/03/25 revealed that the Kitchen Area-Interior.Cafeteria-Interior was treated to exterminate for pests (mice) with glue boards. A review of a Pest Elimination Service Report dated 07/18/25 revealed that the exterior area was treated to exterminate for pests (mice) with bait stations.During a face-to-face interview on 07/23/25 at approximately 10:00 AM, Employee #5 (Director of Nutrition) stated that the facility receives scheduled and as needed pest extermination services from a professional pest exterminating company

Based on the record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to send notification of discharge to the resident's representative (RP) and a copy of the notice to the Office of the State Long-Term Care Ombudsman. Resident #65. The findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses that included the following: Chronic Lung Disease, Krabee Disease, Global Development Delay, and Spastic Tetraplegia. Review of the resident's medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded that the resident was in a persistent vegetative state/no discernable consciousness. A Physician's Note dated 07/07/23 documented, [Resident #65] was in his usual state of health at [Facility Name] on June 2, 2023, when he was transported to his routine neurology follow-up appointment at [Clinic Name]. Received a notification from the clinic physician around 5 pm that he was having a seizure and was being sent to the ED (emergency department). At that time information was relayed that he was stable and likely to return to [Facility Name]. After arrival in the ED, there was concern for respiratory depression and he was admitted to PICU (pediatric intensive care unit). When this information was relayed, he was discharged from [Facility Name]. Review of the Resident's medical record on 08/07/24 showed no there was no documented evidence that notification of the resident's discharge was sent to the resident's RP or that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. During a face-to-face interview on 08/08/24 at approximately 3:00 PM, Employees #1 (Administrator) and Employee #2 (Director of Nursing/DON) acknowledged the findings with Employee #1 stating, [Employee #2] and I were not employed at the facility when the resident was discharged .

Based on the record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to code the Resident #10's Minimum Data Set (MDS) for his use of bed rails. The findings included: Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including Self-Injurious Behavior, [NAME]- [NAME] Syndrome, Developmental Delay, and Nephrocalcinosis. Review of Resident #10's medical record showed the following: A physician's order note dated 06/07/24 at 4:36 PM documented, Bed rails to be up when resident is not directly supervised due to medical and/ or developed safety concerns. The number and position of side rails to be used are specified. An admission MDS dated [DATE], showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 08, indicating moderate cognitive impairment; in Section P (Restraints and Alarm), under Physical Restraints, bed rails was coded 0 - not used. During an observation on 08/05/24, 08/06/24, and 08/07/24, Resident #10 was observed lying in bed, with both side rails up and in use for the resident's safety. During a face-to-face interview conducted on 08/08/24 at 1:14 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and made no comments. Cross Reference 22B DCMR Sec. 3231.12

3. Facility staff failed to develop and implement a comprehensive person-centered care plan for Resident #2's court ordered decision for no cardiopulmonary resuscitation (CPR), cardioversion/defibrillation, and no administration of cardiac medications in the event of a cardiac emergency. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included: Anoxic Brain Damage, Chronic Respiratory Failure, Brain Damage, Cortical Blindness, and Dependence on Ventilator. Review of Resident #2's medical record revealed the following: A court document dated [DATE] titled Superior Court of the District of Columbia Family Court Juvenile and Neglect Branch documented in part: - Further ordered that this court adopts treatment parameters recommended by (Physician Name) and orders that the following treatments shall be withheld and not utilized in treatment and care of [Resident #2] by hospitals, physicians, medical professionals and their agents and/or employees, who may be charged with providing his care: 1. Cardiopulmonary resuscitation 2. Cardiac compressions, 3. Medications to restart the heart, 4. Defibrillation and related procedures. A Physician's Progress Note dated [DATE] at 10:34 AM documented the following: On [DATE], Court order was provided based on decision of health agent [Guardian's Name], that indicates that in the event of a cardiac arrest, CPR (including chest compressions, cardioversion/defibrillation, cardiac meds (medications) will not be performed. There are no other changes to his current care plan. Review of the Resident #2's comprehensive care plan on [DATE] at 12:30 PM showed no documented evidence of a care plan with goals and interventions that addressed the residents code status. During a face-to-face interview conducted on [DATE] at 4:55 PM, Employee #2 (DON) acknowledged the findings and stated, We did not do a care plan for the code status because it is documented in many places. Based on record review and staff interviews, for four (4) of nine (9) sampled residents, facility staff failed to develop comprehensive resident-centered care plans. The findings included: Review of the facility's Care Planning dated [DATE] documented: - [Facility Name] Care Planning/Interdisciplinary Team (IDT) is responsible for the development of an individualized comprehensive care plan for each resident. - The care plan is based on resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary team. 1. Facility staff failed to develop a care plan with goals and interventions to address to address Resident #9's use of peripheral intravenous device (IV); use of an IV antibiotic medication; and that he was on transmission-based precautions (E. Coli in urine). Resident #9 was admitted to the facility on [DATE] with diagnoses that included: Recurrent Urinary Tract Infection (UTI), Bilateral Hydronephrosis, and Chronic Respiratory Failure. Review of Resident #9's medical record revealed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] that showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognitive response; had an indwelling catheter; always incontinent of bowel and bladder; received Antibiotic medications in the last 7 days; had an IV access and received IV medications. A Laboratory Report dated [DATE] at 9:40 PM documented, [NAME] Blood Cell (WBC) count 14.68 (high) cells per cubic millimeter of blood (cells/mm3); normal range 4 - 11. Physician's order dated [DATE] at 8:34 AM directed, Isolation type: contact, indication: MDRO (Multi-Drug-Resistant Organism). During a tour of the unit on [DATE], at 9:55 AM, Resident #9 was observed lying in bed, in his room. The resident was noted to with a peripheral IV to his left hand. A Urine Culture Report dated [DATE] at 5:16 PM documented: - More than 100, 000 colony-forming unit per millilitre (cfu/ml) Providencia stuartii (50% of total); more than 100, 000 cfu/ml Escherichia coli (E.coli) (50% of total). A Physician's order dated [DATE] directed, Cefepime (antibiotic medication) 2,000 mg (milligrams)/50 ml (milliliters), premix IV, every 8 hours. Review of the Resident #9's comprehensive care plan on [DATE] showed no documented evidence that facility staff developed a care plan with goals and interventions to address use his use of a peripheral IV; use of antibiotic medications for UTI; or that he was not on transmission-based contact precautions. During a face-to-face interview on [DATE] at 3:46 PM, Employee #2 (Director of Nursing/DON) reviewed the Resident #9's care plans, acknowledged the finding, and stated, Every Friday, the IDT does do mini rounds and anything immediate or newly identified, a care plan is either developed or updated. Those must've been missed. 2. Facility staff failed to develop a care plan with goals and interventions to address that Resident #13 received an oral diet. Resident #13 was admitted to the facility on [DATE] with diagnoses that included: Gastrostomy Status and Quadriplegia. Review of Resident #13's medical record revealed the following: A Nutrition Follow-up assessment dated [DATE] at 11:35 PM documented: - Over the past seven days ([DATE] - [DATE]) [Resident #13] 100% of ordered gastrostomy tube and free water flushes. - He appears to be frequently refusing meals or eating 10% to 40%. - Recommendations: continue regular diet; if patients weight continues to trend down with refusal of PO (by mouth) feeds, suggest increasing gastrostomy tube feedings. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 09, indicting moderately impaired cognition; dependent on staff for everyday activities to include eating; no signs and symptoms of swallowing disorder; received nutrition 26 - 50 percent of nutrition via feeding tube; and received mechanically altered oral diet. A Physician's order dated [DATE] directed, Regular diet International Dysphagia Diet Standardization Initiative (IDDSI) level 7 - easy to chew, upright in chair, cut in small, bites, follow bites by sip of water, check mouth, make sure swallows, limit distraction; [NAME] Farms (type of nutritional tube feed) Pediatric blended meals 250 ml over 1 hour BID (twice a day) at 9:00 AM and 6:00 PM. Review of Resident #13's comprehensive care plan on [DATE] showed no documented evidence that facility staff developed a care plan with goals and interventions to address that the resident received an oral diet. During a face-to-face interview on [DATE] at 3:46 PM, Employee #2 (Director of Nursing/DON) reviewed the Resident #13's care plans, acknowledged the finding, and stated, Every Friday, the IDT does do mini rounds and anything immediate or newly identified, a care plan is either developed or updated. This was missed. 4. Facility staff failed to develop a resident person-centered comprehensive care plan with goals and approaches for Resident #12's use of a Gastrostomy-tube (G-tube) feeding. Resident #12 was admitted to the facility on [DATE] with diagnoses that included: G - tube Dependency, DiGeorge Syndrome, and Severe Neurological Injury after Intracranial Hemorrhage. Review of Resident #12's medical record revealed the following: A Nutrition Follow-Up assessment dated [DATE] documented, Nutrition order: Nutren 1.5 via GT (gastric tube). Feed 300ml 5x/day at 6 am, 10 am, 2 pm, 6 pm, and 10 pm; Rate:150ml/hrx2hrs. Water flush:240ml 5x/day after each feed (1200ml total). A Quarterly MDS dated [DATE] revealed that facility staff coded yes for feeding tube- nasogastric or abdominal (PEG) while a resident in the section for nutritional approaches. Review of Resident #12's comprehensive care plans on [DATE], that were last revised on [DATE] showed no documented evidence that a care plan was developed with goals and approaches for his use of G-tube for nutrition. During a face-to-face interview on [DATE] at 3:39 PM, Employee #2 (DON) acknowledged the findings and stated that the care plans were being reviewed. Cross Reference: 22B DCMR Sec. 3210.4

Based on observations and staff interview, facility staff failed to ensure that expired medication syringes were not stored for use. The findings included: During an observation on [DATE] at 12:35 PM of the unit's clean storage/supply, the following was noted: - Thirteen (13) [NAME]-[NAME] (BD), Luer-Lok Tip, 10 ML (milliliters) syringes stored for use that had an expiration date of [DATE]. During a face-to-face interview on [DATE] at 12:39 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated, I will remove them. Cross Reference 22B DCMR Sec. 3226.3

Based on record review and staff interview, the facility's Administrator failed to conduct and document a facility-wide assessment annually to determine what resources are necessary to care for its residents competently during the day-to-day operations (including nights and weekends) and emergencies. The facility's census on the first day of the survey was 14. The findings included: Review of the facility's SNF (skilled nursing facility)-Administrative - 009 policy last reviewed in January 2020, documented in part: - A facility assessment is conducted annually to determine and update SNF's capacity to meet the needs of and completely care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. It is the responsibility of the Administrator to lead this assessment with a multidisciplinary team. Policy /Procedures #1. Once a year and as needed, a designated team conducts a facility-wide assessment to ensure that resources are available to meet the specific needs of our residents. During the Recertification Survey conducted from 08/05/24 to 08/08/24, this surveyor met with Employee #1 (Administrator) on 08/08/24 at10:00 AM, to inquire about the facility assessment. The employee stated that the facility assessment was last completed in 2022 and that there is not a complete or current facility assessment. Employee #1 further stated, We are in the process of reviewing and updated the facility assessment. It is not complete. And provided the surveyor a copy of the Facility Assessment for 2022. The evidence showed that the facility was not in compliance with completing its annual facility assessment. Cross Reference 22B DCMR Sec. 3201.5

Based on observations, record review and interview, the facility failed to provide the State Survey Agency with immediate access to medical records. While this was evident for all medical records of the facility, it delayed the State Agencies ability to review medical records for the three of 13 residents selected for sampling during this survey. (Residents #1, #2, and #3) The findings included: According to a Survey and Certification (S&C) memo from the Centers for Medicare and Medicaid Services dated 8/14/09, During the entrance conference, surveyors will verify with the facility the process they will follow in order to have unrestricted access to the medical record. During an entrance conference on 12/11/23 for investigation of a facility reported incident (DC~12475) starting at approximately 9:00 AM, Employee #1 (Administration) was made aware that the State Survey Agency needed access to residents' electronic medical records (EMRs). The Administrator stated that a month ago they started using a new EMR, and she would inform the IT department of the need for access. Also, the Administrator stated that the facility's census was 13. During a face-to-face interview on 12/11/23 at approximately 11:00 AM, Employee #2 (Lead Quality Personnel) stated that the IT department was working on granting the State Survey Agency surveyor access to the residents' EMRs. During a face-to-face interview on 12/11/23 at approximately 2:30 PM, Employee #1 (Administrator) stated that they were still working on giving the State Survey Agency surveyor access to the facility's EMR. During the interview, the State Agency's Program Manager was on the phone. The Program Manager advised the facility's Administrator to provide the surveyor access to residents' EMRs as soon as possible. The Administrator offered the surveyor the use of Employee #2's (Quality Lead Personnel) laptop and indicated the employee would navigate the laptop to access documents that the surveyor requested to view. After the facility was informed by the State Survey Agency Program Manager that the surveyor needed uninhibited access to a facility's laptop and resident's electronic medical record, the facility created a dropbox with Resident #1's medical record in it. On 12/11/23 at 4:57 PM, the facility sent the surveyor an email inviting her to register for access to the facility's EMRs. It should be noted that the surveyor left the facility at 4:45 PM on the same day. On 12/12/23 at approximately 9:00 AM, the surveyor requested a password for the facility's electronic medical record, however, the surveyor was informed IT had to approve the password before the surveyor could access the facility's EMRs. During a face-to-face interview on 12/12/23 at approximately 10:00 AM, Employee #2 (Quality Lead Personnel) stated that the facility recently began using a new EMR. The EMR passwords were sent to applicants within 24 hours of applying. In addition, the employee called the IT department during the interview to request an expedited password for the surveyor. On 12/12/13 at approximately 1:00 PM (12 hours after the start of the survey), the facility approved the surveyor's password, provided her with a laptop, and gave her access to residents' EMRs.

Based on record reviews and interviews, the facility's staff failed to provide continuous pulse-oximeter monitoring, as ordered for one (1) of three (3) sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Developmental Delays. A physician order dated [DATE] instructed, Monitor Pulse Oximetry Continuous per parameters HR (heart rate) ,d+[DATE] (beats per minute), POX (pulse-ox) ,d+[DATE] (saturation rate). A quarterly MDS dated [DATE] documented, the resident had a Brief Interview for Mental Status summary score of 05 indicating the resident had a severely impaired cognitive status. In addition, the resident was coded for impaired bilateral lower extremities, always incontinent of bladder and bowel, dependent of staff for all Activities of Daily Living, and using a wheelchair. A nurses note dated [DATE] at 11:53 PM documented, Patient Care Overview: Safety check on resident done at 1930 (7:30 PM). Resident in bed, alert/active, no distress. Came into resident's room at 2109 (9:09 PM) and found resident in bed unresponsive. Called for help from other nurses and respiratory, started CPR immediately, and code called. Code team responded. A physician note dated [DATE] at 2:40 PM documented the following but not limited to: Received Report on sign out at approximately 6 pm on [DATE], that patient was reported of fever 99F by school nurse, but no other symptoms of cough, congestion or any other clinical changes. Checked with Nursing on rounding, for VS - temperature reported wnl (within normal limits) - VS at 14:18 was 37.7C (99.8 F), (an temperature prior to that - the night before, before going to school was 36.4 (97.5 F), rest of VS (vital signs) at 14:18 was -HR 90, RR 18, BP ,d+[DATE], Sats 95% on RA. On patient eval at approximately 6:30 pm on [DATE], patient was awake in bed, lying supine, in NAD (no apparent distress), moving, with normal perfusion and no signs of congestion, and did not appear with coughing or other symptoms, and appeared afebrile. Patient awake, at baseline mental status and activity level, and appeared at usual state of health, with no agitation or distress, and was calm and alert at baseline, and moving head/extremities at baseline. Code Blue was called at 9:11 pm on [DATE]. - on arrival, patient was found unresponsive, limp, and was already receiving CPR/chest compressions and receiving PPV via bag-mask 100% FiO2. Patient pronounced deceased at 22:13 (10:13 PM). Preliminary diagnosis: likely Cardiopulmonary arrest related to [NAME]-[NAME] syndrome. Of note, patient had similar previous episode of Apnea/Cardiac arrest (Hx: [DATE] x 2 code episodes). Per Genetics: patient can have unexplained apnea, due to underlying condition of [NAME]-[NAME] syndrome. During a face-to-face interview on [DATE] at approximately 11:00 AM, Employee #6 (Nursing Supervisor) stated that according to the facility's protocol, staff should connect residents to continuous monitors (pulse-oximeter) when they are not in the presence of staff, such as when they are in their rooms. During a telephone interview on [DATE] at 1:47 PM, Employee #3 (CNA) stated that during the evening shift on [DATE] Resident #1 was his normal self. She last saw the resident at 8:00 PM. And because the resident was still awake, Employee #3 didn't connect the pulse oxygen monitor. According to her, the resident's condition (Lesch Nyhan Disease) caused him to move a lot, which prevented the monitor from staying on. Her plan was to set the monitor up when the resident was asleep. However, an hour after she left the room, she heard a Code Blue called for the resident. In addition, she explained that everyone knew it was difficult to keep the pulse oximeter connected, so staff waited until the resident was asleep to connect it. During a telephone interview on [DATE] at 2:00 PM, Employee #4(RN) stated that when she made her first rounds on [DATE] at 7:30PM she did not observe any signs of distress. He was in bed awake, smiling, and the pulse-oximetry monitor was connected. When she made her second round on [DATE] at 9:00 PM, the resident was unresponsive and had no pulse. After calling for help, she began CPR. In addition, the employee said that the resident's pulse-oximeter was at bedside and not connected to the resident. The employee said she didn't know why the pulse-oximeter was not connected.

Based on a record review and an interview, at the time of survey, the facility failed to have documented evidenced that a thorough investigation had been conducted after the death of a resident for one (1) of three (3) sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Developmental Delays. A State Survey Agency Facility Reported Incident form # DC~12475 documented, Bedside RN [Employee #4] went in to provide care for [Resident #1] and noticed discoloration in the lips and resident was unresponsive. Rapid Response called and [Resident #1] coded for over an hour but pronounced deceased . SNF Administrator and DON notified, and Medical Examiner called and 911 notified and detectives came out to the facility. Parents notified. A nurses note dated [DATE] at 11:53 PM documented, Patient Care Overview: Safety check on resident done at 1930 (7:30 PM). Resident in bed, alert/active, no distress. Came into resident's room at 2109 (9:09 PM) and found resident in bed unresponsive. Called for help from other nurses and respiratory, started CPR immediately, and code called. Code team responded. A review of the staffing assignment for the [DATE] evening shift (3PM-11PM) revealed a resident census of 14. Staffing included three (3) nurses and two (2) certified nursing assistants (CNAs). However, the facility's investigation documents lack documented evidence that witnesses who may have had knowledge of the incident, including evening shift employees and the resident's roommate, were interviewed. During a telephone interview on [DATE] at approximately 3:00 PM, Employee #1 (Administrator) stated that the DON interviewed staff. Because the DON was on vacation, she couldn't find where the staff interviews were filed. The Administrator also said she would forward a copy of the staff interviews to DC Health when the DON returns from vacation. Please cross reference 483.12 Freedom from Abuse, Neglect, and Exploitation. F600

Based on record reviews and staff interview, the facility's staff failed to develop Baseline Care Plans within 48 hours of admission for two (2) of three (3) sampled residents. (Residents #1 and #2). The findings include: 1.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Developmental Delays. A review of the resident's care plan revealed that the care plan was initiatied on 07/20/23. An Admission Minimum Data Set, dated dated dated [DATE] documents the resident's admitted as 07/06/23. This resident had a Brief Interview for Mental Status summary score of 05, indicating severe cognitive impairment. Also, the resident was coded as dependent on staff for all Activities of Daily Living, always incontinent of bladder and bowel, and wheelchair dependent. 2. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Global Developmental Delays. A review of the resident's care plan revealed that the care plan was initiatied on 07/20/23. An Admission Minimum Data Set, dated dated dated [DATE] documented, the resident's admitted was 07/06/23. The resident had a Brief Interview for Mental Status summary score of 13 indicating intact cognitive status. Also, the resident was coded as dependent on staff for all Activities of Daily Living, always incontinent of bladder and bowel, and wheelchair dependent. During our telephone interview on 12/13/23 at approximately 11:00 AM, Employee #5 (MDS Coordinator) said it was her responsibility to develop the resident's initial care plan. The employee stated that the facility was improving its care plan development and review process.

Based on record review and staff interview, the facility failed to develop a care plan for a resident's use of a pulse-ox monitor for three (3) of 3 sampled residents. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Developmental Delays. A physician order dated 11/01/23 instructed, Monitor Pulse Oximetry Continuous per parameters HR (heart Rate) 60-120 (beats per minute). POX (pulse-ox) 90-100 (saturation rate). A review of the resident's care plan with a review date of 11/21/23 lacked documented evidence that the facility's staff developed a care plan with goals and interventions for his use of a continuous pulse-oximeter monitoring. During our telephone interview on 12/13/23 at 11:00 AM, Employee #5 (MDS Coordinator) said that the facility was improving their process of developing and reviewing care plans.

Based on record review and staff interview, for three (3) of 3 residents, the facility failed to ensure residents care plans were reviewed by the Inter-disciplinary Team; and for one (1) of three (3) sampled residents, the resident's care plan was not reviewed by the Inter-disciplinary Team after each quarterly Minimum Data Set. (Residents #1, #2, and #3). 1. The facility failed to ensure Residents #1, #2, and #3 care plans were reviewed by the Inter-disciplinary Team. 1a. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Developmental Delays. A quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status summary score of 05 , indicating severe cognitive impairment. Also, the resident was coded as dependent on staff for all Activities of Daily Living, always incontinent of bladder and bowel, and wheelchair dependent. A review of the resident's care plan revealed that it was reviewed by Employee #5 (MDS Coordinator) on 11/21/23. However, there was no documented evidence that it was reviewed by the Inter-disciplinary Team. 1b. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Global Developmental Delays. A quarterly Minimum Data Set, dated dated dated [DATE] documented, the resident had a Brief Interview for Mental Status summary score of 13 indicating intact cognitive status. Also, the resident was coded as dependent on staff for all Activities of Daily Living, always incontinent of bladder and bowel, and wheelchair dependent. A review of the resident's care plan revealed that it was reviewed by Employee #5 (MDS Coordinator) on 11/21/23. However, there was no documented evidence that it was reviewed by the Inter-disciplinary Team. 1c. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Chronic Atelectasis, Chronic Respiratory Failure, and Anemia. A quarterly Minimum Data Set, dated dated dated [DATE] documented, the resident had a Brief Interview for Mental Status summary score of 12 indicating intact cognitive status. Also, the resident was coded as dependent on staff for all Activities of Daily Living, always incontinent of bladder and bowel, and receiving physical therapy services, occupational therapy services, and respiratory therapy services. A review of the resident's care plan revealed it was reviewed by Employee #5 (MDS Coordinator) on 05/02/23. However, there was no documented evidence that it was reviewed by the Inter-disciplinary Team. During our telephone interview on 12/13/23 at 11:00 AM, Employee #5 (MDS Coordinator) said the facility was improving their process for reviewing care plans.

Based on record reviews and interviews, the facility's staff failed to provide continuous pulse-oximeter monitoring, as ordered for one (1) of three (3) sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Lesch Nyhan Syndrome, Nephrocalcinosis, Self-Injurious Behavior, and Developmental Delays. A physician order dated [DATE] instructed, Monitor Pulse Oximetry Continuous per parameters HR (heart rate) ,d+[DATE] (beats per minute), POX (pulse-ox) ,d+[DATE] (saturation rate). A quarterly MDS dated [DATE] documented, the resident had a Brief Interview for Mental Status summary score of 05 indicating the resident had a severely impaired cognitive status. In addition, the resident was coded for impaired bilateral lower extremities, always incontinent of bladder and bowel, dependent of staff for all Activities of Daily Living, and using a wheelchair. A nurses note dated [DATE] at 11:53 PM documented, Patient Care Overview: Safety check on resident done at 1930 (7:30 PM). Resident in bed, alert/active, no distress. Came into resident's room at 2109 (9:09 PM) and found resident in bed unresponsive. Called for help from other nurses and respiratory, started CPR immediately, and code called. Code team responded. A physician note dated [DATE] at 2:40 PM documented the following but not limited to: Received Report on sign out at approximately 6 pm on [DATE], that patient was reported of fever 99F by school nurse, but no other symptoms of cough, congestion or any other clinical changes. Checked with Nursing on rounding, for VS - temperature reported wnl (within normal limits) - VS at 14:18 was 37.7C (99.8 F), (an temperature prior to that - the night before, before going to school was 36.4 (97.5 F), rest of VS (vital signs) at 14:18 was -HR 90, RR 18, BP ,d+[DATE], Sats 95% on RA. On patient eval at approximately 6:30 pm on [DATE], patient was awake in bed, lying supine, in NAD (no apparent distress), moving, with normal perfusion and no signs of congestion, and did not appear with coughing or other symptoms, and appeared afebrile. Patient awake, at baseline mental status and activity level, and appeared at usual state of health, with no agitation or distress, and was calm and alert at baseline, and moving head/extremities at baseline. Code Blue was called at 9:11 pm on [DATE]. - on arrival, patient was found unresponsive, limp, and was already receiving CPR/chest compressions and receiving PPV via bag-mask 100% FiO2. Patient pronounced deceased at 22:13 (10:13 PM). Preliminary diagnosis: likely Cardiopulmonary arrest related to [NAME]-[NAME] syndrome. Of note, patient had similar previous episode of Apnea/Cardiac arrest (Hx: [DATE] x 2 code episodes). Per Genetics: patient can have unexplained apnea, due to underlying condition of [NAME]-[NAME] syndrome. During a face-to-face interview on [DATE] at approximately 11:00 AM, Employee #6 (Nursing Supervisor) stated that according to the facility's protocol, staff should connect residents to continuous monitors (pulse-oximeter) when they are not in the presence of staff, such as when they are in their rooms. During a telephone interview on [DATE] at 1:47 PM, Employee #3 (CNA) stated that during the evening shift on [DATE] Resident #1 was his normal self. She last saw the resident at 8:00 PM. And because the resident was still awake, Employee #3 didn't connect the pulse oxygen monitor. According to her, the resident's condition (Lesch Nyhan Disease) caused him to move a lot, which prevented the monitor from staying on. Her plan was to set the monitor up when the resident was asleep. However, an hour after she left the room, she heard a Code Blue called for the resident. In addition, she explained that everyone knew it was difficult to keep the pulse oximeter connected, so staff waited until the resident was asleep to connect it. During a telephone interview on [DATE] at 2:00 PM, Employee #4(RN) stated that when she made her first rounds on [DATE] at 7:30PM she did not observe any signs of distress. He was in bed awake, smiling, and the pulse-oximetry monitor was connected. When she made her second round on [DATE] at 9:00 PM, the resident was unresponsive and had no pulse. After calling for help, she began CPR. In addition, the employee said that the resident's pulse-oximeter was at bedside and not connected to the resident. The employee said she didn't know why the pulse-oximeter was not connected.

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by privacy curtains that were hanging loose, detached from the curtain tracks in five (5) of eight (8) resident's rooms, and wall clocks in eight (8) of eight (8) resident's rooms that did not display the correct time. The findings included: 1. Privacy curtains in residents' rooms #1077, #1078, #1079, # 1080, and #1082 were hanging loose, detached from curtain hooks and ceiling tracks. 2. Wall clocks in eight (8) of eight (8) resident's rooms did not display actual time. Employee #1 acknowledged the findings during a face-to-face interview on February 8, 2023, at approximately 10:00 AM.

Based on record review and staff interviews for three (3) of 13 sampled residents, facility staff failed to implement its written policies and procedures to investigate any potential allegations of neglect as evidenced by the facility's staff failure to investigate two incidents involving residents with a dislodged g (gastrostomy)-tube and one incident involving a resident's decannulation of the tracheostomy tube. (Residents' #1, #8 and #4). The findings included: Review of the facility's policy titled Abuse Investigation and Reporting with a reviewed date of 01/2020, instructs .If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will investigate or assign the investigation to an appropriate individual . 1. Facility staff failed to follow its policies to investigate potential neglect by failing to investigate Resident #1's dislodged G-tube. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Chronic Respiratory Failure, Anoxic Brain Damage, Seizure Disorder, and Encounter for Attention to Gastrostomy. Review of a Facility Reported Incident (FRI), DC00010993, submitted by the facility to the State Agency on 09/20/22 documented, CNA (certified nurse aide) called RN (Registered Nurse) to bedside. RN noted that resident's G-tube (Gastrostomy tube) had dislodged with a busted balloon. G-tube was replaced. Resident tolerated G-tube change well. He had no signs of distress or discomfort. Resident is stable. Medical decision maker has been inform (ed) (sp) A review of Resident #1's medical record revealed the following: Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the resident as being in a persistent vegetative state and with no discernible consciousness. The facility staff coded the resident as having a feeding tube and receiving 51% or more calories and 500 cc (cubic centimeter) or more per day through tube feeding. A review of the resident's care plan with a focus area revised on 08/04/22 revealed .(Resident #1) has an enteral feeding tube to meet nutritional and hydrational needs due to the resident's medical diagnosis . and had the following intervention .Gastrostomy tube care as ordered . 09/15/22 at 2:19 PM [Patient Care Notes] .writer was called to the residents bedside by CNA (certified nurse aide) performing care, due to G (Gastrostomy)-tube dislodgement. Upon assessment, residents G-tube was noted to be dislodged with a busted balloon .G-tube was replaced with a new one and 4ml water inserted in balloon . The medical record lacked documented evidence that the facility staff investigated Resident #1's dislodged G-tube and busted balloon. During a face-to-face interview conducted on 02/09/23 at 11:09 AM, Employee #2 (Director of Nursing) acknowledged the findings and stated If a dislodgement occurs and we can see it's a balloon failure it is investigated not as a care failure but as a manufacturer failure. 2. Facility staff failed to follow its policies to investigate potential neglect by failing to investigate Resident #8's decannulation of the tracheostomy tube. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including the following: Diffuse Traumatic Brain Injury with Loss of Consciousness, Seizure Disorder, Chronic Respiratory Failure, and Dependence on Ventilator. Review of a Facility-Reported Incident (FRI) DC00010811, submitted to the State Agency on 06/15/22, documented .Resident decannulated while CNA (was providing care on 6/13/2022. RN re-inserted trach immediately following decannulation. Resident remained stable. Resident's mother was informed via email. A review of Resident #8's medical record revealed the following: Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the resident as having a diagnosis of respiratory failure. The facility staff coded that the resident received suctioning, tracheostomy care, and an Invasive mechanical Ventilator in the facility. A review of the resident's care plan with a focus area of Resident #8 is dependent upon a tracheostomy tube and mechanical ventilation for breathing and oxygenation due to his medical diagnosis. revised on 05/17/22, and has the following interventions Emergency supplies at the bedside readily accessible (back up trachs [same-size, downsize], ambu-bag (Manual Resuscitator) connected to O2, working suction, and code sheets) .Continuous pulse oximetry per protocol. 06/13/22 at 1:00 PM [Patient Care Note] .responded to ventilator alarm for resident at approximately 1200. Resident could be heard crying to which [Staff Name] assessed trach stoma site to find trach had been dislodged .attempted reinsertion and was unsuccessful. [Staff Name] called out for help and prepared the same size trach at the bedside in the respiratory supplies basket for insertion. [Staff member] removed previous ties and inserted the new same size trach (Tracheostomy) and attached new trach to existing ventilator tubing. Resident saturation went down to 87% and recovered to 99% without supplemental oxygen or bagging. [Staff Name] arrived at bedside and assisted [Staff Name] with securing trach with trach ties and both assessed resident . The facility was not able to provide any evidence that any investigation was conducted regarding the resident's tracheostomy dislodgement that occurred on 06/13/22. During a face-to-face interview conducted on 02/08/23 at approximately 10:00 AM, Employee #2 (Interim Director of Nursing) acknowledged the findings and stated, all CNA's (certified nurse aide) and RN's (registered nurse) go through training annually for decannulation. 3. Facility staff failed to follow their written policies on thoroughly investigating allegations of abuse or neglect, as evidenced by not investigating a Resident #4sdislodged g-tube. Resident #4. On 10/24/22 at 3:28 PM, the facility submitted an incident report (DC11094) documenting the following: Resident's g-tube dislodged on 10/23/2022, and it was replaced. Resident suffered no complications. Resident #4 was admitted to the facility on [DATE] with diagnoses including Unspecified Focal Traumatic Brain Injury (TBI), Diabetes Insipidus, Gastrostomy tube (G-tube) dependent, Tracheostomy on Room Air, Chronic Constipation, Scoliosis, and Global Delays. Review of Resident #4's medical record revealed: A Quarterly Minimum Data Set (MDS) dated [DATE] showed that facility staff documented the Resident was totally dependent on staff for all activities of daily living (ADLs - transfers, eating, dressing, toileting, bathing, and personal hygiene), had a G-tube and required suctioning and tracheostomy care. 06/15/21 at 4:04 PM [Physician's Order] directed: HOB (height of bed) elevated at least 30 min (minutes) post-feeding. Avoid excess movement and handling post feedings 04/29/22 at 9:00 AM [Physician's Order] directed: Pediasure (Tube feeding formula) reduced calorie 0.6 Kcal/ml (kilocalorie per milliliter) via GT (G-tube), 225 ml QID (four times a day) .Total free water 850 ml daily: 250 (ml) Miralax (stool softener), 50 (ml) before and 60 ml after feeds (110 x4=440), 20 ml x 8 (eight times) for med flushes (160 ml) . 10/23/22 at 08:03 AM [Nurse Progress Note] documented: .Around 645 (6:45 AM), while PCA (Patient Care Assistant) was providing her morning ADLs (activities of daily living), she called and notified me abot (about) the dislodgement. Upon assessment, the balloon was found to be busted. The tube was held in place, stoma was patency (patent). There was no current size (12 French, 1.2 centimeters) available for replacement. The house supervisor (was) notified, attending Dr. (doctor) called, awaiting the order for alternative. Report (was) given to the in-coming nurse for continuity of care. Resident stable at this hour. 10/23/22 at 12:26 PM [Nurse Progress Note] documented: Resident remains in a stable condition, per report g-tube was found dislodged .MD verbally adviced (sp) (advised) to put regular g-tube #12 fr (French) until same size available, this writer placed a new g-tube per order .with 3 ml (milliliters) sterile water in balloon, no post procedure-related complications noted, will continue to monitor closely. The Registered Nurse (RN) and the CNA (Certified Nurse Aide) who provided care for Resident #4 when the g-tube dislodged on 10/23/22 were unavailable for an interview during the survey. Review of Resident #4's medical record lacked documented evidence that facility staff conducted an investigation of Resident #4's dislodged g-tube on 10/23/22. During a face-to-face interview on 02/08/23 at 4:04 PM, Employee #7, CNA caring for Resident #4, stated that she recalled having an issue with the Resident's g-tube a few months ago-the balloon busted, and the g-tube became dislodged. She added that it could have happened when she and the nurse were assisting the Resident with removing a back brace that the Resident wears for scoliosis, but she was unsure. During a face-to-face interview Employee #3 (Director of Patient Care) stated that the facility had problems with g-tube dislodgements due to the balloons on the g-tubes bursting. She reported that facility staff had made the facility's leadership and g-tube vendor aware of the issue, and at the time, there were no other vendors to choose from. The Employee then acknowledged that the facility had not investigated the Resident's g-tube dislodgement. Cross-Reference 22-B DCMR sec. 3232.2

Based on record review and staff interviews for three (3) of 13 sampled residents, facility staff failed to conduct thorough investigations as evidenced by there being no evidence that the facility investigated an incident involving one (1) resident's decannulation of the tracheostomy, and for two resident's incidents in which their G (Gastrostomy)-tube dislodged. (Resident's #1, #8, and #4. The findings included: Review of the facility's policy titled Abuse Investigation and Reporting with a reviewed date of 01/2020, instructs .If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of an unknown source is reported, the Administrator will investigate or assign the investigation to an appropriate individual .The individual conducting the investigation will as a minimum .Review the resident's medical record to determine events leading up to the incident; Interview persons reporting the incident . 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Chronic Respiratory Failure, Anoxic Brain Damage, Seizure Disorder, and Encounter for Attention to Gastrostomy. A review of the resident's care plan with a focus area revised on 08/04/22 revealed .(Resident #1) has an enteral feeding tube to meet nutritional and hydrational needs due to the resident's medical diagnosis . and had the following intervention .Gastrostomy tube care as ordered . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the resident as being in a persistent vegetative state and with no discernible consciousness. The facility staff coded the resident as having a feeding tube and receiving 51% or more calories and 500 cc (cubic centimeter) or more per day through tube feeding. A patient care note date 09/15/22 at 2:19 PM documented, .writer was called to the residents bedside by CNA (certified nurse aide) performing care, due to G (Gastrostomy)-tube dislodgement. Upon assessment, residents G-tube was noted to be dislodged with a busted balloon .G-tube was replaced with a new one and 4ml water inserted in balloon . Review of a Facility Reported Incident (FRI), DC00010993, submitted by the facility to the State Agency on 09/20/22 revealed, CNA (certified nurse aide) called RN to bedside. RN noted that resident's G-tube had dislodged with a busted balloon. G-tube was replaced. Resident tolerated G-tube change well. He had no signs of distress or discomfort. Resident is stable. Medical decision maker has been inform (ed) (sp) The medical record lacked documented evidence that the facility staff conducted an investigation into Resident #1's dislodged G-tube and busted balloon. During a face-to-face interview conducted on 02/09/23 at 11:09 AM, Employee #2 (Interim Director of Nursing) acknowledged the findings and stated If a dislodgement occurs and we can see it's a balloon failure it is investigated not as a care failure but as a manufacturer failure 2. Facility staff failed to show documented evidence of investigating an incident involving Resident #8's decannulation of the tracheostomy. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including the following: Diffuse Traumatic Brain Injury with Loss of Consciousness, Seizure Disorder, Chronic Respiratory Failure, and Dependence on Ventilator. A review of the resident's care plan with a focus area of Resident #8 is dependent upon a tracheostomy tube and mechanical ventilation for breathing and oxygenation due to his medical diagnosis. revised on 05/17/22 and has the following interventions Emergency supplies at the bedside readily accessible (back up trachs [same-size, downsize], ambu-bag connected to O2, working suction, and code sheets) .Continuous pulse oximetry per protocol. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that the facility staff coded the resident as having a diagnosis of respiratory failure. The facility staff coded that the resident received suctioning, tracheostomy care, and an Invasive mechanical Ventilator in the facility. Review of a Facility-Reported Incident (FRI), DC00010811, submitted to the State Agency on 06/15/22, documented, .Resident decannulated while CNA (was providing care on 6/13/2022. RN re-inserted trach immediately following decannulation. Resident remained stable. Resident's mother was informed via email. A 06/13/22 at 1:00 PM Patient Care Note documented, .responded to ventilator alarm for resident at approximately 1200. Resident could be heard crying to which [Staff Name] assessed trach stoma site to find trach had been dislodged .attempted reinsertion and was unsuccessful. [Staff Name] called out for help and prepared the same size trach at the bedside in the respiratory supplies basket for insertion. [Staff member] removed previous ties and inserted the new same size trach and attached new trach to existing ventilator tubing. Resident saturation went down to 87% and recovered to 99% without supplemental oxygen or bagging. [Staff Name] arrived at bedside and assisted [Staff Name] with securing trach with trach ties and both assessed resident . The facility was not able to provide any evidence that any investigation was conducted regarding the resident's tracheostomy dislodgement that occurred on 06/13/22. During a face-to-face interview conducted on 02/07/23 at 3:07 PM with Employee #5 (Registered Nurse) acknowledged the findings and stated, (staff name) was shouting help he secured the trach he needed someone to assist in placing the ties . During a face-to-face interview conducted on 02/08/23 at approximately 10:00 AM, Employee #2 (Interim Director of Nursing) acknowledged the findings and stated, all CNA's (certified nurse aide) and RN's (registered nurse) go through training annually for decannulation. 3. Facility staff failed to investigate and report its findings of an incident involving Resident #4's g-tube dislodgement. Resident #4 was admitted to the facility on [DATE] with diagnoses including Unspecified Focal Traumatic Brain Injury (TBI), Diabetes Insipidus, Gastrostomy tube (G-tube) dependent, Tracheostomy on Room Air, Chronic Constipation, Scoliosis, and Global Delays. A physician's order dated 06/15/21 at 4:04 PM directed: HOB (height of bed) elevated at least 30 min (minutes) post-feeding. Avoid excess movement and handling post feedings . A Quarterly Minimum Data Set (MDS) dated [DATE] showed that facility staff documented the Resident was totally dependent on staff for all activities of daily living (ADLs - transfers, eating, dressing, toileting, bathing, and personal hygiene), had a G-tube and required suctioning and tracheotomy care. A 04/29/22 at 9:00 AM Physician's Order directed: Pediasure (Tube feeding formula) reduced calorie 0.6 Kcal/ml (kilocalorie per milliliter) via GT (G-tube), 225 ml QID (four times a day) .Total free water 850 ml daily: 250 (ml) Miralax (stool softener), 50 (ml) before and 60 ml after feeds (110 x4=440), 20 ml x 8 (eight times) for med flushes (160 ml) . The following nursing progress notes were found in Resident #4's medical record: -10/23/22 at 08:03 AM [Nurse Progress Note] documented: .Around 645 (6:45 AM), while PCA (Patient Care Assistant) was providing her morning ADLs (activities of daily living) she called notified me abot (about) the dislodgement. Upon assessment, the balloon was found to be busted. The tube was held in place, stoma was patency (patent). There was no current size (12 French, 1.2 centimeters) available for replacement. The house supervisor (was) notified, attending Dr. (doctor) called, awaiting the order for alternative. Report given to the incoming nurse for continuity of care. Resident stable at this hour. -10/23/22 at 12:26 PM [Nurse Progress Note] documented: Resident remains in a stable condition, per report g-tube was found dislodged .MD verbally adviced (advised) to put regular g-tube #12 fr (French) until same size available, this writer placed a new g-tube per order .with 3 ml (milliliters) sterile water in balloon, no post procedure-related complications noted, will continue to monitor closely. On 10/24/22 at 3:28 PM, the facility submitted an incident report (DC00011094) that documented the following: Resident's g-tube dislodged on 10/23/2022 and it was replaced. Resident suffered no complications. The Registered Nurse (RN) and the CNA (Certified Nurse Aide) who provided care for Resident #4 when the g-tube dislodged on 10/23/22 were unavailable for an interview during the survey. Review of Resident #4's medical record lacked documented evidence that facility staff conducted an investigation of Resident #4's dislodged g-tube on 10/23/22. During a face-to-face interview on 02/08/23 at 4:04 PM, Employee # 7, CNA caring for Resident #4, stated that she recalled having an issue with the Resident's g-tube a few months ago . the balloon busted, and the g-tube became dislodged . She added, It could have happened when me and the nurse were assisting the resident with removing a back brace that the resident wears, but I am not sure. During a face-to-face interview for QAPI, Employee #3 (Patient Care Director) stated that the facility had been made aware of an overall concern with the g-tube balloons (used to hold the g-tube in place) bursting, resulting in g-tube dislodgement for multiple residents. She stated that facility staff had made the facility's leadership and g-tube vendor aware of the issue, and there were no other vendors to choose from at this time. The Employee then acknowledged that the facility had not investigated the Resident's g-tube dislodgement. Cross-Reference 22-B DCMR sec. 3232.2