Every finding on record at Unique Rehabilitation and Health Center LLC

Based on observations, record reviews, and resident and staff interviews, the facility staff failed to develop a care plan for one (1) of four (4) residents who used a powered(electric) wheelchair. (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Morbid Obesity, Chronic Bilateral Lower Extremities Lymphedema, and Muscle Weakness.An admission Minimum Data Set (MDS) assessment dated [DATE] documented in part that the resident had a Brief Interview Mental Status summary score of 15 indicating that at the time of the assessment the resident had an intact cognitive status. Also, the resident was coded for lower extremity impairment, requiring staff assistance when using a manual wheelchair, and receiving occupational therapy services. A delivery ticket from a local medical supply store dated 04/17/25 documented a power(electric) wheelchair was delivered to the facility for Resident #2.A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented in part that the resident had a Brief Interview Mental Status summary score of 15 indicating that at the time of the assessment the resident had an intact cognitive status. Also, the resident was coded for lower extremity impairment, independently using a manual wheelchair, and receiving occupational therapy services. A review of a wheelchair and seating device assessment dated [DATE] documented, The resident on electric wheelchair demonstrates safe operation on the wheelchair.A review of the resident care plans showed there was no documented evidence of care plan to address the resident use of a manual or electric wheelchair.Multiple observation from 11/17/25 to 11/21/25 showed the resident in her room watching tv while sitting in a powered wheelchair. At the time of the observation on 11/17/25 at approximately 11AM, the resident stated that staff helps her transfer from the bed to her wheelchair. The resident also said that she can independently operate her (electric)wheelchair in her room, the bathroom, around the facility, and outside the facility.During a face-to-face interview on 11/24/25 at approximately 2PM, Employee #4 (RN/Unit Manager) reviewed the care plans. Then the employee stated that the resident's care plans did not have a care plan to address the resident's use of a powered (electric) wheelchair.

Based on record review and staff interviews, facility staff failed to have documented evidence that they followed their policy by providing education for one of four residents who used medical equipment (powered wheelchair). Resident #2The findings included:The facility's Resident Medical Equipment policy with a review date of 01/2025 instructed staff to, Document receipt of equipment. Documentation may include .date/time received, equipment type, delivered by (vendor, family member, etc.).Education on how to use the equipment may be provided for staff or for the resident.Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Morbid Obesity, Chronic Bilateral Lower Extremities Lymphedema, and Muscle Weakness.A delivery ticket from a local medical supply store dated 04/17/25 documented a power(electric) wheelchair was delivered to the facility for Resident #2.A review of resident's medical record to include progress notes from nursing, rehab and social services and inventory sheets dated from 04/17/25 to 06/05/25 lacked documented evidence that the resident received a powered wheelchair on 04/17/25.A review of a wheelchair and seating device assessment dated [DATE] documented, The resident on electric wheelchair demonstrates safe operation on the wheelchair.A review of progress notes from 06/05/25 to 07/03/25 revealed there was no documented evidence that staff provided the resident education on how to use a powered(electric) wheelchair. It should be noted that the resident was discharged home on [DATE] and re-admitted on [DATE].Multiple observations from 11/17/25 to 11/21/25 showed the resident in her room watching tv while sitting in a powered wheelchair. At the time of the observation on 11/17/25 at approximately 11AM, the resident stated that Employee #3 (Unit Manager/RN) and the technician who delivered the wheelchair provided education for her on the day the wheelchair was delivered. The resident, however, could not remember the specific date her electric wheelchair was delivered. Additionally, the resident stated the day her wheelchair was delivered was the first time she used an electric (powered) wheelchair. During a face-to-face interview on 11/19/25 at 2PM, Employee #3 stated that she provided education for the resident on how to safely operate her new powered wheelchair during her wheelchair assessment date 06/06/25. The employee then stated that it was an oversight that she did not document the education she provided in the resident's medical record. Additionally, the employee said that she could not remember the specific date the wheelchair was delivered and she did not see in the resident's record where nursing documented the date the resident's wheelchair was delivered.

Based on observation, record reviews and staff interviews, for one (1) of three sampled residents, the facility staff failed to report an injury of unknown origin to the Administrator, and for two (2) of three sampled residents, the facility staff failed to report a resident-to-resident altercation to the Administrator of the facility and to other officials (including to the State Survey Agency, Adult Protective Services, and Metropolitan Police Department) within the required timelines per the facility's Abuse policy and federal regulations. Residents #1 and #2. The findings included: 1.Facility staff failed to report Resident #1's injury of unknown origin to the Administrator per the facility's policy as evidenced by:A review of the facility's policy entitled, Abuse, Neglect, Exploitation, revised on 01/01/25, documented: Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.Reporting Allegations to the Administrator and Authorities, 1. If abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials, according to state law. Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Alzheimer's Dementia, Major Depressive Disorder, Cognitive Communication Deficit, Restlessness and Agitation, and Unspecified Psychosis.A review of Resident #1's medical record revealed: A quarterly minimum data set (MDS) assessment dated [DATE] that documented that Resident #1: had severely impaired cognitions,; displayed physical (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) for 1 to 3 days; was independent with transferring in and out of bed ,and could ambulate independently at least 150 feet in the room or in the corridor.The following physician orders dated 04/17/25 at 3:00 PM that directed:- Anti-Psychotic: Targeted Behavior Monitoring: Kicking, yelling/screaming, hitting, hallucinations, delusions etc. If behavior is observed, document behavior with interventions and notify the provider every shift for behavior.- Clopidogrel Bisulfate Oral Tablet 75 mg (Clopidogrel Bisulfate (anticoagulant/blood thinner) Give 1 tablet by mouth one time a day related to Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris,- Monitor resident for bleeding, bruises and discoloration r/t (related to) anticoagulant every shift. Alert MD (Medical Director) for any changes and document in progress note every shift. A physician's order dated 08/28/25 at 7:00 AM that directed: Maintain resident on 1:1 every shift.A physician's order dated 08/28/25 at 5:00 PM that directed: Risperdal Oral Tablet 1 mg (Risperidone) Give 1 tablet by mouth two times a day for psychosis. A physician's order dated 08/28/25 at 5:00 PM that directed: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth three times a day for mood swings. A review of an SBAR (Situation, Background, Assessment and Recommendation) - Physician/ Nurse Practitioner (NP)/Physician Assistant (PA) Communication Tool dated 09/05/25 that documented: Situation: Resident's daughter alleged that resident has been physically abused by the facility staff.Background: Dementia, Alzheimer's, Depression.Assessment: Resident is alert x 1 with confusion, changes in mental status. Not observed in pain or discomfort; Recommendation/Progress Note (PN): Resident daughter alleged that [Resident #1] has been physically abused by the facility staff, head-to-toe assessment done by the staff, skin is intact. MD notified investigation initiated. A review of an incident report [Incident 2621432] to the State agency on 09/05/25 that documented: Initial report: [Name of Resident #1] .was admitted to the facility on [DATE] with the Dx (diagnoses) Altered mental status, Dementia with psychotic disturbance of Alzheimer's disease, [and] Major depressive [disorder], to name a few of them. The resident[s] daughter alleged that [Name of Resident #1] has been physically abused by the facility staff. The resident is not in any distress at this time. The full investigation will follow.On 09/11/25, the facility submitted a final investigation report of the incident [Incident 2621432] to the State agency that documented: Final investigation report: The result of the investigation is as follows: The daughter reported that when she visited the resident, she had noticed a discoloration below his left eye and alleged trauma/abuse that may have been caused by facility staff. Immediately upon notification, a head-to-toe assessment was done on [Resident #1]. No new discoloration was noted anywhere near the left eye and no new indication of pain.uniform baseline pigmentation of the face and body; . The Medical Director was notified and ordered an x-ray of the face. X-ray done with a negative result of fracture.A review of the facility's investigation documents showed a written statement from Employee #4, Charge Nurse who was assigned to Resident #1 on 08/30/25 from 7:00 AM to 3:00 PM. The Employee's statement documented: Saturday morning made rounds on Unit 3 South. Resident [1] was facing the wall and daughter was in the room with resident. She didn't want him disturbed. [I] Went back into [the] room to administer AM medications [to the Resident]. The daughter had taken pictures and asked me, 'Who did this, if [the] resident was on one-to-one monitoring?' I asked the CNAs (Certified Nurse Assistants), 'Did anyone report any incident?' They all said 'No.'. The daughter said it looked like it happened last evening. I checked the computer system for any notes of the incident' there were none. The daughter asked for a washcloth to clean resident's face after breakfast, and an ice pack. [I] placed ice into a washcloth, as she asked. She kept asking, 'Who did this?' I couldn't indicate when it took place and who did it. During a telephone interview with Resident #1's representative on 09/19/25 at 9:32 AM, the representative stated that on 08/30/25 at around 7:00 AM while visiting Resident #1, she noticed discoloration under the Resident's left eye. She asked Employee #6, (1:1 Monitor/Certified Nurse Assistant/CNA assigned to Resident #1) if something happened to the Resident overnight that caused the discoloration under the Resident's left eye, and he said No. Resident #1's representative stated that she mentioned the discoloration to Employee #4 (Charge Nurse assigned to Resident #1 on 08/30/25), and she asked the Employee if she was aware of any incident which may have caused the Resident's injury. Employee #4 stated that she was not aware of any incident that occurred, and she stated that she would let the Unit Manager know about the Resident's injury. Resident #1's representative added that for several days she received no follow-up from the facility staff about the Resident's injury. On 09/05/25 she reported Resident#1's injury of unknown origin to Employee #5 (3 South Unit Manager) and alleged that the Resident had been abused by the facility staff. Further review of Resident #1's medical record showed no documented evidence that Employee #4 ever reported Resident #1's injury any other facility staff. The evidence showed that Employee #5 was first informed of Resident #1's injury of unknown origin by the Resident's representative on 09/05/25. Of note, Employees #4 and #5 were not available for interview during the survey. 2. Facility staff failed to report a resident-to-resident altercation between Resident #1 and Resident #2 to the Administrator and to other officials (including to the State Survey Agency, Adult Protective Services, and Metropolitan Police Department) within the required timelines per the facility's Abuse policy and federal regulations as evidenced by:A review of the facility's policy entitled, Abuse, Neglect, Exploitation, revised on 01/01/25, documented: All reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Reporting Allegations to the Administrator and Authorities, 1. If abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials, according to state law. On 09/11/25, the facility submitted a final investigation report of the incident [Incident 2621432] to the State agency that documented: Final investigation report: The result of the investigation is as follows: The daughter reported that when she visited the resident, she had noticed a discoloration below his left eye and alleged trauma/abuse that may have been caused by facility staff .During the investigation, unit staff noted that the resident, [Resident #1], was walking up and down in the hallway and was accompanied by his assigned aide, and his foot unintentionally made contact with another resident's [Name of Resident #2] foot which made [Resident #2] upset. Per the aide, she reacted quickly to put herself between the two residents and called for help, to stop both residents from fighting. Other staff members intervened and helped to redirect the residents and take [Resident #1] to his room. Per the assigned aide's statement, she immediately got in between the residents; she did not see any physical altercation between them and did not witness any direct injury to the residents. Per the charge nurse's statement, the CNA (Certified Nurse's Assistant) who supervised [Resident #1] told her that when the two residents were about to fight, she intervened immediately and called for help and no physical altercation (contact) was reported. A. Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Alzheimer's Dementia, Major Depressive Disorder, Cognitive Communication Deficit, Restlessness and Agitation, and Unspecified Psychosis.A review of Resident #1's medical record revealed: A quarterly minimum data set (MDS) assessment dated [DATE] that documented that Resident #1: had severely impaired cognitions,; displayed physical (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) for 1 to 3 days; was independent with transferring in and out of bed ,and could ambulate independently at least 150 feet in the room or in the corridor.A physician's order dated 08/28/25 at 7:00 AM that directed: Maintain resident on 1:1 every shift every shift.A physician's order dated 08/28/25 at 5:00 PM that directed: Risperdal Oral Tablet 1 mg (Risperidone) Give 1 tablet by mouth two times a day for psychosis. A physician's order dated 08/28/25 at 5:00 PM that directed: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth three times a day for mood swings. A Psych Progress Note dated 09/11/2025 that documented: Chief Complaint/Reason for this Visit: Patient seen due to other behavioral disturbance.[Name of Resident #1], who has a history of dementia and major depressive disorder, underwent a thorough evaluation today after a recent incident.During this assessment, he demonstrated alertness and stability, with no signs of agitation or aggression. Collaborating closely with the nursing team, we confidently determined that it is safe for him to remain on the unit. The incident was thoroughly reviewed and deemed an accident, not a result of intentional behavior. B. Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), Mood [Affective] Disorder, Psychoactive Substance Abuse with Psychoactive-Induced Mood Disorder. Cognitive Communication Deficit, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of Resident #2's medical record revealed: An admission minimum data set (MDS) assessment dated [DATE] that documented that Resident #1 had a Brief Interview for Mental Status (BIMS) summary score of 03, that indicating that the Resident had severely impaired cognitions. In addition, staff documented that Resident #2: had displayed behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days; and required supervision or touching assistance when ambulating.A physician's order dated 08/21/25 that directed: Namenda Oral Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth one time a day for Dementia related to Cognitive Communication Deficit.A revised care plan initiated on 03/11/25 that documented: Focus: [Resident #2's Name] has a mood problem r/t (related to) Disease Process. Goal: [Resident #2] is on Namenda oral tablet for dementia. [Resident #2] will have improved mood state (happier, calmer appearance, no s/sx (sign as and symptoms) of depression, anxiety or sadness. Interventions: .Monitor/record mood to determine if problems. A review of an SBAR (Situation, Background, Assessment and Recommendation) - Physician/ Nurse Practitioner (NP)/Physician Assistant (PA) Communication Tool dated 09/05/25 that documented: Situation: Per staff report another resident stepped on [Resident #2]'s foot and he reacted back by fighting with the resident;.Background: Metabolic Encephalopathy.Assessment: Head to toe assessment done and resident remain stable. No change in mental status.; Recommendation/Progress Note (PN): Per staff report another resident stepped on [Resident #2]'s foot and he reacted back by fighting with the resident. The staff present were able to separate both residents. Head to toe assessment done and resident remain[ed] stable. No new skin issue noted. MD and Psych NP made aware. Plan of care continued. A review of the facility's investigation packet for Incident #2621432 showed the following:1) Written Statement from Employee #6 (CNA/1:1 Monitor assigned to Resident #1 on 08/30/25), that documented: On that day I was working on 4th South when I was [asked] to float to 3 South for a one-to-one shift with [Name of Resident #1]. During the whole night the Resident (Resident #1) was sleeping. He woke up before 6:00 AM and decided to do a walking (sp.) [walk] so I have [had] to follow him. He went to his old room, but he didn't enter and then decided to walk back. He's [was] walking back to the exit door when he steps [stepped] on [Name of Resident #2]'s feet. Immediately he [Resident #2] tried to slap [Resident 3], but I was in the middle. Then I called my coworker for help. When they got there, they stopped him [Resident #2], and I took [Resident #1} back to his room. 2) A metropolitan police report dated 09/15/25 that documented CNN #25141427 Public Incident Reporting Party-1 (RP-1/Name of Facility's Director of Nursing]) . Public Narrative. On September 15th, 2025, officers responded to [Facility's Address] to complete a miscellaneous report. On scene, RP-1 [Reporting Party -1] reported that W-1 (Witness-1/Resident #1's daughter) shared images of SB-1(Subject-1/Resident #1) who had minor apparent injuries to the face. RP-1 reports that SB-1 sustained those injuries from an affray with a resident within [the] facility. No probable cause for arrest or allegation of elder abuse was found. During a telephone interview on 09/18/25 at 11:43 AM Employee #6 stated: I worked the night shift (11PM on 08/29/25 to 7:00 AM 08/30/25). I was the CNA and one-to-one (1:1) monitor assigned for Resident #1. I was walking with the Resident, at around 6:00 AM. As we turned back up the hall toward the nurses' station, I observed Resident #2 sitting in a chair near the nurses' station watching television. Resident #2 was not paying attention and did not move his feet. as me and Resident #1 were walking toward him. That is when I observed Resident #1 step on Resident #2's foot. Resident #2 then stood up and started hitting at Resident #1. I could not tell if the residents made physical contact or not, but I stepped between the two residents, and I called for help. My coworkers came to the nurses' station to assist me in separating the residents. We called the Charge Nurse who came out of the office. She followed us as we walked Resident #1 back to his room to see how he was doing, and she checked on Resident #2. Resident #1 put himself back in bed. The Resident was not observed with any bleeding or injury at that time. All of staff who worked on the floor of that shift knew what happened. I did not report the incident because I did not see the Residents make physical contact during their altercation, and since the charge nurse was aware of the incident between the residents, I thought the charge nurse would report it.During a telephone interview on 09/19/25 at 2:06 PM Employee #7 (3 South Charge Nurse not assigned to Resident #1) stated that she was in the restroom, when she heard a CNA (Employee #6) call for assistance. By the time she got to the scene, she stated that she saw Employee #6 standing between Resident #1 and #2. She also reported that another CNA (Employee #8) had arrived to assist with separating the residents. She asked Employee #6 what happened. The Employee told her that Resident #1 stepped on Resident #2's foot by mistake, and Resident #2 started hitting at Resident #1. She then stepped between the residents and called for assistance. Employee #7 further stated, I did not see the actual incident between Residents #1 and #2. I just saw Employee #6 standing between the two residents. I did not see any injuries to either of the residents, or anything to report, so I did not report the incident. A review of Resident's #1 and #2 medical records, and a review of the facility's investigation documents showed no evidence that facility staff reported the altercation between Residents #1 and #2 that occurred on 08/30/25, to the Administrator, per the facility's abuse policy. As a result, the Administrator did not report the resident-to-resident altercation to the State Survey Agency, Adult Protective Services, and Metropolitan Police Department until 09/05/25, five days after the resident-to-resident altercation. On 09/18/25 a complaint survey to investigate Incident 2621432 was initiated by the State Agency. On 09/17/25, the facility had taken several actions to address the deficient practice of not reporting incidents of unknown origin and incidents of alleged abuse. Past Non-compliance InformationDuring a face-to-face interview conducted on 09/18/25 at 12:05 PM, Employee #1 (Administrator) indicated that the facility implemented interventions on or before September 17, 2025, to address the deficient practice. On 09/05/25 the following interventions were implemented:- The facility initiated an investigation of Resident 1's injury of unknown origin (discoloration under Resident's left eye) and the staff-to-resident physical abuse allegation reported by Resident #1's representative.- Resident #1 was assessed by the Unit Manager, the DON and the Administrator. - The Medical Director was made aware of the discoloration under Resident #1's left eye. An x-ay was ordered and completed in house. The x-ray results were negative. The Medical Director also came to the facility to assess the Resident.- The nursing staff who worked day and evening shifts on unit where Resident #1 resided, were asked to provide written statements regarding discoloration under Reisdent#1's left eye. Four staff provided account of an unreported altercation that occurred on 08/30/25 between Resident #1 and #2 in their written statements.- The 1:1 monitor /CNA, and the Charges Nurses were suspended pending the facility's investigation for Resident #1's injury of unknown origin and the investigation of the unreported altercation between Resident# 1 and #2. - The Psychiatrist was notified of Resident #1 altercation with Resident #2, and both Residents were assessed by the Psychiatrist. In addition, the Psychiatrist made - Mandatory education and training in-services were conducted on abuse and reporting incidents of unknown origin, starting with evening staff on 09/05/25. - Care plans for Residents #1 and #2 were updated.- A Performance Improvement Plan (PIP) for the facility was initiated. The PIP included a root cause analysis, away to track and improve On 09/08/25 the following interventions were implemented:- Implemented an audit tool for all residents in the facility for Allegations of Abuse, Identifying and Reporting Abuse and Injuries of Unknown Origin, and Reporting Changes. 100% audit was completed for Weeks 1 with no additional concerns identified. Weekly audits were to continue thereafter for 4 weeks x 2 months.- Psychiatrist provided additional n-service training on providing care for Residents with Dementia. On 09/11/25 the following interventions were implemented:- The investigation for Incident # was completed.- Employee#4 Charge Nurse for Resident #1 was terminated for failure to report an injury of unknown origin.- Employee #6 Assigned CNA for Resident on 08/30/25 was terminated, for failure to report a resident-to-resident altercation to the Charge Nurse. On 09/17/25, 90% of all facility staff had received the in-service training on Abuse, and on 09/18/25, 100% of all facility staff had received the in-service training on, Abuse, Identifying and Reporting Abuse and Injuries of Unknown Origin, and Reporting Changes.- Corrective actions were implemented and monitored, with ongoing oversight by the QAPI committee through November 30, 2025.

Based on observation, record review, and staff and resident interview, facility staff failed to develop care plans for two (2) of nine sampled residents to address: (1) Resident #6's refusal to allow nursing staff to clean his room, including the nightstand and closet; and (2) Resident #4's use of a mechanical lift for transfer out of bed. (Residents #4 and #6). The findings included: Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including Major Depression, Adjustment Disorder, Psychoactive Substance Abuse, Alcohol Use, Generalized Muscle Weakness, and Dependence of Wheelchair. An annual Minimum Data Set assessment dated [DATE] documented in part that Resident #6's Brief Interview Mental Status summary score was coded as 14 indicating resident had an intact cognitive status. Additionally, the resident was coded for impairment of both lower extremities and independent with using a manual wheelchair. An observation on 06/02/25 at approximately 12:45 PM, showed the resident's nightstand drawers contained multiple empty liquor bottles, a bottle of Theraflu (cough syrup), and a tube of Diclofenac Sodium Topical Gel 1% (arthritis medicine). Additionally, the resident's closet was noted to have multiple dirty clothing items and multiple pieces of paper. A review of the resident's care plan lacked documented evidence that the facility developed a care plan that outlined the nursing staff's role when the resident refused to allow them to clean his room, including his nightstand and closet or make his bed. During a face-to-face interview on 06/02/25 at approximately 1PM, Employee #4 (assigned CNA) stated that she has worked with the resident for three months and she has not cleaned his nightstand or closet because he will not allow her to touch any of his things. The employee also said that the resident will not allow her to make his bed or change his linen. During a face-to-face interview on 06/03/25 at approximately 10 AM, Employee #3 (RN/Unit manager) stated that the facility's protocol is that nursing assistants will clean residents' nightstands and closets daily. However, Resident #6 will not allow nursing staff to clean his room, make his bed or change his linen. Employee #3 reviewed the resident's care plan and stated she did not see a care plan that addressed Resident #6's refusal to allow nursing staff to clean his room. 2. Resident #4 was admitted on [DATE] with multiple diagnoses including history of Falls, Muscle Weakness, and Obesity. A quarterly Minimum Data Set assessment documented in part that Resident #4's Brief Interview of Mental Status summary score was coded as 14 indicating that the resident had an intact cognitive status. The resident was coded for no impairment of both upper and lower extremities, totally dependent on staff for activities of daily living and mobility. The resident was coded as 5 feet, 6 inches in height with a weight of 316 pounds. During an observation on 06/05/25 at approximately 10AM, Resident #4 was observed lying in bed watching television. She was alert and oriented to name, place, time, and situation. At the time of the observation, the resident stated the staff gets her out of bed at least one time a week. The staff uses a mechanical lift to get her out of bed. There are at least 2 staff members helping her to get out of bed. She gets out of bed at least once a week because she has a pressure ulcer and is not allowed to sit up for long periods. It should be noted that the resident was admitted with a Stage 3 sacral pressure ulcer. During a face-to-face interview on 06/05/25 at approximately 11:50 AM, Employee #6 (CNA) stated that at least two staff members help her when she gets the resident out of bed. Additionally, they use a mechanical lift to help get the resident out of bed. During a face-to-face interview on 06/05/25 at approximately 1 PM, Employee #5 (RN/Unit Manager) reviewed the resident's care plan and stated that she did not see a care plan that addressed the use of a mechanical lift to transfer the resident out of bed.

Based on observations, record reviews, resident and staff interviews, for four (4) out of 40 sampled residents identified as smokers, facility staff failed to ensure effective and adequate supervision was provided as evidenced by the surveyor's observing residents in non-designated smoking areas with smoking paraphernalia that included cigarettes and/or lighters. Residents' #103, #117, #43, #21. Due to these failures, an Immediate Jeopardy (IJ) was identified on 11/05/24 at 12:15 PM and an IJ was called on 11/12/24 at 1:15 PM related to supervision of resident's who smoke. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on 11/12/24 at 9:25 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on 11/15/24 at 3:00 PM. After removal of the immediacy, the deficient practice was lowered to a scope and severity of E, no actual harm with the potential for more than minimal harm. The findings included: A facility policy titled 'Smoking Policy - Residents' with a review date of 11/01/24 documented: - 1. Designated Smoking area: Smoking is only permitted in designated resident smoking areas during designated smoking times and will be monitored by a staff/smoking monitor and Smoking of any kind is not allowed inside the facility under any circumstances. - Smoking agreement with the residents: An agreement/contract is issued to the residents that are deemed as smokers as per the smoking evaluation and Searches will be conducted if facility suspects that cigarettes and/or smoking materials are kept in their personal space (room) and This facility maintains the right to confiscate smoking items found in violation of our smoking policies to ensure the safety of staff and other residents and Residents are strongly discouraged from keeping any smoking items, including cigarettes, tobacco, etc., except under direct supervision. 1A. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses that included: Human Immunodeficiency Virus (HIV) Disease, Chronic Obstructive Pulmonary Disease (COPD), and Cerebrovascular Accident (CVA) with right sided weakness. A review of Resident #103's medical record revealed: A Safe Smoker assessment dated [DATE] documented, resident is a smoker. A Smoking Agreement signed and dated on 06/19/23 by Resident #103 and a Social Worker at the facility documented, All residents who wish to smoke at [Facility name] are allowed to do so, subject to the following rules: 1. You give the facility permission to search your room every shift for cigarette lighters, cigarettes and other smoking items. 8. Good safety awareness may also be defined as using smoking materials safely; and may also be defined as not giving, selling, or leaving smoking materials so that other residents may have access to them. 9. Residents/patients are not permitted to keep their cigarettes on their person or in their personal space at anytime. 11. Residents will be subject to unannounced room searches with resident/responsible party notification. 12. Residents safety awareness will be evaluated quarterly or as determined by the IDT - inter-Disciplinary Team. 15. Actions including but not limited to smoking in non-designated areas, allowing any other patient to use, borrow, buy or have access to smoking materials, or any behavior considered to exhibit poor safety awareness may result in revocation of smoking privileges. 16. Violation of this agreement or smoking contract will bring restrictions of smoking privileges or possible discharge from the facility, if behaviors present danger to others. A care plan dated 08/07/24 documented, [Resident's name] is non adherent/non-compliant to the facility smoking policies; Refusing to give cigarette and lighter to the staff on the smoking porch for safe keeping. Goal: 08/07/24 [Resident's name] will remain compliant with facility smoking policies through review date. Interventions: 08/07/24 Check room prn (as needed) for cigarettes, lighters, matches and remove and keep in designated area; Instruct to ask staff to provide/light smoking material; Observe for compliance with smoking plan. Report noncompliance or viewed unsafe practices. Reassess as needed; Staff will continue to educate/encourage resident to give cigarette and lighter for safekeeping. A Quarterly 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 Abilities and Goals that documented: one-person physical assist with bed mobility, transfers, eating and toilet use; limited range of motion/impairment on one side to upper and lower extremities, and used a motorized wheelchair for locomotion on/off the unit. During an observation on 11/05/24 from 12:15PM to 12:45PM, the State Surveyor observed an unlit cigarette on Resident #103's bedside table. During a face-to-face interview conducted on 11/05/24 at 12:50PM Employee #5 (RN) stated, I didn't know that was there. I last saw her around 10:45AM, she left for an appointment out of the facility and haven't came back to the unit that I'm aware of. Maybe she came back but no one saw her. During a face-to-face interview conducted on 11/05/24 at 12:50PM Employee #2 (DON) stated, We have to develop a different approach with her for monitoring to be more frequent, right now she's every two hours. The smoking agreement that the smoker signs gives the facility staff the right to search her room for paraphernalia every shift to check for non-compliance with smoking policy. It should be noted that the facility staff were unaware that a cigarette was in the resident's room, or how long it had been left unattended on the resident's bedside table. The cigarette was observed at the resident's bedside table for a period of 45 minutes by the State Surveyor. 1B. Resident #117 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Aphasia and Lack of Coordination. Review of the resident's medical record revealed the following: A physician's order dated 10/09/23 that directed, [Resident #117] is a Smoker. Care plan focus area: [Resident #117] is non adherent/noncompliant to the facility smoking policies, refusing to give cigarette to the staff on the smoking porch for safe keeping; [Resident #117] has a behavior of lighting his cigarette from another resident's lit cigarette while in the smoking courtyard instead of letting the smoking aide assist; [Resident #117] was put on a behavioral plan for smoking compliance, revised on 08/07/2024. Goal: [Resident #117] will remain compliant with facility smoking policies through review date. Interventions: Check room prn for cigarettes, lighters, matches and remove and keep in designated area; do not leave unattended while smoking; observe for compliance with smoking plan; report noncompliance or viewed unsafe practices. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 10, indicating moderately impaired cognitive status; and mobilized by manual wheelchair. A Smoking Agreement was signed and dated on 06/19/23 by Resident #117. A Quarterly Safe Smoker assessment dated [DATE] at 12:50 PM: - Current tobacco use, cigarettes - The interdisciplinary team (IIDT) determined that the resident is deemed a safe smoker. During an observation on 11/05/24 at 1:14 PM, Resident #117 was observed with a cigarette (unlit) in his mouth, while in the building on unit 1 south, propelling his wheelchair to the smoking area. The resident passed by multiple facility staff members who did not intercede when observing the resident with smoking paraphernalia. When the surveyor asked Resident #117 where he got the cigarette, the resident stated, I keep my own cigarettes. Once outside in the courtyard/smoking area, the surveyor and the two (2) assigned smoke monitors observed as another resident approached Resident #117 to light his cigarette. The assigned smoke monitors made no attempt to stop the residents. During a face-to-face interview conducted on 11/05/24 at 1:26PM Employee #6 (Smoking Monitor) stated, I search them before they leave the courtyard to make sure they don't have cigarettes, I check their pockets. Nobody is allowed to have a lighter or cigarettes with them. We give them two [cigarettes] in the morning, two [cigarettes] in the afternoon, and two [cigarettes] in the evening some of them take three [cigarettes]. Sometimes they smoke one [cigarette] and take the other one back in the building. 1C. Resident #43 was admitted to the facility 12/02/19 with diagnoses of Cerebrovascular Disease, Ventricular Fibrillation, Major Depressive Disorder, Congestive Heart Failure. Review of the resident's medical record revealed: A care plan focus area: [Resident #43] wishes to smoke at the facility and is assessed by the IDT as a Safe Smoker, Nicotine dependence, last revised 05/13/24. Goals: will be able to smoke safely without causing injury to themselves or others through next review date; will comply with facility smoking policy through next review date; will smoke safely in designated area and at designated times through next review date. Interventions: Resident needs supervision while smoking; courtyard (smoking) monitor to provide supervision when resident is smoking; monitor resident's room for hidden cigarette, lighter; notify Responsible/Resident Representative of noncompliant behaviors; orient the resident to facility's smoking policy, procedures, including designated smoking areas and designated smoking times; resident will not have smoking paraphernalia in the room and resident's room will be checked for smoking material every hour and compliance with smoking policy; resident/Representative has signed the smoking contract. Interdisciplinary staff will observe and assess for compliance with smoking policy and contact. A Quarterly MDS assessment dated [DATE] showed facility staff coded: a BIMS summary score of 00, indicating severely impaired cognitive status. A Smoking Agreement signed and dated on 06/19/23 by Resident #43. A Safe Smoker assessment dated [DATE] documented: - Current tobacco use, - The IDT determined the resident is deemed safe smoker. During an observation on 11/06/24 at 10:50 AM, Resident #43 was observed propelling her wheelchair to exit the facility into the facility courtyard, passing by an assigned smoke aide. When she arrived out to the smoking area, Resident #43 was observed pulling a cigarette out of the side of her wheelchair cushion, lit it with a lighter that she had and began smoking. During a face-to-face interview at the time of the observation, Employee #7 (Smoking Monitor) stated, No, I did not give Resident #43 the smoking items (cigarette and lighter). During an observation on 11/07/24 at approximately 1:30 PM Residents' #43 and #103, were observed with smoking paraphernalia outside the designated smoking area. All the observed residents were identified by the facility as smokers. During a face-to-face interview conducted on 11/07/24 at 1:45PM Employee #7 (Smoking Monitor) stated, I'm not going to fight with them (the residents) to do what they supposed to do. During a face-to-face interview conducted on 11/07/24 at 1:49PM Employee #1 (Administrator) acknowledged the findings and stated, They [the residents] are not allowed to have smoking paraphernalia (i.e., cigarettes, lighters). Sometimes they choose to do what they want despite the education. Smoking paraphernalia should be kept with the smoke aid, that's in our policy and the smoking agreement that they sign. 1D. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included Nicotine Dependence and Chronic Obstructive Pulmonary Disease. Review of the resident's medical record revealed the following: A physician's order dated 08/31/23 that directed, Encourage d/c (discontinue) smoking. A Smoking Agreement signed and dated on 06/20/23 by Resident #21 A Quarterly Safe Smoker assessment dated [DATE] at 4:08 PM - Current tobacco use, cigarettes. - The interdisciplinary team (IDT) determined that the resident is deemed safe smoker. A Quarterly MDS assessment dated [DATE] showed that facility staff coded: a BIMS summary score of 11, indicating moderately impaired cognitive function and had no functional limitations in range of motion in upper extremities. Care plan focus area: [Resident #21] is non adherent/noncompliant to the facility smoking policies; Refusing to give cigarette and lighter to the staff on the smoking porch for safe keeping, revised on 09/03/24. [Resident #21] is on a behavioral plan for smoking policy/agreement. Goal: [Resident #21] will remain compliant with facility smoking policies through review date. Interventions: Check room prn for cigarettes, lighters, matches and remove and keep in designated area. Complete smoking evaluation per facility guidelines. Do not leave unattended while smoking. Instruct family members, responsible parties or visitors about smoking guidelines prn. Instruct patients, family members, and visitors not to share lighted cigarettes, lighters or other smoking materials with other patients. Instruct to ask staff to provide/light smoking material. Observe for compliance with smoking plan. Report noncompliance or viewed unsafe practices. Reassess as needed. Staff will continue to educate/encourage resident to give cigarette and lighter for safekeeping. A physician's order dated 11/05/24 that directed, Search for smoking paraphernalia, notify the Supervisor and Provider if smoking items are found, and complete appropriate documentation, every shift. During an observation on 11/08/24 at 1:45 PM, the surveyor observed Resident #21 in the smoking area, using her lit cigarette to light the cigarette of another resident. During a face-to-face interview at the time of the observation, Employee #7 (Smoking Monitor) stated, The residents try to fight me when I ask them if they have cigarettes or anything else (lighters) on them. An Immediate Jeopardy (IJ-K) was called on 11/12/24 at 1:15 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted 11/12/24 at 9:25 PM that included the following: 1. Resident#2 l, #43, #103 and #117 were assessed by the licensed nurse between 11/06/2024 and 11/07/2024 with no new issues found. A thorough room search was done between 11/05/2024 and 11/09/2024 by the Unit Managers/designee for all the residents that smoke and the smoking paraphernalia was taken away from them and safely secured in the smoking cart. 2. Resident#21 #43 #103, #117 were educated/encouraged on 11/07/2024 and 11/08/2024 by the social services personnel on following facility's smoking agreement for smoking paraphernalia and to hand it over to the smoking monitor. Residents that are non-compliant with smoking agreement will have q shift check to ensure resident does not have any smoking paraphernalia in their possession and if found with any, it will be reported to the supervisor for further actions. 3. A new smoking assessment was completed for all smokers between 11/05/2024 and 11/07/2024 by licensed nursing personnel. The Unit Managers have ve1ified the EMR that all smoking residents' care plans had effective interventions in place. This was completed by 11/12/2024. 4. Per the smoking assessments completed, only 1 resident as of 11/12/2024 requires smoking apron and is provided with one as per the plan of care. 5. Resident council meeting was held on 11/06/2024 to review the smoking policy and smoking agreement as enforced in the facility led by the Administrator and the Activities Director. 6. The Social Services personnel/designee reiterated the policy and smoking agreement to the residents and their RP for the residents that could not participate in the resident council meeting that was held on 11/06/2024 and for the residents that lack the capacity to understand the policy. This was completed by 11/12/2024. 7. A sign is posted on the smoking area, the security desk and entrance doors to remind residents, family members and visitors not to bring in cigarettes or any smoking paraphernalia before reente1ing the facility and to hand these items back to the staff. Residents that smoke, who go on leave of absence from the facility, are informed per signage at the front door and security desk to ensure that any smoking paraphernalia is turned in to the security staff. 8. A robo-call/auto text was done on 11/05/2024 for all resident family members to ensure they tum over smoking materials to the security personnel. 9. Rooms of residents identified as smokers will be inspected per the smoking agreement, daily, to ensure no smoking paraphernalia are present. The auditor will notify the supervisor, attempt to immediately confiscate the item to store or destroy it approp1iately. If unable to confiscate the smoking paraphernalia immediately, depending on the item (lighter or cigarettes) monito1ing for compliance will be enhanced (increased frequency of checks eg. Qshift/ Q hour/Q 15mins or 1:1 until compliance is achieved). The interdisciplinary team will determine if frequency of room checks will be reduced for residents that are consistently compliant with the smoking agreement. 10. Education will be completed by the Staff Educator/Development for all staff to review the Smoking Policy and Procedures and on ensuring that cigarettes and any smoking paraphernalia are not kept in resident room. 100% Compliance achieved on 11/11/2024. The Staff Educator/Development will ensure that any staff that has not received their education by 11/11/24 will receive it before resuming work. 11. Education will done by the Staff Educator by 11/13/2024 for the smoking monitors regarding their responsibilities to assist residents, safeguarding the smoking materials, assist with lighting their cigarettes, offer apron to those who need it, ensuring they offer only 1 cigarette at a time, and to report non-compliance of turning in smoking paraphernalia to the security/supervisor. 12. An ongoing audit of the smoking resident's compliance to the proper storing of smoking paraphernalia per the smoking agreement will be done by the Administration/designee. This audit began on 11/07/2024 will be conducted daily x 1-week, weekly x 4, monthly x2. Any issues found will be addressed immediately, if any prohibited items are found, the auditor will notify the supervisor, attempt to immediately confiscate the item to store or destroy it appropriately. If unable to confiscate the smoking paraphernalia immediately, depending on the item (lighter or cigarettes) monito1ing for compliance will be enhanced (increased frequency of checks eg. Q shift/ Q hour/ Q 15mins or 1:1 until compliance is achieved). The interdisciplinary team will determine if frequency of room checks will be reduced for residents that are consistently compliant with the smoking agreement. Upon discovery and will be reported to the QAPI committee. If there is non-compliance with the smoking agreement is observed, the length of audit will be extended per the interdisciplinary team to achieve substantial compliance with the smoking agreement. 13. The Smoking Policy has been updated as of 11/12/2024 to reflect that smoking aprons will be offered and provided only to residents who need them as determined by their most recent smoking assessment. 14. The Administrator/Designee will conduct random audits of the smoking cart and smoking area 3x per week x 4 weeks to ensure that resident's cigarettes, resident lighters and facility provided lighters are stored in the cart. 15. The results of the monitoring and care plan review completed under this action plan are submitted to the QA/QI Committee for review and follow-up monthly. Our date of compliance will be 11/13/2024. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on 11/15/24 at 3:00 PM.

Based on observations made during an environmental walkthrough of the facility on November 20, 2024, between 11:30 AM, and 1:00 PM, facility staff failed to maintain resident call bells in good condition as evidenced by call bells in two (2) of 23 resident rooms, and in two (2) of three (3) shower rooms that did not initiate an alarm when tested; and failed to provide a call system to Resident #39 that was adequately equipped to allow the resident to call for staff assistance from the resident's bedside. The findings included: 1. Call bells in two (2) of 23 resident rooms (#324 A, 401A), did not alarm when tested, 2. Call bells in two (2) of three (3) shower rooms on unit 2 South did not alarm when tested. Employee #10 acknowledged the findings during a face-to-face interview on November 20, 2024, at approximately 4:00 PM. 3. Facility staff failed to provide a call system to Resident #39 that was adequately equipped to allow the resident to call for staff assistance from the resident's bedside. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Gastrostomy Status, Schizophrenia, Seizures, Pressure Ulcer of Sacral Region Stage 4 and Anemia. A review of a Facility Reported Incident (FRI) DC#00012152, submitted to the State Agency on 08/01/23, documented the following: On rounds resident was observed lying on the floor in her room beside her bed with nonskid socks on. Upon assessment, the resident was noted with a small laceration on the left eyebrow measuring 7 x (times) 4 cm (centimeters) with moderate bleeding. The area was cleaned with normal saline, pat dry and pressure dressing applied. Resident could not verbalize what happened. Review of Resident # 39's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the facility staff coded the resident as having moderately impaired cognition. The facility staff coded Resident #39 as requiring substantial/maximal assistance-helper does more than half for all of the following: Toileting, Shower/Bath, Personal Hygiene, Oral Hygiene, Upper and Lower Body Dressing. During an observation conducted on 11/25/24 at approximately 2:50 PM, Resident #39 was observed lying in bed with the head of bed elevated and the call light was observed laying on the floor underneath the resident's bed. Staff were immediately notified. Staff placed the call light on the resident's bed and pressed the call light button to show the surveyor that it worked. The call light button did not work and was defective. During an Interview conducted at the time of observation with Employee #25 (1 South Unit Manager) stated that she will call the engineering technician to get Resident #39's call light replaced. During a face-to-face interview conducted on 11/25/24 at approximately 3:10 PM, Employee #30 (Engineering Technician) stated that he was there to replace the call light.

Based on observations and staff interview, facility staff failed to maintain essential mechanical and electrical equipment in safe condition. The findings included: 1. One (1) of two (2) food warmers failed to reach an internal set temperature of 180 degrees Fahrenheit. The internal temperature when tested was 96 degrees Fahrenheit. 2. Three (3) of six (6) burners from the one (1) of two (2) gas range stove did not light up when tested. Employee #11 acknowledged the findings during a face-to-face interview on November 19, 2024, at approximately 11:00 AM.

Based on observations and staff interview, facility staff failed to serve foods under sanitary condition, causing possible risk of infection. The findings included: During observations in dietary services on November 12, 2024, and November 15, 2024, at approximately 11:00 AM: 1. Staff failed to ensure that pellet warmers on the tray line were dry before using them to help maintain resident's food at an acceptable temperature. 2. Water leaked from the ceiling in the dishwashing machine room. Employee #11 acknowledged the findings during a face-to-face interview on November 19, 2024, at approximately 11:00 AM.

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions. The findings included: During observations in dietary services on November 12, 2024 and November 15, 2024, at approximately 11:00 AM, the following issues were identified: 1. One (1) of two (2) food warmers failed to reach an internal set temperature of 180 degrees Fahrenheit (F). The internal temperature when tested was 96 degrees Fahrenheit (F). 2. The lids to four (4) of seven (7) steam table pans used on the tray line, were missing a handle. 3. The handle to two (2) of seven (7) steam table pan lids were loose. 4. Staff failed to ensure that pellet warmers on the tray line were dry before using them to help maintain resident's food at an acceptable temperature. 5. Water leaked from the ceiling in the dishwashing machine room. 6. Ceiling tiles grids located above the dishwashing machine room were rusty. 7. The drainpipe from one (1) of one (1) two-compartment sink in the dishwashing machine room was leaking. 8. The floor in the dish machine room was stained throughout. 9. Three (3) of six (6) burners from the one (1) of two (2) gas range stove did not light up when tested. 10. The hot water knob from the handwashing sink in dishwashing machine room was broke. Employee #11 acknowledged the findings during a face-to-face interview on November 19, 2024, at approximately 11:00 AM.

Based on record review and staff interview, for one (1) of 75 sampled residents, facility staff failed to follow the physician's order for narcotic pain administration. Resident #229. The findings included: Review of the facility's Physician Medication Orders policy dated 11/01/24 documented: - Medications shall be administered only upon the written order of a person licensed to prescribe such medications. Resident #229 was admitted to the facility on [DATE] with multiple diagnoses that included: Pain, Malignant Neoplasm of Left Female Breast, and Neoplasm Related Pain. Review of the resident's medical record revealed the following an admission Minimum Data Set (MDS) assessment dated [DATE] showing facility staff coded: clear speech; clear comprehension of others; able to make self-understood; received scheduled and as needed pain medication and received opioid medications in the last seven (7) days. A physician's order dated 11/25/24 directed, Hydromorphone (narcotic pain reliever) 2 milligrams (mg), give one (1) tablet by mouth every 4 hours as needed for chronic pain due to Malignant Neoplasm of Left Female Breast. During a narcotic count on 11/26/24 at 1:41 PM on unit 3 north with Employee #19 (Licensed Practical Nurse/LPN), Resident #229's Hydromorphone blister packet showed that it had 4 remaining tablets, and the Controlled Drug Administration Record sheet showed that the employee documented that Resident #229 was administered the Hydromorphone 2 mg, two (2) tablets on 11/26/24 at 11:15 AM. Review of Resident #229's physician's orders with Employee #19 revealed that the resident had no active order to administer Hydromorphone 2 mg, two tablets. When asked why she administered Hydromorphone 2 mg, two tablets instead of the ordered one tablet to Resident #229, Employee #19 did not provide an answer. The evidence showed that Employee #19 failed to follow the physician's order of administering 1 tablet of Hydromorphone 2 mg to Resident #229. It should be noted that Resident #229 did not suffer any harm or adverse effects from being administered the two tablets of Hydromorphone 2 mg. Cross Reference 22B DCMR Sec. 3225.1

Based on observations, record reviews and staff interviews for one (1) of 75 sampled residents, the facility staff failed to implement a comprehensive person-centered care plan for Resident #175 as evidenced by the staff failing to implement the residents falls care plan intervention to place the residents bed in the lowest position. (Resident #175) The findings included: Resident #175 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Displaced Fracture of Base of Neck of Right Femur, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting the Right Dominant Side, and Repeated Falls. Review of Resident #175's medical record revealed the following: [Care Plan] focus area initiated on 03/27/24 documented (Resident #175) is at risk for falls r/t (related to) muscle wasting and atrophy not elsewhere classified, multiple sites, muscle weakness, had the following interventions initiated on 03/27/24 anticipate and meet the residents needs, bed in lower position and follow facility fall protocol. A review of a Facility Reported Incident (FRI) DC#00013084 submitted to the State Agency on 08/28/24 at 8:53 AM, documented the following: On 8/26/24, the CNA (certified nurse aide) further stated that just about 5 minutes after he left resident's room, he heard a loud scream help, help. He rushed to the resident's room and observed the resident laying on his right side on the floor close to his bed. The MD (medical doctor) ordered the resident to be transferred to the hospital for further evaluation due to a laceration on the right eye Resident returned to the facility on 8/28/24. Upon review of the hospital paperwork and the medical director consulted and confirmed the meaning of the diagnostics studies with the radiologist, was noted that he had an acute over chronic subdural hematoma. Resident has a history of subdural hematoma due to falls prior to initial admission A review of a Facility Reported Incident (FRI) DC#00013161 submitted to the State Agency on 09/27/24 documented the following: Resident was on every hour rounding due to high risk of falling. Today at about 3pm, during routine round to resident room, resident was noted on the floor, fall documentation and neuro-check was initiated and upon pain assessment, resident complained of a right hip pain, (Medical Doctors name) was notified, and he gave an order for an X-ray of right-hip to be done. The x-ray was done on the resident and the result came in at 11pm noticeable of Mildly displaced acute right transcervical versus [NAME] (sp) cervical femoral neck fracture. The hips are congruent with mild joint space loss. Resident has been transferred to the nearest ER. During an observation conducted on 11/22/24 at 2:00 PM, Resident #175 was observed laying in a hospital style bed in his room with the head of the bed raised approximately 45 degrees and the entire bed was elevated at the highest height from the ground. A face-to-face interview was conducted at the time of observation with Employee #25 (1 South Unit Manager) who acknowledged the finding and who was observed by the surveyor lowering Resident #175's bed to the lowest position. During a face-to-face interview conducted on 11/27/24 at 3:30 PM, Employee #35 (Director of Quality) stated that they are reeducating staff, and disciplinary actions have improved performance. Cross Reference 22B DCMR 3210.4 (a)

Based on record reviews and staff interviews for four (4) of 75 sampled residents the facility staff failed to notify the State agency of allegations of abuse or neglect as evidenced by the following: a resident to resident altercation with injuries not being reported in the required 2-hour timeframe,a report of an unusual incident involving a resident who was found unresponsive and administered Naloxone by staff and an incident where a resident alleged he was handled roughly by a certified nurse aide. (Residents #24, #216, #412 and #56) The findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and investigations with a revision date of 01/24 documented the following: All reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The administrator or designee reports the suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Law enforcement officials; The resident's attending physician; and the facility medical director. Immediately is defined as: Within 2 hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury 1) The facility staff failed to notify the State Agency of a resident-to-resident altercation in the required timeframe for Resident #24 and #216. 1A) Resident #24 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Chronic Diastolic Congestive Heart Failure, Schizophrenia, Unspecified Dementia, Major Depressive Disorder and Tobacco Use. A review of a Facility Reported Incident (FRI) submitted to the State Agency on 10/26/23 at 10:13 AM, documented the following: Notified of resident-to-resident altercation. One of the resident transferred to the hospital for evaluation. Investigation initiated A review of Resident #24's medical record revealed the following: [Alert Note] dated 10/26/23 at 2:09 AM, A staff heard someone yelling for help and when staff went into the first floor dinning area observed this resident (Resident #24) hitting his roommate in the first floor dining room, with a chair. [Alert Note] dated 10/26/23 at 2:10 AM, Resident stated that he left his room to avoid excalation (sp) of argument between him and his roommate but his roommate followed him into the dining room and proceeded to engage him in coversation (sp) again. [Physicians Progress Note] dated 10/26/24 at 2:29 PM Last night, (Resident #24) attacked another resident with a chair, which is a change from his baseline, as he has not attacked other residents previously. (Resident #24) continues to be resistant to care, and requires psychotropic medication, which he has refused. Interview attempt was unsuccessful as (Resident #24) became irritable, aggressive, and threatened harm to me. Based on this presentation, I believe that (Resident #24) requires a higher level of care than we can provide at this time, and would best benefit from treatment in inpatient psychiatric care for stabilization of his aggressive behavior, as well as work-up and treatment of chronic medicalconditions (sp). Discussion of the case was performed with another psychiatrist, (Doctors name) who is in agreement with this assessment and plan. Based on the above exam and presentation, I plan to file an FD-12 (admission record for emergency mental health observation and diagnosis) application for hospitalization for (Resident #24). 1B) Resident #216 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Left Dominant side, Memory Deficit Following Other Cerebrovascular Disease, and Other seizures. Review of Resident #216's medical record revealed the following: [Alert Note] dated 10/26/23 at 1:16 AM Resident stated that his roommate had an argument with him in their room, however his room mate left the room and when he saw him in the dinning room he went to speak to him but roommate used some foul language on him and picked up a chair and hit him twice on his forehead and back of his head as well. [Alert Note] dated 10/26/23 at 1:17 AM, documented Head to toe assessment done, resident observed with some bruising to his face, multiple areas of laceration to his right, left cheek,and neck, and contusions to scalp, back of the head, reports pain 2/10, he remained alert awake oriented, verbal with clear speech, MDnotified (sp), 911 called, police arrived, officer (Officer's Name) and her team arrived at the facility to take his statement/interview him and advised him to decide if he wants to press charges, case number 23-176 121 given, and he was taken to (hospital abbreviation name) for further examination and treatment per MD orders. [Nurse Progress Note] dated 10/26/23 at 7:39 AM, documented Resident was engaged in a fight with his roommate (sp) last night at about 23:00AM (11:00 PM), per report. Assessment done,resident substained some skin bruises to his face. 911 and EMS (emergency medical services) called, resident was transfer to (Hospital abbreviation). A review of Resident #216's hospital Discharge summary dated [DATE] at 5:01 PM, documented the following: Discharge Diagnoses DKA (Diabetic Ketoacidosis), Facial Contusion, Assault. Presentation and Hospital Course presented to ED (emergency room) after reported involvement in a fight with his roommate in his nursing facility. Pt (patient) presented with right facial bruising/swelling, though pt (patient) is a poor historian and a full history was unable to be obtained from the patient Review of the facility's incident investigation revealed that the facility staff submitted the notification of this incident to the State Agency on 10/26/23 at 10:13 AM. There was a resulting harm from the incident that was first documented at 2:09 AM on 10/26/23, The facility therefore did not submit a notification of this incident within the required 2 hour timeframe. During a face-to-face interview conducted on 11/19/24 at 12:44 PM, Employee #25 (1 South Unit Manager) stated that she was not certain why the incident was not reported to the State Agency in the required timeframe and that the supervisor who sent the report no longer works at the facility. 2) The facility staff failed to report an unusual incident involving Resident #412 who was found unresponsive and administered Naloxone (opioid antagonist) by staff, to the State Agency in the required time frames. Resident #412 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Multiple Fractures Ribs Unspecified Side Subsequent Encounter for Fracture with Routine Healing, Traumatic Subcutaneous Emphysema, Other Pneumothorax, Alcohol Abuse, History of Falling, Cocaine Use, Cannabis Dependence, and Other Chronic Pain. A review of a Facility Reported Incident (FRI) was submitted by the facility to the State Agency on 03/11/21 at 5:04 PM, documented the following: On 3/9/2024 Resident was received alert and verbally responsive in his wheelchair. At about 6:00 pm the charge nurse was called by assign CNA (certified nurse aide) that resident is sitting in his wheelchair in his room with his head bent down. Charge nurse went there and saw resident in a deep sleep and looking drowsy unable to say what happen. Residents were put back to bed and made comfortable, head of bed elevated to improve breathing. V/S (vital signs) within normal range. The supervisor made aware came on the unit. MD (medical doctor) was made aware, Naloxone (opioid antagonist) 0.4 mg(milligrams)/ml (milliliters) intramuscular via left deltoid was given from the emergency kit and O2 2 L/m(liters per minute) via N/C (nasal canula) was also administered per MD order. A review of Resident #412's medical record revealed the following: Review of the MAR (Medication Administration record) showed that Resident #412 was administered Naloxone HCl (Opioid Antagonist) Injection Solution 0.4 MG/ML (milligrams/milliliter) (Naloxone HCl) (opioid antagonist) Inject 0.4 ml intramuscularly one time only for Drug overdose until on 03/09/24 at 7:35 PM. [Progress Note] dated 03/09/24 at 10:05 PM documented Resident was received alert and verbally responsive in his wheelchair. About 6:00 pm writer was called by assign CNA (certified nurse aide) that resident is sitting in his wheelchair in his room with his head bent down. Writer went there, and saw resident in a deep sleep and looking drowsy unable to say what happen. Resident was put back to bed to be made comfortable. V/S (vital signs) within normal range. Supervisor made aware came on the unit. Naloxone (opioid antagonist) 0.4 mg/ml intramuscular via lift deltoid was given from the emergency kit. PRN SPO2(Oxygen saturation) 2L/hr (Liters per hour) via N/C (nasal canula) was also initiated. MD (medical doctor) was notified. Pharmacy called to replace emergency kit. Resident is self RP (representative). All due medications given as ordered. P O (by mouth) fluid encouraged. Skin is warm and dry to touch. Lying comfortable in his room with call light within his reach and bed in the lowest position. Denied pain at this time. Will continue to monitor. [SBAR-(Situation Background Assessment Recommendations) -Physician/NP (Nurse Practitioner) PA (Physician Assistant) Communication Tool] dated 03/11/24, documented Resident was received alert and verbally responsive in his wheelchair. About 6:00 pm charge nurse was called by assign (ed) (sp) CNA (certified nurse aide) that resident is sitting in his wheelchair in his room with his head bent down. charge nurse went there and saw resident in a deep sleep and looking drowsy unable to say what happen. Resident was put back to bed to be made comfortable. V/S (vital signs) within normal range. Supervisor made aware came on the unit. MD (medical doctor) made aware, naloxone 0.4mg(milligram)/ml (milliliter) intramuscular via left deltoid was given from the emergency kit and SPO2 (oxygen saturation) 2 L/M (liters per minute) via N/C (nasal canula) administered per MD's order. It is noted that the above SBAR Progress note documents the incident occurred on 03/09/24. The facility staff submitted the incident to the State Agency on 03/11/24 at 3:52 PM. During a face-to-face interview conducted on 11/25/24 at 3:40 PM, Employee #25 (1 South Unit Manager) stated that the incident happened on the weekend and when they (unit manager) came in on Monday they sent the report in then. Employee #25 acknowledged the finding and stated that the facility policy was not followed. Cross Reference 22B DCMR 3232.4 3. Facility staff failed to report to the State Agency an incident where Resident #56 alleged that he was handled roughly by a Certified Nurse's Aide (CNA). Resident #56 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Respiratory Failure, Malignant Neoplasm of Lower Gum and Mouth, and Dysphagia. Review of the resident's medical record revealed the following: A Modified admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: no speech; makes self-understood; able to understand others; a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognitive response; and no potential indicators of psychosis. A Resident - Family Complaint Form (facility's grievance form) document dated 07/15/24 documented: - [Resident #56] is the person initiating the report. - Date of incident: 07/15/24; date report completed 07/15/24. - Name of person receiving complaint: Employee #18 (Unit 2 north/south Social Worker) and Employee #17 (2 north Unit Manager). - Complaint: [Employee #18] and [Employee #17] interviewed resident at bedside concerning a complaint he made about his care received. He stated that the aide handled him roughly during ADL (activities of daily living) care. He also stated that she appeared to be in a hurry. He stated ADL was being done while the respiratory therapist was providing trach care. He stated, 'It was too much on me.' - Investigation report: Social Worker and Nurse Manager interviewed resident at bedside and addressed his concerns about care received. Resident was reassured that all residents needs will be met in a timely manner, and he will be treated with dignity and respect. - Action Initiated: Staff in-service on providing gentle care during ADLs (activities of daily living). To also treat residents with dignity and respect. - Disposition: Staff education good. Unit Manager noted the issue and notified the resident. - Signed and dated by Employee #1 (Administrator) on 07/15/24. A face-to-face interview was conducted on 11/22/24 at 9:28 AM with Employee #18 and Employee #17. The following was stated: - Employee #17, We talked with him (Resident #56) at the bedside and provided him assurance about educating the staff about answering call lights, treating residents with respect and dignity, and handing the residents. I did not talk to the respiratory therapist, try to identify the aide who handled him roughly or get statements from them regarding what happened. Reports that get reported to the DOH are allegations of abuse, neglect, hitting a resident, verbal abuse, taking a resident's belongings. I wouldn't call a resident telling me that they were handled roughly abuse. - Employee #18 stated, I feel the same, I don't consider being 'roughly handled' to be abuse. During a face-to-face interview on 11/22/24 at 4:09 PM, Employee #1 (Administrator) stated, When an allegation of abuse is made and we can't pinpoint exactly when the alleged abuse occurred, we interview staff who worked the last 72 hours or more if needed to try to catch it. Being 'handled roughly by an aide' is not necessarily an allegation of abuse. What we do is look at circumstances, interview the resident with follow-up questions and do an initial inquiry to know which route to take as far as reporting to DOH and education to the staff. When asked did the facility identify or try to identify the aide or interview the respiratory therapist mentioned in the grievance, the employee stated, No. The findings showed that Resident #56 filed a grievance and reported to facility staff that an incident occurred where he alleged the aide handled him roughly during ADL care and that it was too much on me. However, facility staff did not consider the allegation abuse and therefore failed to report it to the State Agency or investigate. Cross Reference 22B DCMR Sec. 3232.4

Based on record reviews and staff interviews, for three (3) of 75 sampled residents, the facility staff failed to implement its own written policies and procedures for reporting allegations of abuse or neglect in the required timeframes for three residents. (Residents' #24, #216, and #412) The findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and investigations with a revision date of 01/24 documented the following: All reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The administrator or designee reports the suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Law enforcement officials; The resident's attending physician; and the facility medical director. Immediately is defined as: Within 2 hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury 1) The facility staff failed to follow its policy to notify the State Agency of a resident-to-resident altercation in the required timeframe for Resident #24 and #216. 1A) Resident #24 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Chronic Diastolic Congestive Heart Failure, Schizophrenia, Unspecified Dementia, Major Depressive Disorder and Tobacco Use. A review of a Facility Reported Incident (FRI) submitted to the State Agency on 10/26/23 at 10:13 AM, documented the following: Notified of resident-to-resident altercation. One of the resident transferred to the hospital for evaluation. Investigation initiated A review of Resident #24's medical record revealed the following: [Alert Note] dated 10/26/23 at 2:09 AM, A staff heard someone yelling for help and when staff went into the first floor dinning area observed this resident (Resident #24) hitting his roommate in the first floor dining room, with a chair. [Alert Note] dated 10/26/23 at 2:10 AM, Resident stated that he left his room to avoid excalation (sp) of argument between him and his roommate but his roommate followed him into the dining room and proceeded to engage him in coversation (sp) again. [Physicians Progress Note] dated 10/26/24 at 2:29 PM, Last night, (Resident #24) attacked another resident with a chair, which is a change from his baseline, as he has not attacked other residents previously. (Resident #24) continues to be resistant to care, and requires psychotropic medication, which he has refused. Interview attempt was unsuccessful as (Resident #24) became irritable, aggressive, and threatened harm to me. Based on this presentation, I believe that (Resident #24) requires a higher level of care than we can provide at this time, and would best benefit from treatment in inpatient psychiatric care for stabilization of his aggressive behavior, as well as work-up and treatment of chronic medicalconditions (sp). Discussion of the case was performed with another psychiatrist, (Doctors name) who is in agreement with this assessment and plan. Based on the above exam and presentation, I plan to file an FD-12 (admission record for emergency mental health observation and diagnosis) application for hospitalization for (Resident #24). 1B) Resident #216 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Left Dominant side, Memory Deficit Following Other Cerebrovascular Disease, and Other seizures. Review of Resident #216's medical record revealed the following: [Alert Note] dated 10/26/23 at 1:16 AM Resident stated that his roommate had an argument with him in their room, however his room mate left the room and when he saw him in the dinning room he went to speak to him but roommate used some foul language on him and picked up a chair and hit him twice on his forehead and back of his head as well. [Alert Note] dated 10/26/23 at 1:17 AM, documented, Head to toe assessment done, resident observed with some bruising to his face, multiple areas of laceration to his right, left cheek,and neck, and contusions to scalp, back of the head, reports pain 2/10, he remained alert awake oriented, verbal with clear speech, MDnotified (sp), 911 called, police arrived, officer (Officer's Name) and her team arrived at the facility to take his statement/interview him and advised him to decide if he wants to press charges, case number 23-176 121 given, and he was taken to (hospital abbreviation name) for further examination and treatment per MD orders. [Nurse Progress Note] dated 10/26/23 at 7:39 AM, documented, Resident was engaged in a fight with his roommate (sp) last night at about 23:00AM (11:00 PM), per report. Assessment done,resident substained some skin bruises to his face. 911 and EMS (emergency medical services) called, resident was transfer to (Hospital abbreviation). A review of Resident #216's hospital Discharge summary dated [DATE] at 5:01 PM, documented the following: Discharge Diagnoses DKA (Diabetic Ketoacidosis), Facial Contusion, Assault. Presentation and Hospital Course presented to ED (emergency room) after reported involvement in a fight with his roommate in his nursing facility. Pt (patient) presented with right facial bruising/swelling, though pt (patient) is a poor historian and a full history was unable to be obtained from the patient Review of the facility's incident investigation revealed that the facility staff submitted the notification of this incident to the State Agency on 10/26/23 at 10:13 AM. There was resulting harm from the incident and there is no documented evidence that the facility staff notified the State Agency in the required two hour timeframe. During a face-to-face interview conducted on 11/19/24 at 12:44 PM, Employee #25 (1 South Unit Manager) stated that she was not certain why the incident was not reported to the State Agency in the required timeframe and that the supervisor who sent the report in late no longer works at the facility. 2) The facility staff failed to follow its policy to report an unusual incident involving Resident #412 who was found unresponsive and administered Naloxone (opioid antagonist) by staff, to the State Agency in the required time frames. Resident #412 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Multiple Fractures Ribs Unspecified Side Subsequent Encounter for Fracture with Routine Healing, Traumatic Subcutaneous Emphysema, Other Pneumothorax, Alcohol Abuse, History of Falling, Cocaine Use, Cannabis Dependence, and Other Chronic Pain. A review of a Facility Reported Incident (FRI) was submitted by the facility to the State Agency on 03/11/21 at 5:04 PM, documented the following: On 3/9/2024 Resident was received alert and verbally responsive in his wheelchair. At about 6:00 pm the charge nurse was called by assign CNA (certified nurse aide) that resident is sitting in his wheelchair in his room with his head bent down. Charge nurse went there and saw resident in a deep sleep and looking drowsy unable to say what happen. Residents were put back to bed and made comfortable, head of bed elevated to improve breathing. V/S (vital signs) within normal range. The supervisor made aware came on the unit. MD (medical doctor) was made aware, Naloxone (opioid antagonist) 0.4 mg(milligrams)/ml (milliliters) intramuscular via left deltoid was given from the emergency kit and O2 2 L/m(liters per minute) via N/C (nasal canula) was also administered per MD order. A review of Resident #412's medical record revealed the following: Review of the MAR (Medication Administration record) showed that Resident #412 was administered Naloxone HCl (Opioid Antagonist) Injection Solution 0.4 MG/ML (milligrams/milliliter) (Naloxone HCl) (opioid antagonist) Inject 0.4 ml intramuscularly one time only for Drug overdose until on 03/09/24 at 7:35 PM. [Progress Note] dated 03/09/24 at 10:05 PM documented, Resident was received alert and verbally responsive in his wheelchair. About 6:00 pm writer was called by assign CNA (certified nurse aide) that resident is sitting in his wheelchair in his room with his head bent down. Writer went there, and saw resident in a deep sleep and looking drowsy unable to say what happen. Resident was put back to bed to be made comfortable. V/S (vital signs) within normal range. Supervisor made aware came on the unit. Naloxone (opioid antagonist) 0.4 mg/ml intramuscular via lift deltoid was given from the emergency kit. PRN SPO2(Oxygen saturation) 2L/hr (Liters per hour) via N/C (nasal canula) was also initiated. MD (medical doctor) was notified. Pharmacy called to replace emergency kit. Resident is self RP (representative). All due medications given as ordered. P O (by mouth) fluid encouraged. Skin is warm and dry to touch. Lying comfortable in his room with call light within his reach and bed in the lowest position. Denied pain at this time. Will continue to monitor. [SBAR-(Situation Background Assessment Recommendations) -Physician/NP (Nurse Practitioner) PA (Physician Assistant) Communication Tool] dated 03/11/24, documented, Resident was received alert and verbally responsive in his wheelchair. About 6:00 pm charge nurse was called by assign (ed) (sp) CNA (certified nurse aide) that resident is sitting in his wheelchair in his room with his head bent down. charge nurse went there and saw resident in a deep sleep and looking drowsy unable to say what happen. Resident was put back to bed to be made comfortable. V/S (vital signs) within normal range. Supervisor made aware came on the unit. MD (medical doctor) made aware, naloxone 0.4mg(milligram)/ml (milliliter) intramuscular via left deltoid was given from the emergency kit and SPO2 (oxygen saturation) 2 L/M (liters per minute) via N/C (nasal canula) administered per MD's order. It is noted that the above SBAR Progress note documents the incident occurred on 03/09/24. The facility staff submitted the incident to the State Agency on 03/11/24 at 3:52 PM. During a face-to-face interview conducted on 11/25/24 at 3:40 PM, Employee #25 (1 South Unit Manager) stated that the incident happened on the weekend and when they (unit manager) came in on Monday they sent the report to the Department of Health (State Agency) on Monday. Employee #25 acknowledged the finding and stated that the facility's policy was not followed.

Based on record review and staff interview for one (1) of 75 sampled residents, facility staff failed to provide adequate supervision and intervention to prevent one resident's aggressive behavior towards others from escalating as evidenced by a resident-to-resident altercation in the courtyard and subsequently, one resident sustaining an injury. (Residents #220 and #222) Findings include: Review of a facility-reported incidents showed the following altercations involving Resident #222 and #220. A. Resident #222 was admitted to the facility on [DATE] with the diagnosis of COPD [Chronic Obstructive Pulmonary Disease], HIV [Human Immunodeficiency Virus], Chronic Viral Hepatitis C, Asthma, Vitamin D Deficiency, Unspecified, Malignant Neoplasm of Endocervix, Low Back Pain, Muscle Weakness, Anemia, and Hypertension. Review of Resident #222's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded a BIMS [Brief Interview for Mental Status] summary score of 11, indicating moderate cognitive impairment, no potential indicators of psychosis, no physical or verbal symptoms, Supervision with set-up help only for ADL's [activity of daily living], and no limitations in range of motion. B. Resident #220 was admitted to the facility on [DATE] with a diagnosis of Paranoid schizophrenia, status epilepticus, acute hypoxic respiratory failure secondary to status epilepticus requiring intubation and sedation, acute delirium and essential hypertension. Review of Resident #220's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed he is self-ambulatory without the use of an assistive device. The residents have a BIMS summary Score of 06 indicating severe cognitive impairment. Section E (Behavior) Physical behavior's symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others coded as 1 indicating behaviors of this type occurred 1 to 3 days. Other behavior symptoms not directed toward others (physical syndrome such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing body wastes, or verbal/vocal symptoms like screaming disruptive sounds) coded as 2 indicating behavior of this type occurred 4 to 6 days but less than daily. Has the resident wandered coded 2 indicating behaviors of this type occurred 4 to 6 days but less than daily, Section G (Functional Status) Bed mobility, Transfer, locomotion on unit, locomotion off unit self-performance coded Supervision with one-person physical assist. Review Resident #220's Care Plan initiated on 7/27/2023 with Focus area: Resident is a smoker. Goal: Resident will not smoke without supervision. Intervention: Instruct the residents about the facility policy: location, times, and safety concerns. A nurses note dated 07/27/2023 14:15 documented, Resident #220 very upset. Exhibited verbal and physical behavior. Resident yelling at staff and other residents at will. Thrust fits with force and anger. Resident indicated that he wants to leave this place right now, kicking at the door, unapproachable, physically thrust soda bottle at CNA [certified Nursing Assistant] head and aiming to slap residents in the face. lifting chairs to throw and pushing tables in dining area. Resident takes off shoe and throw at resident and staff. Resident inconsolably. Subjective: Resident throws food/food trays on the floor/walls. Knocks residents 'drinks on the floor. Objective: He states verbatim. He wants everyone to die. He hates it here. He wants no food to eat. He wants to go home now. Contacted supervisor about behavior, contact the security for safety of staff and residents, Place residents in room area x [time] 1 CNA to monitor resident. Resident remains physically, verbally, and aggressive, Resident was seen by [Psych] on 7/22/23 (psychogeriatric services) for evaluation of mental status/adjust medication for behavioral disturbances. All medication was taken as directed. Review of the Physician Orders showed the following orders for Psychotropic medications for Resident #220: -7/21/23 Abilify (Aripiprazole) 10mg tablet Give 1 tablet by mouth at bedtime for Schizophrenia; -8/1/23 Ativan (Lorazepam) 0.5mg tablet Give 1 tablet by mouth two times a day for Anxiety ' -8/9/23 Ativan (Lorazepam) injection solution 2mg/ml, inject 2mg intramuscularly every 8hrs [hours] as needed for anxiety. Resident #220's August 2023 Medication Administration record revealed the following: -Ativan 0.5 mg by mouth was discontinued on 8/9/23. -Ativan 2mg injection to be started on 8/9/23, the spaces for 8/9, 8/10, 8/11, 8/12, and 8/13 allotted for Medication given were left blank indicating not given for 5 days. -Ativan injection 2mg [milligram] intramuscular was then given on 08/14/23 at 0107. Review of a facility reported incident (DC00012197) reported on 08/15/2023 at 09:50 AM to the state agency revealed, [Residnet #222] verbalized that another resident allegedly hit her on her left forearm while she was trying to get through the door at the courtyard. On head-to-toe assessment, the resident complained of pain to his [her] left forearm and rated pain 04/10 on a scale of 0-10. On further assessment, no swelling, bruising, discoloration, redness, or open areas noted on the left forearm or any other areas on the resident's body. [Dr. name] was notified and Ordered Stat X-ray of left upper extremity and PRN [as needed] Tylenol 325mg 2 tabs Q[every] 6 hours for pain. The resident is self RP [responsible party] and was notified of the attending physician orders and she verbalized understanding. Pain medication was administered and 30 minutes later the resident rated pain level 1/10. Resident son who is the first Emergency contact [son name] was called on [phone number] but was unable to be reached on the phone. The resident mother, who is her second Emergency Contact [mother name] was called on [phone number] and notified of the alleged incident. and the attending physician orders, and she verbalized understanding. During the conversation, resident Mother stated that When [the resident] my daughter, was 2 years old, she broke that same arm, and she was treated. Resident emergency contact was notified that she will be updated with the X-ray result, and she verbalized understanding. Mobile Medical Imaging was called, and a STAT X-ray was initiated. Resident remains in a stable condition at this time with no physical or respiratory distress noted. Resident is self-ambulatory, and she ambulates in and out of the unit. STAT X-RAY has been done awaiting result. Situational background assessment request (SBAR) dated 08/14/2023. The resident [resident #220] is self-ambulatory with a BIMS score of 6 and he is not a good historian. On assessment, the resident was confused requiring frequent redirection and was unable to verbalize if he allegedly hit another resident at the courtyard. The resident is calm with no agitation, anxiety or exhibiting any violent behaviors to self or others noted. The resident is currently on Ativan for anxiety and Abilify for Schizophrenia. All medications are tolerated with good effect. For safety reasons the attending physician ordered the resident to be immediately placed on 1:1 [one-to-one] until seen and cleared by a Psychiatrist. 1:1 monitoring initiated. Review of Resident #222's medical record revealed a nursing note dated 8/15/2023 21:35 documenting, [Resident #222] X-ray result of Left Forearm was received on 8/15/2023 around 1:41 AM. The X-ray result of the left forearm showed a fracture of the distal radial and ulnar diaphysis. No dislocation is seen. The adjacent soft tissues appear unremarkable. The X-ray result also showed a normal examination of the elbow and the left humerus. The attending physician [Dr. name] was notified and ordered to transfer resident to the hospital for further evaluation and treatment. The resident was transferred to [hospital name]. The resident returned to the facility at about 2:20 pm on 8/15/2023. Per discharge paperwork from the hospital CT [Computerized Tomography] Spine Cervical without contrast shows no abnormalities and the ventricles and cortical sulci are within normal limits. CT Scan of the Cervical, thoracis, and lumbar spine showed no fracture, dislocation, or other acute bony abnormalities identified. The CT scan shows Right upper lobe infiltrate. X-Ray of left Humerus/shoulder complete shows no fracture of the humerus. The result also shows the resident has Osteopenia and Degenerative Joint Disease (DJD). X-Ray of Left upper forearm shows fracture of the distal ulna with posterior angulation at the fracture site. The fracture is not articular. X-ray of the wrist shows a transverse, nondisplaced fracture through the distal radial diaphysis. The visualized wrist and elbow are unremarkable. No significant soft tissue abnormality is identified. The resident was discharged with order for azithromycin 250 mg oral tablet 1 tab by mouth x 4 days for pneumonia. A cast/splint was applied to resident left forearm and resident will be scheduled for a follow-up orthopedics appointment in 2-3 weeks at [hospital name]. The attending physician was called and notified of resident returned to the facility, X-ray report/CT Scan findings and discharge summary report. The attending physician gave an order to add Osteopenia and Degenerative Joint Disease (DJD) to the diagnosis list. The attending physician also approved the order for azithromycin x 4 days for pneumonia. Residents remain in a stable condition, she is self-ambulatory without the use of an assistive device. Residents remain alert and oriented x 4 without any issues. Resident is self RP, but Emergency contact 1 who is residents son [son name] was called and notified of resident returned to the facility, hospital X-Ray/CT Scan results and follow-up orders and he verbalized understanding and appreciation. Resident follow-up Appointment has been scheduled at [hospital name] orthopedic department on 8/29/23 at 11:00 am Status post left Ulnar fracture & temporary splint. MD [medical doctor], resident, and resident emergency contact made aware. Resident remain in a stable condition with no physical or respiratory distress. Current plan of care (POC) will continue. It should be noted that Resident #220 was 5 days including the day of the altercation in the courtyard without his medication for anxiety. During a visit to the courtyard on 11/6/24 at 10:15 AM to evaluate the plastic smoke equipment Resident #220 used to hit Resident #222, Employee #7 [smoking monitor] was interviewed concerning resident supervision while in the courtyard. She stated the unit managers or security is called for residents that are aggressive to others while in the courtyard. She reported that staff was not able to reach both residents at the time to prevent Resident #220 from picking up the plastic smoke equipment and then proceeded to hit Resident #222 on her arm. She also stated, smoker aides are only supervising the residents for safe smoking. Review of the Smoking Aide Job description 11/5/24 at 11:00 AM showed, Supervise all smokers in all areas of the facility including non-designated area. Resident rights Report any complaints or grievances made by residents, report incidents or suspected incidents of resident abuse immediately. The evidence showed that facility staff failed to provide adequate supervision and intervention to prevent Resident #220's aggressive behavior toward others from escalating into the resident altercation with Resident #222. It is to be noted Resident #220 was off his anxiety medication for 5 days [PRN anxiety medication not given] during the time he was out in the smoking area and engaged in a physical altercation with Resident #222, which resulted in Resident #222 fracturing her left forearm. During a face-to-face interview conducted on 11/14/2024 at approximately 3:00 PM with Employee#2 [clinical coordinator]. She acknowledged the findings and stated, The smoke aides are to monitor and supervise the residents that are outside in the courtyard. Cross Reference 22B DCMR Sec. 3269.1(L)

Based on record reviews and staff interviews, for one (1) out of 75 sampled residents, facility staff failed to ensure that they took the steps to investigate Resident #56's grievance that an aide handled him roughly during ADL care. The findings included: Review of the facility's Grievance Policy (not dated) documented: - This policy ensures acknowledgement of grievance procedures and fair and timely resolution of grievances. - Grievances can include behavior of staff, care and treatment provided by the staff or other concerns regarding their long-term or short-term stay. - The facility has 72 hours to investigate and resolve the grievance. - The following grievances are reported to Department of Health (DOH) - abuse and neglect. - The facility must ensure that all written grievance decisions include steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Respiratory Failure, Malignant Neoplasm of Lower Gum and Mouth, and Dysphagia. Review of the resident's medical record revealed the following a modified admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: no speech; makes self-understood; able to understand others; a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognitive response; no potential indicators of psychosis; no behavioral symptoms; had functional impairment on one side for upper and lower extremities; and required substantial/maximal assistance for toileting hygiene and personal hygiene. A Resident - Family Complaint Form (facility's grievance form) dated 07/15/24 documented: - [Resident #56] is the person initiating the report. - Date of incident: 07/15/24; date report completed 07/15/24. - Name of person receiving complaint: Employee #18 (Unit 2 north/south Social Worker) and Employee #17 (2 north Unit Manager). - Complaint: [Employee #18] and [Employee #17] interviewed resident at bedside concerning a complaint he made about his care received. He stated that the aide handled him roughly during ADL (activities of daily living) care. He also stated that she appeared to be in a hurry. He stated ADL was being done while the respiratory therapist was providing trach care. He stated, 'It was too much on me.' - Investigation report: Social Worker and Nurse Manager interviewed resident at bedside and addressed his concerns about care received. Resident was reassured that all residents needs will be met in a timely manner, and he will be treated with dignity and respect. - Action Initiated: Staff in-service on providing gentle care during ADLs (activities of daily living). To also treat residents with dignity and respect. - Disposition: Staff education good. Unit Manager noted the issue and notified the resident. - Signed and dated by Employee #1 (Administrator) on 07/15/24. A face-to-face interview was conducted on 11/22/24 at 9:28 AM with Employee #18 and Employee #17. The following was stated: - Employee #17, We talked with him (Resident #56) at the bedside and provided him assurance about educating the staff about answering call lights, treating residents with respect and dignity, and handing the residents. I did not talk to the respiratory therapist, try to identify the aide who handled him roughly or get statements from them regarding what happened. Reports that get reported to the DOH are allegations of abuse, neglect, hitting a resident, verbal abuse, taking a resident's belongings. I wouldn't call a resident telling me that they were handled roughly abuse. - Employee #18 stated, I feel the same, I don't consider being 'roughly handled' to be abuse. During a face-to-face interview on 11/22/24 at 4:09 PM, Employee #1 (Administrator) stated, When an allegation of abuse is made and we can't pinpoint exactly when the alleged abuse occurred, we interview staff who worked the last 72 hours or more if needed to try to catch it. Being 'handled roughly by an aide' is not necessarily an allegation of abuse. What we do is look at circumstances, interview the resident with follow-up questions and do an initial inquiry to know which route to take as far as reporting to DOH and education to the staff. When asked did the facility identify or try to identify the aide or interview the respiratory therapist mentioned in the grievance, the employee stated, No. The findings showed that there was no documented evidence that the facility took the steps to investigate Resident #56's allegation of being handled roughly as evidenced by failure to try and identify or interview the aide or the respiratory therapist that was present when the alleged incident occurred, and the grievance filed. Cross Reference 22B DCMR Sec. 3233.5

Based on observation and staff interview for four (4) of 75 sampled residents, facility staff failed to provide a comfortable, sanitary, homelike environment to four (4) residents, as evidenced by two (2) resident's rooms with dirty floors covered with debris and a sticky-like substance, including multiple wheelchair tire tracks, two (2) resident's rooms with flies, two (2) resident's rooms with a clutter of boxes, bins and other unboxed items piled against the wall and around the resident's bed, two (2) resident's rooms without bed linens on their bed, one (1) resident with a foul odor of urine beginning at the doorway, and one(1) resident with a dirty sticky floor and a foul odor in the room. Residents #76, #7,#103 and #115. The findings included: 1. Resident #76 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side, Atherosclerosis of Native Arteries of Other Extremities with Ulceration, Peripheral Vascular Disease, and Muscle Wasting and Atrophy. A review of Resident #76's medical record revealed a Quarterly 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 Abilities and Goals that documented: totally dependent on staff for chair/bed-to-chair transfer; required Substantial/Maximal assistance with personal hygiene, toileting, bathing and dressing; used a motorized wheelchair for locomotion on/off the unit. During an observation conducted on 11/04/24 at 12:20 PM Resident #76's room was noted to be cluttered with personal belongings creating a trip hazard, including food and clothing piled up in a corner and on the resident's bare mattress. There were no bed linens on the resident's bed, the floor was littered with debris and food crumbs, and there was a fly observed flying around the room during the observation. During a face-to-face interview conducted with Resident #76 he stated, There's an issue with getting clean linen every day for my bed and no one asked to help clean my room. 2. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Hemiplegia and Hemiparesis following Other Cerebrovascular Accident affecting Right Non-Dominant Side, Speech and Language Deficits following Unspecified Cerebrovascular Accident, and Muscle Wasting and Atrophy. A review of Resident #7's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '09,' indicating the resident was moderately impaired. Functional Abilities and Goals that documented: Substantial/maximal assistance from staff with toileting, personal hygiene, bathing, dressing and Partial/moderate assistance from staff with chair/bed-to-chair transfer; used a manual wheelchair for locomotion on/off unit. During an observation conducted on 11/04/24 at 12:30 PM Resident #7's room was noted to have a foul odor of urine beginning at the doorway and inside of the resident's room. There were several flies in the room and concentrated on and around the resident's bed and the floor was dirty with an unknown sticky substance covering part of the floor. 3. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses that included Human Immunodeficiency Virus (HIV) Disease, Chronic Obstructive Pulmonary Disease (COPD), and Cerebrovascular Accident (CVA) with right sided weakness. A review of Resident #103's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] that documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating the resident was cognitively intact. Functional Abilities and Goals that documented: one-person physical assist with bed mobility, transfers, eating and toilet use; limited range of motion/impairment on one side to upper and lower extremities, and used a motorized wheelchair for locomotion on/off the unit. During an observation conducted on 11/04/24 at 12:45 AM Resident #103's room was noted to have a dirty floor with an unknown sticky-like substance and wheelchair tire marks. The mattress was bare, without clean bed linens. The area surrounding the resident's bed was cluttered with personal belongings creating a tripping hazard, including storage bins, cardboard boxes and other unboxed items piled against the wall. During a face-to-face interview conducted on 11/04/24 at approximately 1:00 PM Employee #14 (RN) acknowledged the findings and stated, We ran out of linens, just waiting to see when we will get some more. Will have to check with the resident to see when it's a good time to clean the room. Cross Reference 22B DCMR § 3256.1 4. Resident #163 was admitted to the facility on [DATE] with diagnoses that included: Dislocated Right Hip Arthroplasty, Cervical Spinal Stenosis, Osteomyelitis, Dependence on a Wheelchair, Psychoactive Substance Use, Alcohol Abuse, Type 2 Diabetes Mellitus, Tobacco Use, and Moderate Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of Resident #163's medical record revealed a Face Sheet which showed that Resident #163 was the responsible party. A review of Resident #163's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a BIMS score of 14, indicating intact cognition. During an initial tour of Unit # 3 North on 11/06/24 at 10:31 AM, Resident #163's room was observed with a sticky, dirt-stained floor and a foul-smelling odor in the Resident #163's room. The Resident was not in his room at the time of the observation. The Resident's bed (Bed A) was unmade with the bed linens, drawn back in disarray and a personal blanket partially on the bed and on the floor at the foot of the Resident's bed. Piled in the center of the Resident's bed mattress were the resident s belongings including his wallet and single dollar bills. On the floor at the foot of the Resident's bed, were two (2) large, clear trash bags with the Resident's belongings in them. Next to the resident's bed on the floor was an empty urinal. The Resident's roommate who was nonverbal, was asleep in Bed B. During a face-to-face interview with Employee #29/Certified Nurse Aide (CNA), said she was not aware of the condition of the Resident's room, because she was not assigned to the resident. She then added that she would let the Unit Manager know that the Resident's room needed to be cleaned. At approximately 11:30 AM on 11/06/24, Resident #163's room was observed in the same condition and the Resident was not in the room. During a face-to-face interview with Employee #28/3 North Unit Manager,(Registered Nurse), on 11/06/24 at approximately 11:30 AM, she acknowledged that the floor was dirty, and there was an odor in the resident's room. She stated that the Resident had spilled the urinal on the floor, and he would not allow EVS (environmental services) staff to come in and clean the room while he was there. She then stated that she was unaware that the Resident had left his room. She then asked EVS to clean the Resident's room. When asked if the room was cleaned daily, she stated that it was, and added that she would have EVS clean the Resident's room. Cross Reference 22B DCMR § 3256.1

Based on observation, record review and staff interviews for one (1) of 75 sampled residents, facility staff failed to respect a resident's right to personal privacy, including the right to promptly receive unopened mail, evidenced by a resident's personal mail being opened without his signed consent. (Resident #111) The findings included: An undated facility policy titled Mail Handling documented, Each resident shall be ensured the right to privacy in written communications including promptly sending and receiving unopened mail and having access to stationary, postage, and writing implements, and, Procedures: 1. Mail will be delivered to the resident unopened and unread, including magazines and newspapers, within 24 hours of arrival in the facility by Designated personnel and/or assigned volunteers. 2. Residents/Responsible Party (RP) who desire to have their mail opened and read to them shall make this request in writing or sign a release form stating this fact. The appropriate legal signature is required. All information will be treated confidentially. A facility policy titled 'Resident Rights' with a review date of 06/2023 documented, Employees shall treat all residents with kindness, respect, and dignity. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, and communicate in person and by mail, email and telephone with privacy. Resident #111 was admitted to the facility on [DATE] with multiple diagnoses that included: Stroke with Hemiplegia, Hypertension and Coronary Artery Disease. A review of Resident #111's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] that documented a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating the resident was cognitively intact. Functional Abilities and Goals that documented: limited range of motion/impairment on one side to upper and lower extremities; used a cane and wheelchair for locomotion on/off the unit; Independent with eating, oral hygiene and upper body dressing. During an observation conducted on 11/13/24 at 2:43 PM the State Surveyor observed Resident #111's personal mail that was not in its original envelope. The one-page letter was inside of a plain white mailing envelope with his full name and room number written on it. During a face-to-face interview conducted on 11/13/24 at 2:45 PM Resident #111 stated, The Social Worker opened up my mail yesterday. I went to Security to find out who opened my mail, and the Security told me that the Social Worker opened it. I didn't give them permission to open my personal mail. During a face-to-face interview conducted on 11/15/24 at 2:38 PM Employee #8 (Activities Aide) stated, I remember the resident, it was [Resident #111's name], because he brought it to my attention when I gave it to him. He said someone opened his mail. It's only the in-house mail that's not sealed because all the residents get the same in-house mail that contains facility information. I do remember that it was opened and stuffed into the envelope, and he said something to me about it, but I thought it was in-house mail since it was already opened. During a face-to-face interview conducted on 11/15/24 at 3:00 PM Employee #9 (Security Officer) stated, Something was reported a few days ago about opened mail, he (Resident #111) came to the front desk to complain. We told him we don't open any mail and to check with recreation (Activities Department) or the Social Worker. I don't know what happened after that. During a face-to-face interview conducted on 11/15/24 at 3:08 PM Employee #12 (Social Worker) stated, If it seems to be any certain type of mail from the court, voter registration, housing, or legal matters it comes to me or my supervisor. When we get those type[s] of mail if I think the resident is competent, I just give it to them, but if I don't think they are competent I open it. I have opened mail for [another resident] before. Employee #12 was asked if its documented anywhere that she opens the residents personal mail and she stated, No. During a face-to-face interview conducted on 11/15/24 at 3:13 PM Employee #13 (Activities Director) acknowledged the findings and stated, At no time does the staff open a resident's mail without permission.

Based on observations record reviews and staff interviews for one (1) of 75 sampled residents, the facility staff failed to ensure that a resident who is fed by enteral means received appropriate treatment and services to prevent complications as evidenced by an observation in which Resident #39's enteral tubing was observed tied in a knot. Resident #39. The findings included: Resident #39 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Gastrostomy Status, Schizophrenia, Seizures, Pressure Ulcer of Sacral Region Stage 4 and Anemia. A review of a Facility Reported Incident (FRI) DC#00012152, submitted to the State Agency on 08/01/23, documented the following: On rounds resident was observed lying on the floor in her room beside her bed with nonskid socks on. Upon assessment, the resident was noted with a small laceration on the left eyebrow measuring 7 x (times) 4 cm (centimeters) with moderate bleeding. The area was cleaned with normal saline, pat dry and pressure dressing applied. Resident could not verbalize what happened. A review of the facility's policy titled G(gastrostomy) Tube feeding-Eternal (sp)(Enteral) Nutrition with a revision date of 11/01/24 documented the following: Nursing will assess and report complications associated with use of feeding tube which include: Clogging of tube Regularly inspect G (gastrostomy)-tube tubing for any damage. A review of Resident #39's medical record revealed the following: [Care Plan] undated focus area documented, (Resident #39) requires feeding tube related to swallowing impairment. Had the following undated interventions Interventions: Administer tube feeding formula, hydration, and flushes per order, Flush tubing with 30ml (milliliters) water before and after administering medication. Flush with5ml water between each medication. Provide local care to G- (gastrostomy) Tube site as ordered and monitor for s/sx (signs and symptoms) of infection every shift and PRN (as needed). [Physician Order] dated 01/26/24 documented Enteral feed order every shift flush tube feeding with 30 ml (milliliters) water before and after administering medication. Flush with 5ml between each medication. [Physician Order] dated 01/27/24 documented Enteral feed order every day shift cleans feeding tube site daily with soap and water and pat dry. Apply clean drain gauze if needed [Physician Order] dated 02/27/24 documented Enteral feed order every night shift water flush 50 ml (milliliters) q (every) 2 hr (hour), start 6 am, end 12 midnight or when total volume 450 ml (milliliters) is infused [Physician Order] dated 07/08/24 documented Enteral feed order every night shift change feeding tube syringe and feeding tube set ever day and prn (as needed) [Physician Order] dated 10/26/24 documented Check tube for proper placement prior to each feeding, flush or medication administration every shift During an observation conducted on 11/25/24 at approximately 3:00 PM, the Surveyor observed the resident lying in bed with tube feeding pump running with tubing that was tied in a knot and laying on bed beside Resident #39. The surveyor immediately alerted Employee #25 (1 South Unit Manager) who was observed untangling the knot which required disconnecting the tubing from the pump. An interview was conducted at the time of the observation with Employee #25 who stated, Someone on night shift must have put it like that.

Based on observation, record review and staff interviews, for one (1) of 75 sampled residents, facility staff failed to ensure that Resident #362 received care and services, consistent with professional standards of practice for her right upper chest central venous intravenous (IV) catheter\line. The findings included: According to the Centers for Disease Control (CDC): Replace dressings used on short-term central venous catheter sites at least every seven (7) days. https://www.cdc.gov/infection-control/hcp/intravascular-catheter-related-infections/summary-recommendations.html Review of the facility's Central Line Dressing Change policy dated 11/2024 documented: - Dressing changes for central lines will be performed weekly, on Wednesdays, or as clinically indicated based on the patient's conditions. - Nurses are responsible for performing the dressing change according to the established protocols. - Each dressing change, including any observations (signs of infection, condition of the catheter), must be documented in the patient's medical record. Resident #362 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Systolic (Congestive) Heart Failure, Cardiomyopathy and Metabolic Encephalopathy. Review of the resident's medical record revealed the following an admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact cognitive response. A physician's order dated 11/01/24 directed, Cefazolin (antibiotic) Sodium Injection Solution Reconstituted 2 GM, use 2 grams intravenously every 12 hours for Methicillin Susceptible Staphylococcus Aureas (MSSA) Bacteremia until 11/23/2024. A physician's order dated 11/04/24 directed, Change central line dressing and caps weekly, every day shift, every Wednesday. Care plan focus area: [Resident #362] has potential for complications at IV insertion site, [NAME] line inserted at right upper chest, initiated on 11/04/24 had interventions that included: dressing change per physician's order and prn if soiled or wet. An 11/10/24 at 8:14 PM admission Note documented: - [Resident #362] was readmitted from [Hospital name] at about 7:00 PM on a stretcher. - Resident has a [NAME] (type of central IV) line for antibiotic administration. An 11/13/24 at 11:48 AM Daily Skilled Note: - No mood indicators noted. - No behavior problems observed. - Received antibiotics, has IV for medication administration. Review of Resident #362's Treatment Administration (TAR) record for November 2024 showed that on 11/13/24, facility staff documented a check mark and their initials to indicate that the treatment, Change central line dressing and caps weekly, every day shift, every Wednesday was completed. During an observation on 11/15/24 at 10:50 AM, Resident #362's central line dressing was noted with a documented date of 11/6/24. During a face-to-face interview at the time of the observation, Employee #20 (Licensed Practical Nurse/LPN) acknowledged the finding and stated that the dressing was going to get changed today. The evidence showed that facility staff failed to ensure that Resident #362 received care and services, consistent with professional standards of practice as evidnced by not chaging her central line dressing weekly, as ordered by the physician.

Based on observation and staff interview, facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks in one (1) of five (5) clean utility rooms observed. The findings included: According to the National Fire Protection Association (NFPA): - Per NFPA 99-2012, 11.6. 5.2, is about ensuring full and empty cylinders are not commingled. Those cylinders defined as 'empty' by the organization shall be segregated from all other cylinders that are intended for patient care use. https://www.nfpa.org/ During an observation of unit 2 north's clean utility room on 11/22/24 at 11:30 AM with Employee #17 (2 north Unit Manager), three (3) oxygen tanks were noted stored for use. Upon closer inspection, it was noted that one of the oxygen tanks showed empty. The evidence showed that facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks. Employee #17 acknowledged the finding at the time of the observation and removed the empty oxygen tank from the utility room.

Based on observation, record reviews, and staff interviews, the facility's staff failed to supervise residents on a secure unit during lunch for one (1) of three sampled residents. As a result, Resident #1 had access to a meal not prescribed. Due to these failures, an immediate jeopardy situation was identified on April 21, 2023, at 5:33 PM. The facility submitted a plan of action on April 21, 2023, at 8:33 PM and it was accepted. Verification of the plan was completed on April 24, 2023, and the immediacy was removed at 1:30 PM. After removal of the immediacy, the deficient practice remained for the potential for minimal harm, at the scope/severity D. The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had a history of Dementia and Gastro-Esophageal Reflux Disease. A review of Resident #1's physician orders dated 06/03/22 instructed, Regular diet, Pureed texture, thin liquids consistency. A review of a physician order dated 06/04/22 instructed, Aspiration Precaution every shift for safety. A review of care plans with a revision date of 06/21/22, documented the following: -Focus area - [Resident #1] is at risk for malnutrition r/t (related to) Diabetes, Dementia, Depression, Dysphagia oropharyngeal Phase, Edentulous on mechanically altered diet. Goal- [Resident #1] will not experience chocking X 90 days. Interventions - provide diet/medications as orders. Swallow precautions as ordered. Setup/supervision with meals . -Focus Area - [Resident #1] has nutritional problem or potential nutritional problem . Interventions - Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage resident to comply. Provide and serve diet as ordered . A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have a Brief Interview for Mental Status summary score indicating the resident was unable to take the test. Continued review showed the resident was not coded for rejection of care. Additionally, the resident was coded for requiring supervision of staff and set up (meals) for eating. During a tour of Unit 3 South on 04/21/23 at approximately 12:30 PM, six residents were eating lunch in the dining area and no staff were noted to be present for approximately five minutes. The surveyor, who stood at the nurses' station across from the dining area, noticed Employee #4 (licensed practical nurse; LPN) walking in an office behind the nurse's station. Employee #4 was asked to come to the nurses station and the survey asked the employee if the facility leaves residents on a secure unit unsupervised while eating lunch. The employee stated, The residents are independent. Employee #4 was then asked why the residents resided on a secure unit if they were independent. The employee stated, Because they have Dementia. While the surveyor was speaking with Employee #4, Employee #3 (Recreation Aide) approached the employee and requested that she come to the dining area. Upon entering the dining area, Resident #1 was observed sitting at a table by a tray containing two plates. On one plate, there was only regular textured barbeque chicken, and the second plate contained mechanical textured food that had been half eaten. Resident #1 were observed with his/her hands on the plate that contained the regular textured barbeque chicken. As Employee #3 removed the tray from Resident #1, she could be heard telling Employee #4, [Resident #1] was eating someone else's food. [Resident #1] is on a pureed diet. A review of Nutritional assessment dated [DATE] documented, Oral/Dental Condition- Edentulous . Mechanically altered Diet- Yes . Pureed . Diet Consistency - Regular/Pureed .Provide diet as ordered monitor intake, supervise during meals to ensure resident is not gulping food into mouth . A review of the assignment sheet dated 04/21/23 for 7:00 AM to 3PM (Dayshift) revealed the floor was staffed with two (2) licensed nurses and four (4) certified nursing assistants. A review of a Situation, Background, Assessment and Request form dated 04/21/23 at 3:28 PM documented, Per staff [Resident #1] was seen taking food from another resident's tray. Resident was assessed from head to toe no distress or discomfort noted .Vitals Temperature 97.6, Pulse 72, Respiration 18, Blood Pressure 122/72, Oxygen Saturation rate 97% on room air . A review of the Director of Nursing progress note dated 04/21/23 at 3:38 PM, documented, Resident was assessed on 04/21/23. Per staff, resident was observed picking food from another resident's tray in the dining room. On Assessment resident is alert and oriented to self .The resident's mouth was empty, hands clean with no food in her hands. There was no evidence of pocketing food, choking, drooling or gagging Attending physician notified .RP (responsible party) notified . A review of the facility's lunch menu for 04.21.23 revealed the facility served BBQ baked chicken, baked beams, corn on the cob, corn bread, apple crisp, baked fish, and beverage. During a face-to-face interview on 04/21/23 at approximately 12:50 PM, Employee #5 (Registered Nurse; RN) stated that she left the dining area for a few minutes. When asked, did she ask another staff member to relieve her as she left the dining room, Employee #5 stated, No. During a face-to-face interview on 04/21/23 at approximately 1:30 PM, Employee #3 (Recreation Aide) reported seeing Resident #1 eating corn (regular texture) from another resident's plate. She then said that's why she came out to get Employee #4 (LPN). The surveyor asked Employee #3 how she was aware of Resident #1's prescribed pureed diet. The employee stated, I just started working in the recreation department in February of this year, but I worked in the dietary department for 13 years, so I know what [Resident #1's] diet is. During a face-to-face interview on 04/21/23 starting at 2:36 PM, Employee #6 (Dietician/ Director of Nutrition Services) stated that Resident #1 was on a pureed diet because the resident gulps food, puts too much in [his/her] mouth, and grabs food. When asked if it was safe to leave Resident #1 unsupervised during meals, Employee #6 stated, No, [Resident #1] needs to be monitored. Due to these failures, an immediate jeopardy situation was identified on April 21, 2023, at 5:33 PM. The facility submitted a plan of action on April 21, 2023, at 8:33 PM and it was accepted. The plan included the following: -The staff member that observed the resident with her hand in another resident's plate, notified the nurse and the staff member removed that plate out of the area. -Resident #1 was assessed by the Director of Nursing on 4.21.23 and there was no evidence of any pocketed food, no choking and no other untoward reaction noted. The resident's mouth was empty, hands were clean, normal breathing and was alert and responsive. -A nursing aide was assigned to stay in the dining area. The name of the assigned staff responsible for supervising the residents will be mentioned on the assignment board and will continue to do so going forward. -An assessment was done on 4.21.23 by the Unit Manager for all residents in the dining area at that time, and no other resident was affected. -Medical Director was notified on 4.21.23, an order for Speech Therapist to evaluate the resident for diet consistency was obtained. -Employee #4 and Employee #5 were in-serviced on 4.21.23 by the Unit Manager on importance of not leaving the resident's unsupervised and if they must leave the dining area during the mealtime or leave the unit, they should inform another staff member that can continue the needed supervision. -An in-service was done by the Unit Manager on 4.21.23 for all the staff present on the secure unit to ensure they understand the importance of resident supervision, especially during meals. -For any other nursing staff that is scheduled to work on the secure unit, the facility will ensure that the staff is educated on the importance of resident supervision, especially during meals before they take over the assignment for the secure unit. This education will be done by the Director of Nursing or the nursing supervisor on duty. -An audit will be done by the manager or designee to ensure that the residents are supervised on the secure unit, especially while dining in the common area. This audit will be done weekly for four (4) weeks and monthly for two (2) months. Any negative findings will be addressed immediately. Results of finding will be forward to QA Committee for review and recommendations. -Date of Compliance: 04/21/2023 Verification of the plan was completed on April 24, 2023, and the immediacy was removed at 1:30 PM. Cross reference 22B DCMR sect. 3211.1

Based on record review and staff interview, for two (2) of 63 sampled residents, facility staff neglected to provide the needed care and services evidenced by 1. Resident #204 developing pressure ulcers that were first observed at an advanced stage, and 2. Resident #3 flipping out of a wheelchair in a transportation vehicle due to staff neglecting to secure him with a seatbelt. These failures resulted in actual harm to Resident #204 and Resident #3. The findings included: 1. Review of a Complaint, DC00010905, received by the State Agency on 07/29/22 revealed allegations that the facility failed to provide the proper to Resident #204. The complaint alleged the resident was neglected and sustained significant physical injuries over an unknown period which resulted in hospitalization . Medical record review indicated Resident #204 was admitted to the facility on [DATE] with multiple diagnoses that included: Mild Protein-Calorie Malnutrition, Dementia, Altered Mental Status, Muscle Weakness and Osteoporosis. Review of physician orders revealed: -07/14/21, Monitor skin for easy bruising (EB), bleeding (B), Skin Discoloration (SD), None (N) every shift and alert MD with any changes, Resident on Aspirin (blood thinner) EC (enteric coated) daily. -08/26/21, Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed. Review of the facility's Wound/Pressure Ulcer Management policy, revised on 10/01/21 showed, . Any alteration in skin integrity will be reported to the physician immediately . Review of the facility's Wound Prevention Program policy (not dated) showed, .Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). Daily, during routine care, the Certified Nursing Assistant will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse . Review of the facility's Treatment/Services to Prevent/Heal Pressure policy (not dated) showed, . The facility will ensure that . a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers . a resident with pressure ulcers receive necessary treatment and services . to promote healing, prevent infection and prevent e ulcers from developing . the nurse will notify the physician anytime the pressure sore is showing signs of non-healing or infection . Per a 03/03/22 physician's order, Resident #204 was to have a Shower twice a week on Monday and Wednesday and per patient request . This order was discontinued on 4/20/22. An Annual Minimum Data Set (MDS) dated [DATE], showed that facility staff coded Resident #204 as having severe cognitive impairment; requiring total dependence with one to -two persons physical assist for bed mobility and transfers; extensive assistance with one person physical assist for toilet use and personal hygiene; frequently incontinent of urine and bowel; active diagnoses of Anemia; no significant weight loss; at risk for pressure ulcers; and no pressure ulcers, wounds or other skin problems. A. Skin area #1- right foot: 04/18/22 at 4:28 PM Nurses Note .Skin warm to touch and no new skin issues noted. Continued to require total care with all ADL (activities of daily living) cares. Turned and repositioned for pressure relief . 04/19/22 at 5:14 PM Skin Observation Tool (Licensed Nurse) . skin is intact, warm and well lubricated. No wound; 04/20/22 [Treatment Administration Record (TAR)] facility staff documented, yes, a check mark (meaning administered), and initialed to indicate that a shower was completed; 04/20/22 [physician's order] Skin Assessment weekly on shower day by license nurse every day shift every Thu (Thursday); 04/20/22 [physician's order] Shower twice a week and per patient request every day shift every Thu, Sat (Saturday); 04/21/22 (Thursday) [Shower/Bath Shower] .12 (skin intact/no irritation); complete bed bath; 04/21/22 treatment administration record [TAR] - facility staff initialed to indicate that the weekly skin assessment was completed; 04/22/22 at 7:34 PM Social Services Note . IDT (interdisciplinary team) meeting was held . No sig. (significant) changes to report resident is stable. A care plan with a review date of 4/22/22 documented the following: -Focus area [Resident #204] has an ADL self-care performance deficit r/t (related to) impaired balance and other conditions .Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed. The resident requires assistance by staff with bathing/showering routinely and as necessary .The resident requires assistance by staff for toileting. -Focus area, [Resident #204] has bladder and bowel incontinence r/t deconditioning . Apply moisture barrier cream to skin after each incontinent care .Report any signs of skin breakdown. -Focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use . Keep skin clean and dry. Use lotion on dry skin. Provide incontinent care routinely and as needed. -Focus area, [Resident #204] is at risk for pressure ulcer development r/t immobility .administer medications as ordered . administer treatments as ordered . assess/record/monitor wound healing every shift . report improvements and declines to the D. On Resident #204's 04/23/22 treatment administration record (TAR) facility staff documented yes, a check mark, and initialed to indicate that a shower was completed. The 04/23/22 (Saturday) [Shower/Bath Sheet] documented .complete bed bath, however there was no licensed nurse signature on the form. The 04/26/22 at 11:29 AM Skin Observation Tool from the Licensed Nurse documented .No new skin issues noted. Review of the April 2022 TAR from 04/01/22 to 04/28/22, showed that facility staff documented N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD (medical doctor) with any changes. Staff also documented no refusal of care behaviors and that the resident was turned and repositioned every two hours. A 04/28/22 at 4:56 PM Podiatry Note documented, .Patient is seen bedside for thick, elongated toenails and wound right foot . Skin: Distal aspect of right hallux with noted sanguinous (sp) scab and eschar (dead tissue) to distal aspect, noted purulence and deep probing sinus . distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular consult to evaluate for healing potential. Ulcer right 5th toe. Dry eschar right 5th toe . Ulcer right Hallux. Pain right Hallux. Partial debridement of ulcer to patient tolerance. Noted deep probing and purulence during exam .Recommend starting antibiotics. Please obtain labs: CBC (complete blood count) with Diff (differential), CMP (complete metabolic panel), ESR (erythrocyte sedimentation rate) Please obtain x-rays of right foot to rule out osteomyelitis of right hallux. 04/29/22 at 9:23 AM Tissue Analytics . Right heel .Length: 2.45 cm; width: 2.67 cm; Wound acquired 4/29/22; [percent] epithelialization 100.00; Stat-s - new; Acquired in house? Yes; Etiology- pressure ulcer - Suspected DTI (deep tissue injury) .Dressing change frequency - daily, dressings- skin prep 04/29/22 at 1:55 PM Tissue Analytics Right great toe . Length: 1.40 cm, width: 1.60 cm; Wound Acquired 4/28/22, [percent] slough/eschar 100.00 .Stat-s - New; Acquired in House? Yes; Etiology Arterial .Dressing change frequency BID (twice a day), cleanse wound with- Normal Saline, dressing- Betadine A 04/29/22 at 10:20 AM Situation Background Assessment Request (SBAR) communication form documented the following: Situation: skin areas on right great toe red right heel. Date problem or symptom started: 04/29/2022 . resident had podiatry foot care at the bed side and then was observed with a right arterial area to the right great toe. Reddened area to the right heel. Skin intact. MD and RP (representative) aware. Treatment order in placed. A 04/29/22 at 11:10 AM late entry note indicated, Nurses Note Late Entry . Resident had Podiatry foot care at the bedside on 4/28/22 and a right great toe ulcer was observed after the podiatry care and Resident has reddened right heel, skin is intact. Responsible party . was made aware. No indication of pain. Right heel elevated on a pillow. The medical record contained wound notes stating: -04/29/22 at 2:18 PM Skin/Wound Note . Comprehensive skin and wound evaluation for consult: right heel, right great toe . Dermatologic - wound(s) present .Right heel DTI. Right great toe arterial ulcer .Patient seen by podiatry 4/28/22. Per podiatry, recommend vascular consultation to evaluate healing potential, recommend x-ray of right foot to rule out osteomyelitis of right hallux -04/29/22 at 2:21 PM Skin/Wound Note Late Entry . MD, R/P . made aware of resident's right heel wound and right great toe (podiatry-caused) wound. Nursing staff aware. The physician gave orders related to these areas on 05/2/22 to request the following: -05/02/22, Right great toe surgical site- Paint with Betadine (antiseptic) and secure with bordered gauze twice daily every day and evening shift for wound healing; and, -05/02/22, Right heel D-I - Apply Skin prep and leave open to air daily every day shift for wound healing. This order was discontinued on 5/9/22. Although the Tissue Analytics documented dressing orders on 4/29/22, there were no physician orders documented until '05/02/22, 4 days later. Furthermore, there was no documented evidence that licensed nursing staff performed dressing changes during those 4 days. Resident #204's care plan was updated on 5/4/22 to show the following: -focus area, [Resident #204] has a right great [toe] wound related to arterial insufficiency initiated on 05/04/22 showed .Administer treatment per physician orders. Notify physician and family/responsible party of skin condition. -focus area, [Resident #204] has right heel [DTI] initiated on 05/04/22 showed, .Apply skin moisturizers to skin as needed. Apply skin prep as ordered. Offload right heel with wedge/cushion foam as ordered. The podiatrist documented on 05/05/22 at 6:02 PM . follow-up wound right foot . Bandage to right heel left intact, deferred to wound care. Distal aspect of right hallux with noted eschar to distal aspect, noted scant purulence however improved since last exam .distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular to evaluate for healing potential (ordered) .Discussed with charge nurse as concern for deep infection . Consider antibiotics pending labs. Please obtain labs . order has been placed. Please obtain X-rays of right foot to rule out osteomyelitis of right hallux (noted order has been placed). Subsequent physician orders revealed: -05/05/22 [physician's order] CBC (complete blood count) with Diff (differential), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein) next lab day, -05/05/22 [physician's order] X rays 3 views of right foot to r/o (rule out) osteomyelitis- deep wound, pain, physical limitation one time only, -05/05/22 [physician's order] Consult for vascular evaluation for healing potential . It should be noted that these treatments were recommended on 04/28/22, however the physician's order was not placed until 05/05/22, 8 days later. The orders were completed, and the results were: -05/07/22 at 10:23 PM Radiology Results Note .Date of Test: 5/6/2022. Type of Test: Right foot, complete, 3+ views . Findings . No evidence of osteomyelitis . -05/24/22 Report of Consultation . Vascular consult for wound healing potential . findings: dry stable gangrene of r (right) hallux . Diagnosis: toe gangrene . -06/08/22 at 10:04 PM Laboratory Note Results. Date of test: 6/8/2022. Type of test . CBC W/Diff . Actions/New Orders: Waiting for doctor's review . Although it was ordered on 05/05/22, the labs were not obtained until 06/08/22, 34 days later. The Nurse Practitioner documented on 06/09/22 at 1:04 PM, .Labs and medications reviewed. For Resident #204's right foot, the evidence mentioned above revealed that although facility staff documented to implementing the interventions for Resident #204 from 04/01/22 to 04/27/22, the resident was first observed with a right great toe wound at 100 percent eschar and a right 5th toe wound at 30 percent eschar on 04/28/22. Facility staff failed to have a doctor's order for dressing changes to the right foot for 4 days and failed to obtain ordered labs in a timely manner. B. Skin area #2- sacrum: 06/28/22 at 9:30 AM Skin Observation Tool (Licensed Nurse) . Site: Right heel. Type -pressure, length 3.79cm, width-4.58cm, depth, 0.0cm, stage -Suspected Deep Tissue Injury; R. (right) great toe site - type - arterial, length-1.28cm, width-0.71cm, depth -0.0cm, stage-N/A. Resident has treatment orders for the sites and is followed by the wound team. 06/29/22 at 12:26 AM Nurses Note . Resident is stable and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe. No drainage noted. Paint with Betadine prep on right great toe in this shift. Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 06/30/22 at 3:25 PM Nurses Note . Resident is alert and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact, no drainage and redness noted, ADLS and oral hygiene provided by staff . 06/30/22 (Thursday) [Shower/Bath Sheet] .12 (skin intact/no irritation); condition of skin section was left blank; complete bed bath given. 07/01/22 at 8:02 AM Nurses Note .skin remain unchanged dry and warm to touch .Turned and repositioned every two hours . Right heel and right great toe wound dressing intact . 07/02/22 [Shower/Bath Sheet] condition of skin section showed facility staff documented a line and 12, indicating skin intact/no irritation and bed bath 07/02/22 at 11:40 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 07/03/22 at 7:43 AM Nurses Note . Turned and repositioned every two hours. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact . 07/03/22 at 3:35 PM Nurses Note .skin dry and warm to touch .Right heel and right big toe wound dressing is changed .ADL provided by staff. 07/03/22 at 11:35 PM Nurses Note .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Changed wound dressing on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. The pressure ulcer is a little wider in the resident's coccyx area. Dressing done . There was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the licensed staff on 07/03/22. 07/04/22 at 1:57 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, No skin bruising and bleeding noted . Right heel and right great toe wound dressing intact . Care plan focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use showed, .07/04/22 IDT meeting held. Care plan reviewed and updated .Patient has an actual wound/sacral DTI. Although it was discussed at the care plan meeting, there was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the IDT on 07/04/22. 07/05/22 at 10:44 PM SBAR .Communication Tool . Situation Pressure ulcer on coccyx, approx. 10cm*10cm*0.2 .Date problem or symptom started 7/3/2022 . Identify whether the problem/symptom has gotten worse/better/stayed the same since it started- Worse . Pressure ulcer of coccyx area got wider and worse .Assessment: In my opinion, residents need active pressure ulcer treatment and care . The above SBAR showed that the licensed nurse completing the form listed her own name under the section person contacted. 07/05/22 at 11:09 PM Nurses Note .Continue monitoring skin wound on right foot and coccyx area. Wound dressing intact on right heel and right great toe .The pressure ulcer of coccyx area is more wider and worse. Approx. 10cm*10cm*0.2, drainage noted. Dressing changed. I notified to Dr. (doctor) about resident's condition via SBAR . Review of the July 2022 TAR from 07/01/22 to 07/05/22, showed that facility staff documented: N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD with any changes; no refusal of care behaviors; a check mark, and initials to indicate that incontinent care was provided with barrier cream applied to peri area every shift; and that the resident was turned and repositioned every two hours, every shift. From 07/03/22 to 07/05/22 (3 days), there was no documented evidence facility staff notified the physician or requested any intervention for Resident #204's sacral area. 07/06/22 at 3:30 PM SBAR .Communication Tool . Situation suspected DTI on the sacral . Date problem/symptom started 07/06/2022 .Person contacted . son [RP] . Provider visit [medical doctor's name] . 07/06/22 at 5:04 PM Skin Observation Tool (Licensed Nurse) . Site: sacrum. Type- pressure, length- 9.0cm, width-12.0cm, depth-0.0cm, stage- suspected deep tissue injury. Resident has a new area to the sacrum suspected DTI. Thin. Frail skin. Pressure relief mattress. Treatment order in place. Repositioning every 2 hours. Labs and Dietary consult. 07/06/22 [physician's order] Sacral Wound: Cleanse with normal saline solution; pat dry, apply silver alginate on wound bed and secure with borded (sp) gauge daily and PRN every day shift for skin care (discontinued 07/08/22) Care plan focus area, [Resident #204] has a new wound site DTI on the sacrum, fragile, thin skin initiated on 07/06/22 showed, Monitor/document wound . Notify physician as indicated. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of infection . 07/07/22 at 11:22 AM Tissue Analytics . Location; sacrum; length 10.80 cm; width 9.48 cm; depth 0.10 cm . Date wound acquired 7/6/22; [percent] slough/eschar 30.00; Wound status - new; acquired in house? Yes . For Resident #204's sacrum area, the above evidence revealed that facility staff failed to: accurately assess, document on the resident's skin on 07/03/22 and report signs of worsening skin breakdown. Additionally, facility staff failed to notify the physician for 3 days after the sacrum wound was first documented as more wider. Subsequently, when seen by the wound Nurse Practitioner on 07/07/22, the sacral area measured 10.80 cm by 9.48 cm by 0.10 cm deep with 30% eschar. During a face-to-face interview on 09/15/22 at 3:25 PM, Employee #2 (Director of Nursing/DON) reviewed the shower/bath sheets for Resident #204 and stated, When the CNA (Certified Nurse Aide) is giving the resident a shower or bath, the nurse is to go in to do the head-to-toe skin assessment with the CNA present. The nurse documents what she sees and they both [CNA and nurse] sign the bath sheet. The Condition of Skin section should always be completed. It documents the resident's current wounds or skin issues and anything new that is noted. If the resident refuses the shower, bath or skin assessment, it is documented on the form, the progress note and the MD and RP are notified. During a telephone interview on 09/15/22 at 4:34 PM, Employee #6 (Podiatrist) stated, I saw [Resident #204] in April (2022) as part of regular podiatry services at the facility done every Thursday. I noted a dry, stable, eschar wound on the right 5th toe and a dry, eschar area near the right big toe. I started to debride the area [right big toe] and pus just started coming out. The nurse was in there with me. I wrote the recommendations [labs, x-ray, and ultrasound] in my note. When I came in on May 5th (2022), I saw that none of the recommendations were followed, so I wrote them again and they were finally ordered. During a face-to-face interview conducted on 09/16/22 at 9:32 AM, Employee #7 (Staff Educator/1 north Unit Manager) reviewed the progress notes and licensed skin assessments for Resident #204 for April 2022 and stated, Looking at the resident's feet is part of the skin assessment. [Resident #204] started getting the wounds on her right foot treated after she was seen by the podiatrist. The staff [nurses and CNAs] did not mention to me that they observed any skin issues on [Resident #204's] feet. Employee #7 then reviewed the July 2022 progress notes and the 07/05/22 SBAR for Resident #204 and stated, The staff documented to doing skin assessments but there's no mention of anything being on her sacrum area until July 3rd [2022]. Whoever first notices the change in the skin is the one who makes the doctor and family aware. The nurses know to notify the doctor immediately for any changes and to document it in the progress notes. This SBAR [dated 07/05/22] was not done properly. Another one was done on the 6th [07/06/22] where the family and doctor were notified. 45104 2. Facility staff failed to provide adequate supervision to Resident #3, who was not secured in the transportation van with a seatbelt and subsequently sustained an injury when he flipped out of his wheelchair during transport to an appointment. Review of the facility's policy entitled, Resident Transportation To and From Medical Appointment (revised 07/2022) documented, The assigned Certified Nursing Assistance (Certified Nursing Aide/CNA) or designee will ensure the resident is safe and well strapped and secure with the belt .while in the transportation van. Resident #3 was readmitted to the facility on [DATE] with diagnoses that included: Acute Osteomyelitis, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication Right Leg, Hemiplegia, Spinal Instabilities of the Cervical Region and Generalized Muscle Weakness. A Quarterly Minimum Data Set (MDS) dated [DATE] documented that facility staff coded: severely impaired cognition; upper and lower extremity impairment on one side; required extensive assistance for transfers; and using an (electrical) wheelchair for mobility. A facility reported incident (DC00010380) received by the State Agency on 11/04/21 at 5:20 PM documented, Resident left the facility this morning at about 10:20 AM, for a scheduled Vascular appointment .with his electric wheelchair accompanied by the facility escort with a Medicaid transportation . At about 11:36 AM on 11/3/2021, the escort who accompanied the resident for the appointment called the facility and stated ,'When we got into the van, the residents ('s) wheelchair was secured by the van driver. The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us, and [Resident #3] fell from his chair and landed on the floor . I then called the facility, and the facility asked for the resident to be transferred to the emergency room for further evaluation and treatment.' .the resident was transported to hospital . Per ER (emergency room ) nurse, a CT (Computed Tomography) , spine cervical w/o contrast and a CT Head w/o (without) contrast were completed with the result showing: 'Comminuted fractures of the right lateral mass of C1 and anterior and posterior ring of C1. Nondisplaced fracture of the right lateral mass of C3' . A review of Resident #3's medical record revealed: 11/03/21 at 5:02 PM, SBAR Situation: The resident had a motor vehicle accident (MVA) on the way to a scheduled vascular appointment at [Local Hospital] and sustained a fracture .Additional Comments: The resident left the facility this morning at about 10:20 AM for a scheduled vascular appointment .At about 11:00 AM on 11/3/2021, per the escort, 'The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us and [Resident #3] fell from his chair and landed on the floor. I immediately told the driver to pull over and stop so we can attend to [Resident #3] which he did.' During a face-to-face interview on 09/22/22 at 2:03 PM, Employee #27 (CNA and escort assigned to Resident #3) stated, The driver put the resident on the van using the lift, and I locked the resident's wheelchair. When asked who secured the resident with the seatbelt, the Employee responded, I went to secure the resident, but the driver said, 'Sit down, I got it.' Normally, I would have grabbed the seatbelt to put it on the resident, but the driver told me to sit down, so I did .The driver was on his phone and wasn't paying attention. I tried to let him [the driver] know that my resident was not secure as we pulled off, but he continued to ignore me. The next thing I knew, the driver hit the brakes. [Resident #3] was thrown out of his wheelchair, and [was] lying beside me on the floor of the van. I yelled, 'Sir, Stop, Stop, my resident,' The van driver then pulled over. I called the Nurse Manager to let her know what happened and to see if the resident needed to be transported to the hospital. Facility staff failed to ensure that Resident #3 was well strapped and secure with a seatbelt prior to the transport van being put into motion. Subsequently, when the van drive hit the brakes on the van, the resident was thrown out of his wheelchair and sustained a fracture. These failures resulted in harm to the resident.

Based on observations, record reviews, and staff interviews, for three (3) of 63 sampled residents, facility staff failed to provide adequate supervision and assistance to residents to prevent accidents and injury as evidenced by: 1. failure to secure Resident #3's wheelchair with the seatbelt in the transportation van; 2. failure to assign a 1:1 monitor to Resident #505; and 3. failure to provide Resident #176 with 1:1 supervision while in the courtyard. (Residents' #3, #505 and #176) These failures resulted in actual harm to Resident #3, example #1. The findings included: 1. Facility staff failed to provide adequate supervision to Resident #3, who was not secured in the transportation van with a seatbelt and subsequently sustained an injury when he flipped out of his wheelchair during transport to an appointment. Review of the facility's policy entitled, Resident Transportation To and From Medical Appointment (revised 07/2022) documented, The assigned Certified Nursing Assistance (Certified Nursing Aide/CNA) or designee will ensure the resident is safe and well strapped and secure with the belt .while in the transportation van. Resident #3 was readmitted to the facility on [DATE] with diagnoses that included: Acute Osteomyelitis, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication Right Leg, Hemiplegia, Spinal Instabilities of the Cervical Region and Generalized Muscle Weakness. A Quarterly Minimum Data Set (MDS) dated [DATE] documented that facility staff coded: severely impaired cognition; upper and lower extremity impairment on one side; required extensive assistance for transfers; and using an (electrical) wheelchair for mobility. A facility reported incident (DC00010380) received by the State Agency on 11/04/21 at 5:20 PM documented, Resident left the facility this morning at about 10:20 AM, for a scheduled Vascular appointment .with his electric wheelchair accompanied by the facility escort with a Medicaid transportation . At about 11:36 AM on 11/3/2021, the escort who accompanied the resident for the appointment called the facility and stated ,'When we got into the van, the residents ('s) wheelchair was secured by the van driver. The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us, and [Resident #3] fell from his chair and landed on the floor . I then called the facility, and the facility asked for the resident to be transferred to the emergency room for further evaluation and treatment.' .the resident was transported to hospital . Per ER (emergency room ) nurse, a CT (Computed Tomography) , spine cervical w/o contrast and a CT Head w/o (without) contrast were completed with the result showing: 'Comminuted fractures of the right lateral mass of C1 and anterior and posterior ring of C1. Nondisplaced fracture of the right lateral mass of C3' . A review of Resident #3's medical record revealed: 11/03/21 at 5:02 PM, SBAR Situation: The resident had a motor vehicle accident (MVA) on the way to a scheduled vascular appointment at [Local Hospital] and sustained a fracture .Additional Comments: The resident left the facility this morning at about 10:20 AM for a scheduled vascular appointment .At about 11:00 AM on 11/3/2021, per the escort, 'The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us and [Resident #3] fell from his chair and landed on the floor. I immediately told the driver to pull over and stop so we can attend to [Resident #3] which he did.' During a face-to-face interview on 09/22/22 at 2:03 PM, Employee #27 (CNA and escort assigned to Resident #3) stated, The driver put the resident on the van using the lift, and I locked the resident's wheelchair. When asked who secured the resident with the seatbelt, the Employee responded, I went to secure the resident, but the driver said, 'Sit down, I got it.' Normally, I would have grabbed the seatbelt to put it on the resident, but the driver told me to sit down, so I did .The driver was on his phone and wasn't paying attention. I tried to let him [the driver] know that my resident was not secure as we pulled off, but he continued to ignore me. The next thing I knew, the driver hit the brakes. [Resident #3] was thrown out of his wheelchair, and [was] lying beside me on the floor of the van. I yelled, 'Sir, Stop, Stop, my resident,' The van driver then pulled over. I called the Nurse Manager to let her know what happened and to see if the resident needed to be transported to the hospital. Facility staff failed to ensure that Resident #3 was well strapped and secure with a seatbelt prior to the transport van being put into motion. Subsequently, when the van drive hit the brakes on the van, the resident was thrown out of his wheelchair and sustained a fracture. These failures resulted in harm to the resident. 2. Facility staff failed to provide Resident #505 with a 1:1 monitor on 09/20/22, subsequently the resident went missing for 30 minutes in the facility. Resident #505 was admitted to the facility on [DATE] with diagnoses that included: Other Symptoms and Signs Involving Cognitive Awareness, Altered Mental Status, Anxiety Disorder, Schizoaffective Disorder, Unspecified Dementia with Behavioral Disturbance, and Disorientation. Review of Resident #505's medical record revealed: 09/02/22 [Admission Minimum Data Set (MDS)] documented that facility staff coded Resident #505 with a Brief Interview for Mental Status (BIMS) summary score of 07, indicating severely impaired cognition. Under Section E (Behaviors), facility staff coded the resident for displaying behavior symptoms of hitting, kicking, pushing, scratching, grabbing, threatening, screaming, and cursing others, as well as wandering and intruding on the privacy of others. 09/02/22 [Physician's Order]: Psychological consult and treatment as needed. 09/03/22 [Physician Order] Resident on 1:1 Nursing Supervision for Elopement and Fall Risk every shift . During a unit tour of 3 North conducted on 09/20/22 at 2:52 PM, the surveyor observed that Resident #505 was not in his room. At the time of the observation when asked where Resident #505 was Employee #33 (Unit Manager) stated that she thought the resident was attending a group activity on the first floor. A second observation on 09/20/22 at approximately 2:53 PM revealed that Resident #505 was not in the activity room on the first floor. Employee #34 (Activities Staff), confirmed that the resident was not in attendance for the activity. During a face-to-face interview on 09/20/22 at 3:00 PM, when asked if Resident #505 was still on 1:1 monitoring, Employee #2 (DON) stated, Yes. The surveyor then informed Employee #2 that at approximately 2:55 PM, Resident #505 was not observed in his room, or in the activity group on the first floor. The Employee then stated that she would go to the unit to investigate this herself. At 3:15 PM on Unit 3 North, the surveyor observed Employee #2 (DON) checking the unit's assignment board. Employee #2 then asked Employee #33 (Unit Manager), Who was assigned as the one to one monitor for [Resident #505] today? Employee #33 replied, I asked Employee #35 (Staffing Coordinator) about this, and he told me there was no one to one coverage for residents on the unit today. It should be noted at 3:20 PM, a Code Pink-Elopement Risk was initiated and Resident #505 was located by staff at 3:25 PM in the 3 North dining room. During a second face-to-face interview on 09/20/22 at 3:40 PM, Employee #2 (DON) stated that both Employee #33 (3rd Floor Unit Manager) and Employee #35 (Staffing Coordinator) knew that Resident #505 had orders for 1:1 monitoring, and should have called her if there was any question. Employee #2 acknowledged that facility staff failed to provide adequate 1:1 monitoring and supervision to Resident #505. 43776 3. Facility staff failed to provide 1:1 supervision of Resident #176 while in the courtyard. Review of the facility's policy titled Smoking policy with a revision date of 10/01/21, documented Residents will be supervised by staff when smoking . Resident #176 was admitted to the facility on [DATE] with diagnoses that included: Alcohol Abuse with Intoxication, Anemia and Atrial Fibrillation. Review of Resident #176's medical record revealed the following: Care plan focus area, [Resident #176] has a behavior problem of drinking liquor in the facility r/t (related to) life style revised on 08/19/22 showed, .can go to [Store] with facility staff or family member .1:1 supervision while in courtyard (initiated 06/08/22) . A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: intact cognition; no physical or verbal behavioral symptoms directed towards others; independent with activities of daily living (ADLs); required supervision for locomotion off the unit; and used a wheelchair for mobility. The facility's visitor log for 09/20/22 showed that Resident #176 had a visitor that took him out of the facility at 12:21 PM and returned at 2:00 PM. During an observation on 09/22/22 at approximately 4:30 PM on unit 4 South, Resident #176 was observed yelling profanities at facility staff as he wheeled himself past the nurses' station with two security officers behind him. When asked what was going on, Employee #12 (Security Officer) stated, I saw [Resident #176] coming in from the courtyard (smoking area) with a bottle of alcohol in his lap that was 75% already drunken. I said to him he's not allowed to have that and he started yelling and cussing at me and got in the elevator. I called [Employee #1/Administrator]. The other security officer came with me and we followed him up here. Review of the smoke aide schedule for 09/22/22 evening shift 3:00 PM - 11:00 PM showed that two employees were scheduled for the courtyard, Employees' #16 and #17, both Smoke Aides. During a face-to-face interview conducted on 09/23/22 at 11:39 AM, when asked if she was aware that Resident #176 required 1:1 supervision at all times when in the courtyard, Employee #16 stated, No. During a telephone interview conducted on 09/23/22 at 11:45 AM, Employee #17 stated that he also was not aware that Resident #176 required 1:1 supervision while in the courtyard. During a face-to-face interview conducted on 09/23/22 at 5:49 PM, Employee #2 (Director of Nursing) stated that administration and the IDT have been trying to work with Resident #176 regarding his drinking alcohol on the premises. Regarding the 1:1 supervision, the employee stated, We don't have the staff for it. 27513 45102

Based on record reviews, resident and staff interviews, for one (1) of 63 sampled residents, facility staff failed to ensure residents received care consistent with the professional standards of practice to prevent the development of pressure ulcers. Resident #204. These failures resulted in actual harm to Resident #204 when the resident obtained facility acquired ulcers first observed at advanced stages. The findings included: Review of the facility's Wound Prevention Program policy (not dated) showed, .Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). Daily, during routine care, the Certified Nursing Assistant will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse . Review of the facility's Treatment/Services to Prevent/Heal Pressure policy (not dated) showed, . The facility will ensure that . a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers . a resident with pressure ulcers receive necessary treatment and services . to promote healing, prevent infection and prevent e ulcers from developing . the nurse will notify the physician anytime the pressure sore is showing signs of non-healing or infection . Review of the facility's Wound/Pressure Ulcer Management policy, revised on 10/01/21 showed, . Any alteration in skin integrity will be reported to the physician immediately . Facility staff failed to ensure Resident #204 received care, consistent with professional standards of practice, to prevent pressure ulcer development found at advanced stages. Resident #204 was admitted to the facility on [DATE] with multiple diagnoses that included: Mild Protein-Calorie Malnutrition, Dementia, Altered Mental Status, Muscle Weakness and Osteoporosis. Review of a Complaint, DC00010905, received by the State Agency on 07/29/22 showed, . [Facility Name] failed to provide the proper care and appropriate care owed to its long-term resident . [Resident #204] was neglected and sustained significant physical injuries over an unknown period which resulted in her current hospitalization . Review of Resident #204's medical record revealed the following: 07/14/21 [physician's order] Monitor skin for easy bruising (EB), bleeding (B), Skin Discoloration (SD), None (N) every shift and Alert MD with any changes, Resident on Aspirin EC (enteric coated) daily 08/26/21 [physician's order] Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed 03/03/22 [physician's order] Shower twice a week on Monday and Wednesday and per patient request . (Discontinued on 04/20/22) An Annual Minimum Data Set (MDS) dated [DATE], showed that facility staff coded: A Brief interview for Mental Status (BIMS) summary score of 7, indicating severe cognitive impairment; required total dependence with one to -two persons physical assist for bed mobility, transfers; extensive assistance with one person physical assist for toilet use and personal hygiene; frequently incontinent of urine and bowel; active diagnoses of Anemia; no significant weight loss; at risk for pressure ulcers; and no pressure ulcers, wounds or other skin problems. Skin area #1- right foot: 04/18/22 at 4:28 PM Nurses Note .Skin warm to touch and no new skin issues noted. Continued to require total care with all ADL (activities of daily living) cares. Turned and repositioned for pressure relief . 04/19/22 at 5:14 PM Skin Observation Tool (Licensed Nurse) . skin is intact, warm and well lubricated. No wound 04/20/22 [Treatment Administration Record (TAR)] facility staff documented yes, a check mark (meaning administered), and initialed to indicate that a shower was completed. 04/20/22 [physician's order] Skin Assessment weekly on shower day by license nurse every day shift every Thu (Thursday) 04/20/22 [physician's order] Shower twice a week and per patient request every day shift every Thu, Sat (Saturday) 04/21/22 (Thursday) [Shower/Bath Sheet] .12 (skin intact/no irritation); complete bed bath 04/21/22 [TAR] - facility staff initialed to indicate that the weekly skin assessment was completed 04/22/22 at 7:34 PM Social Services Note . IDT (interdisciplinary team) meeting was held . No sig. (significant) changes to report resident is stable . Care plan focus area, [Resident #204] has an ADL self-care performance deficit r/t (related to) impaired balance and other conditions, reviewed on 04/22/22 showed, Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed. The resident requires assistance by staff with bathing/showering routinely and as necessary .The resident requires assistance by staff for toileting . Care plan focus area, [Resident #204] has bladder and bowel incontinence r/t deconditioning reviewed on 04/22/22 showed, Apply moisture barrier cream to skin after each incontinent care. Calazime (skin protectant paste) cream to buttocks and perineal area with incontinent changes every shift. Incontinent check every two hours and change when soiled and PRN (as needed). Report any signs of skin breakdown. Care plan focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use reviewed on 04/22/22 showed, Keep skin clean and dry. Use lotion on dry skin. Provide incontinent care routinely and as needed . Care plan focus area, [Resident #204] is at risk for pressure ulcer development r/t immobility reviewed on 04/22/22 showed, .administer medications as ordered . administer treatments as ordered . assess/record/monitor wound healing every shift . report improvements and declines to the MD. 04/23/22 [TAR] facility staff documented yes, a check mark, and initialed to indicate that a shower was completed 04/23/22 (Saturday) [Shower/Bath Sheet] .complete bed bath. There was no licensed nurse signature on the form. 04/26/22 at 11:29 AM Skin Observation Tool (Licensed Nurse) .No new skin issues noted Review of the April 2022 TAR from 04/01/22 to 04/28/22, showed that facility staff documented: N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD (medical doctor) with any changes; no refusal of care behaviors; and that the resident was turned and repositioned every two hours. 04/28/22 at 4:56 PM Podiatry Note . Patient is seen bedside for thick, elongated toenails and wound right foot . Skin: Distal aspect of right hallux with noted sanguinous (sp) scab and eschar (dead tissue) to distal aspect, noted purulence and deep probing sinus . distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular consult to evaluate for healing potential. Ulcer right 5th toe. Dry eschar right 5th toe . Ulcer right Hallux. Pain right Hallux. Partial debridement of ulcer to patient tolerance. Noted deep probing and purulence during exam .Recommend starting antibiotics. Please obtain labs: CBC with Diff, CMP, ESR, CMP. Please obtain x-rays of right foot to rule out osteomyelitis of right hallux . 04/29/22 at 9:23 AM Tissue Analytics . Right heel .Length: 2.45 cm; width: 2.67 cm; Wound acquired 4/29/22; [percent] epithelialization 100.00; Status - new; Acquired in house? Yes; Etiology- pressure ulcer - Suspected DTI (deep tissue injury) .Dressing change frequency - daily, dressings- skin prep . 04/29/22 at 1:55 PM Tissue Analytics Right great toe . Length: 1.40 cm, width: 1.60 cm; Wound Acquired 4/28/22, [percent] slough/eschar 100.00 .Status - New; Acquired in House? Yes; Etiology Arterial .Dressing change frequency BID (twice a day), cleanse wound with- Normal Saline, dressing- Betadine . 04/29/22 at 10:20 AM Situation Background Assessment Request (SBAR) .Communication Tool .Situation: skin areas on right great toe red right heel. Date problem or symptom started: 04/29/2022 . resident had podiatry foot care at the bed side and then was observed with a right arterial area to the right great toe. Reddened area to the right heel. Skin intact. MD and RP (representative) aware. Treatment order in place. 04/29/22 at 11:10 AM Nurses Note Late Entry . Resident had Podiatry foot care at the bedside on 4/28/22 and a right great toe ulcer was observed after the podiatry care and Resident has reddened right heel, skin is intact. Responsible party . was made aware. No indication of pain. Right heel elevated on a pillow. 04/29/22 at 2:18 PM Skin/Wound Note . Comprehensive skin and wound evaluation for consult: right heel, right great toe . Dermatologic - wound(s) present .Right heel DTI. Right great toe arterial ulcer .Patient seen by podiatry 4/28/22. Per podiatry, recommend vascular consultation to evaluate healing potential, recommend x-ray of right foot to rule out osteomyelitis of right hallux . 04/29/22 at 2:21 PM Skin/Wound Note Late Entry . MD, R/P . made aware of resident's right heel wound and right great toe (podiatry-caused) wound. Nursing staff aware. 05/02/22 [physician's order] Right great toe surgical site- Paint with Betadine (antiseptic) and secure with bordered gauze twice daily every day and evening shift for wound healing 05/02/22 [physician's order] Right heel DTI - Apply Skin prep and leave open to air daily every day shift for wound healing (discontinued on 05/09/22) The evidence showed that the Tissue Analytics documented dressing orders however, there was no physician's orders until 05/02/22, 4 days later. Furthermore, there was no documented evidence that licensed staff performed dressing changes during those 4 days. 05/05/22 at 6:02 PM Podiatry Note .follow-up wound right foot . Bandage to right heel left intact, deferred to wound care. Distal aspect of right hallux with noted eschar to distal aspect, noted scant purulence however improved since last exam .distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular to evaluate for healing potential (ordered) .Discussed with charge nurse as concern for deep infection . 05/05/22 [physician's order] Consult for vascular evaluation for healing potential . 05/07/22 at 10:23 PM Radiology Results Note .Date of Test: 5/6/2022. Type of Test: Right foot, complete, 3+ views . Findings . No evidence of osteomyelitis . 05/24/22 Report of Consultation . Vascular consult for wound healing potential . findings: dry stable gangrene of r (right) hallux . Diagnosis: toe gangrene . For Resident #204's right foot, the evidence mentioned above revealed that although facility staff documented to implementing the interventions for Resident #204 from 04/01/22 to 04/27/22, the resident was first observed with a right great toe wound at 100 percent eschar and a right 5th toe wound at 30 percent eschar on 04/28/22. Facility staff failed to have a doctor's order for dressing changes to the right foot for 4 days. Skin area #2- sacrum: 06/28/22 at 9:30 AM Skin Observation Tool (Licensed Nurse) . Site: Right heel. Type -pressure, length 3.79cm, width-4.58cm, depth, 0.0cm, stage -Suspected Deep Tissue Injury; R. (right) great toe site - type - arterial, length-1.28cm, width-0.71cm, depth -0.0cm, stage-N/A. Resident has treatment orders for the sites and is followed by the wound team. 06/29/22 at 12:26 AM Nurses Note . Resident is stable and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe. No drainage noted. Paint with Betadine prep on right great toe in this shift. Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 06/30/22 at 3:25 PM Nurses Note . Resident is alert and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact, no drainage and redness noted, ADLS and oral hygiene provided by staff . 06/30/22 [Shower/Bath Sheet] .12 (skin intact/no irritation); condition of skin section was left blank; complete bed bath given. 07/01/22 at 8:02 AM Nurses Note .skin remain unchanged dry and warm to touch .Turned and repositioned every two hours . Right heel and right great toe wound dressing intact . 07/02/22 [Shower/Bath Sheet] condition of skin section showed facility staff documented a line and 12, indicating skin intact/no irritation and bed bath 07/02/22 at 11:40 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 07/03/22 at 7:43 AM Nurses Note . Turned and repositioned every two hours. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact . 07/03/22 at 3:35 PM Nurses Note .skin dry and warm to touch .Right heel and right big toe wound dressing is changed .ADL provided by staff. 07/03/22 at 11:35 PM Nurses Note .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Changed wound dressing on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. The pressure ulcer is a little wider in the resident's coccyx area. Dressing done . There was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the licensed staff on 07/03/22. 07/04/22 at 1:57 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, No skin bruising and bleeding noted . Right heel and right great toe wound dressing intact . Care plan focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use showed, .07/04/22 IDT meeting held. Care plan reviewed and updated .Patient has an actual wound/sacral DTI. Although it was discussed at the care plan meeting, there was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the IDT on 07/04/22. 07/05/22 at 10:44 PM SBAR .Communication Tool . Situation Pressure ulcer on coccyx, approx. 10cm*10cm*0.2 .Date problem or symptom started 7/3/2022 . Identify whether the problem/symptom has gotten worse/better/stayed the same since it started- Worse . Pressure ulcer of coccyx area got wider and worse .Assessment: In my opinion, residents need active pressure ulcer treatment and care . The above SBAR showed that the licensed nurse completing the form listed her own name under the section person contacted. 07/05/22 at 11:09 PM Nurses Note .Continue monitoring skin wound on right foot and coccyx area. Wound dressing intact on right heel and right great toe .The pressure ulcer of coccyx area is more wider and worse. Approx. 10cm*10cm*0.2, drainage noted. Dressing changed. I notified to Dr. (doctor) about resident's condition via SBAR . Review of the July 2022 TAR from 07/01/22 to 07/05/22, showed that facility staff documented: N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD with any changes; no refusal of care behaviors; a check mark, and initials to indicate that incontinent care was provided with barrier cream applied to peri area every shift; and that the resident was turned and repositioned every two hours, every shift. From 07/03/22 to 07/05/22 (3 days), there was no documented evidence facility staff notified the physician or requested any intervention for Resident #204's sacral area. 07/06/22 at 3:30 PM SBAR .Communication Tool . Situation suspected DTI on the sacral . Date problem/symptom started 07/06/2022 .Person contacted . son [RP] . Provider visit [medical doctor's name] . 07/06/22 at 5:04 PM Skin Observation Tool (Licensed Nurse) . Site: sacrum. Type- pressure, length- 9.0cm, width-12.0cm, depth-0.0cm, stage- suspected deep tissue injury. Resident has a new area to the sacrum suspected DTI. Thin. Frail skin. Pressure relief mattress. Treatment order in place. Repositioning every 2 hours. Labs and Dietary consult. 07/06/22 [physician's order] Sacral Wound: Cleanse with normal saline solution; pat dry, apply silver alginate on wound bed and secure with borded (sp) gauge daily and PRN every day shift for skin care (discontinued 07/08/22) Care plan focus area, [Resident #204] has a new wound site DTI on the sacrum, fragile, thin skin initiated on 07/06/22 showed, Monitor/document wound . Notify physician as indicated. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of infection . 07/07/22 at 11:22 AM Tissue Analytics . Location; sacrum; length 10.80 cm; width 9.48 cm; depth 0.10 cm . Date wound acquired 7/6/22; [percent] slough/eschar 30.00; Wound status - new; acquired in house? Yes . For Resident #204's sacrum area, the above evidence revealed that facility staff failed to: accurately assess, document on the resident's skin on 07/03/22 and report signs of worsening skin breakdown. Additionally, facility staff failed to notify the physician for 3 days after the sacrum wound was first documented as more wider, subsequently, when seen by the wound Nurse Practitioner on 07/07/22, the sacral area measured 10.80 cm by 9.48 cm by 0.10 cm deep with 30% eschar. During a face-to-face interview on 09/15/22 at 3:25 PM, Employee #2 (Director of Nursing/DON) reviewed the shower/bath sheets for Resident #204 and stated, When the CNA (Certified Nurse Aide) is giving the resident a shower or bath, the nurse is to go in to do the head-to-toe skin assessment with the CNA present. The nurse documents what she sees and they both [CNA and nurse] sign the bath sheet. The Condition of Skin section should always be completed. It documents the resident's current wounds or skin issues and anything new that is noted. If the resident refuses the shower, bath or skin assessment, it is documented on the form, the progress note and the MD and RP are notified. During a telephone interview on 09/15/22 at 4:34 PM, Employee #6 (Podiatrist) stated, I saw [Resident #204] in April (2022) as part of regular podiatry services at the facility done every Thursday. I noted a dry, stable, eschar wound on the right 5th toe and a dry, eschar area near the right big toe. I started to debride the area [right big toe] and pus just started coming out. The nurse was in there with me. I wrote the recommendations [labs, x-ray, and ultrasound] in my note. When I came in on May 5th (2022), I saw that none of the recommendations were followed, so I wrote them again and they were finally ordered. During a face-to-face interview conducted on 09/16/22 at 9:32 AM, Employee #7 (Staff Educator/1 north Unit Manager) reviewed the progress notes and licensed skin assessments for Resident #204 for April 2022 and stated, Looking at the resident's feet is part of the skin assessment. [Resident #204] started getting the wounds on her right foot treated after she was seen by the podiatrist. The staff [nurses and CNAs] did not mention to me that they observed any skin issues on [Resident #204's] feet. Employee #7 then reviewed the July 2022 progress notes and the 07/05/22 SBAR for Resident #204 and stated, The staff documented to doing skin assessments but there's no mention of anything being on her sacrum area until July 3rd [2022]. Whoever first notices the change in the skin is the one who makes the doctor and family aware. The nurses know to notify the doctor immediately for any changes and to document it in the progress notes. This SBAR [dated 07/05/22] was not done properly. Another one was done on the 6th [07/06/22] where the family and doctor were notified. Cross Reference DCMR 3211.1

Based on observation, record review, resident and staff interview for one (1) of three (3) sampled residents, it was determined that facility staff failed to adequately supervise Resident #1 who left the facility unescorted, found in the parking lot, fell , and subsequently fractured his left ankle. This investigation identified actual harm and is being cited as past non-compliance. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Annual Assessment Form completed by the physician on April 15, 2020, Resident #1 has the following diagnoses: Alcoholic Dementia, Hypertension, Diabetes, [CONDITION(S)], Osteopenia, [CONDITION(S)] and Depression. Under Interim History: [AGE] year-old with past medical history of alcoholic dementia, recurrent falls, [CONDITION(S)], osteopenia, has had a stable clinical course at the facility. He/she wanders all day, has baseline confusion, remains high risk of elopement. He/she has stable weight. Department of Health (DOH) received the following incident report on April 22, 2020: Resident is a [AGE] year-old with history of Dementia and confusion, Hypertension, [CONDITION(S)]. On 4/18/2020, security staff reported that resident was observed walking out the back door. Security staff immediately went and checked and observed resident sitting on the pavement of the lower parking lot, with his/her walker next to him. Resident reported to supervisor that, I was just going for a walk Denies hitting his head. Assessment completed of left ankle . According to the following nurse's noted dated April 19, 2020 at 18:55 (6:55 PM): Resident is a [AGE] year-old with history of Dementia with [CONDITION(S)], confusion, Hypertension, diabetes, [CONDITION(S)], recurrent falls, Depression, [CONDITION(S)] and other comorbidities. On 4/18/2020, Security observed resident walking out the back door. Security staff immediately went and checked and observed resident sitting on the pavement of the lower parking lot, with his/her walker next to him/her. Resident reported that, I was just going for a walk and my knees got tired and I sat down. Resident was observed sitting on the ground . On 4/18/2020, resident was observed sitting on the ground. Assessment findings left ankle noted with minimal swelling. MD/RP were made aware. New order for fall protocols and x-ray, bilateral, hips, pelvis, knee, ankle, routine pain management. Today, 4/19/2020 @ 16:22, pm, X-ray results returned and shows medial soft tissue swelling about the ankle with acute medial malleolar fracture. All other x-ray results show no acute changes. Assessment findings, skin warm and dry to touch, swelling remains at the left ankle site. Pedal pulses present bilaterally. Pt able to wiggle toes. Capillary refills brisk. Resident on routine pain management. Resident comfortable and denies pain. Neuro checks in progress and within normal limits.MD made aware and gave new order to transfer resident to acute care for further evaluation and treatment. RP made aware. Resident left for acute care at 18:42 pm via [private ambulance] to [hospital] for further treatment and evaluation of left acute medial malleolar fracture as ordered. RP made aware and agreed with the treatment plan. Vitals 116/81, P-100, RR-20, Spo2 99% on room air, Temp. 98.9. According to the facility investigation completed by Employee #2 (previous Administrator) on April 26, 2020, Per report, on Saturday 4/18/2020, Resident #1 was observed by security from the camera exiting the building when the fire alarm was activated by another resident. Security staff immediately went after resident and notified the supervisor on his way out. When the security officer went outside, he immediately called out to Resident #1 by his/her name. As the resident turned upon hearing his/her name, his/her legs buckled, and he/she sat on the pavement. Review of the hospital's Discharge Summary revealed: 04/19/20 at 23:38 (11:38 PM) Orthopedic Consult note documented, .Preliminary .CT (computerized tomography) scan of LLE (lower left extremity): non-displaced lateral process of the talus fracture. Fracture pattern is commuinuted (bone broken into several pieces) . Fracture is too comminuted to consider operative fixation at this time . 04/20/20 at 01:27 (1:27 AM) Physician Discharge Note documented, Patient signed out by [doctor's name] with orthopedic consult in place for ankle fracture. Orthopedics has splinted leg and patient can be discharged to follow up with Orthopedics in 1 week to see [doctor's name]. Will require transportation back to nursing facility in a.m. Review of Resident #1's medical record revealed the following: 04/16/20 at 19:21 (7:21 PM) Physician Order, Discontinue wander guard bracelet, resident is not an elopement risk. 04/20/20 at 22:04 (10:04 PM) Nursing Note documented, Resident arrived from [hospital's name] following a fall on 4/19/20 .ace wrap to his left ankle . 04/24/20 at 15:58 (3:58 PM) Physician Note documented, The patient apparently walked out through the back door on 4/18/21 .He was observed to be sitting on the pavement of the lower parking lot .sent to [hospital's name] .lower extremity CT without contrast revealed comminuted left talar [sp] fracture, medial malleolus fracture, and soft tissue swelling .Orthopedic surgery was consulted and they performed closed reduction and immobilized the foot in plaster splint. Review of the April 2020 Treatment Administration Record (TAR) revealed the following order: Wander bracelet functionality. Blinking light on bracelet indicates functionality. Report malfunctioning to nursing supervisor for immediate replacement every shift. Wander bracelet placement for elopement every shift. For the aforementioned orders, nurses' initials were recorded for day shift, evening shift, and night shift from 04/01/20 to 04/18/20. The initials indicated that the nursing staff checked the functionality and the placement of Resident #1's wander guard. Review of nursing notes from 04/01/20 to 04/17/20 revealed there was no documented evidence of the resident's wander guard not functioning properly or not in place. Review of the annual Minimum Data Set signed on 04/09/20 revealed the following: In section C0500 (BIMSs Summary Score), Resident #1 had a score of 13, indicating he was cognitively intact. In section E0900 (Wandering - Presence & Frequency), the resident was coded a 0 indicating he did not exhibit this behavior. In section G0110 E (Activities of Daily Living-Locomotion on the unit), Resident #1 was coded a 3 with self-performed indicating that he required extensive assistance. Additionally, in this section Resident #1 was coded a 2 with support indicating that he required one person (staff) to physical assist him in this area. In section G0110 F (Activities of Daily Living-Locomotion off the unit), the resident was coded a 3 with self-performed indicating that he required extensive assistance. Additionally, in this section Resident #1 was coded a 2 with support indicating that he required one person (staff) to physical assist him in this area. In section G0400 A (Functional Limitation in Range of Motion - Upper Extremity), the resident was coded a 0 indicating that he had no impairments in this area. In section G0400 B (Functional Limitation in Range of Motion - Upper Extremity), Resident #1 was coded a 0 indicating that he had no impairments in this area. In section J1900 (Number of Fall since Admission) - This section was blank. P0200 E (Alarms- wander guard/ elopement alarm) - the resident was coded a 2 indicating the resident required the use of a wander guard [Radio-frequency identification technology that tracks residents within set borders]. An observation of Unit #3 South (secured unit) on 05/05/21 at approximately 1:00 PM revealed that a key code was required to enter and exit the unit. Resident #1 was observed sitting at the nurse's station with other residents. He was also observed ambulating in the hallway with a walker and stand-by assistance with one (1) staff member. During a face-to-face interview on 05/05/21 at approximately 1:30 PM with Resident #1. He was able to communicate his name and that he was at a nursing home. The resident stated that he remembered going out back and tripping on the patio, he not trying to leave, and he went outside to see a situation; however, he could not provide any further details. During a face-to-face interview on 05/05/21 at 3:20PM with Employee # 3 (Director of Nursing at the time of the incident), stated that the nursing supervisor informed her that Resident #1 was found outback on the ground, had swelling to the ankle, and an X-ray had been ordered by the resident's physician. During a face-to-face interview on 05/05/21 at approximately 4:10 PM,Employee #4 (Security Guard), stated that he observed the resident on the camera at the backdoor. He notified the nursing supervisor and went downstairs, where he found the resident sitting on the ground (floor) in front of the door leading outside. In addition, Employee #4 said that the nursing supervisor and another nurse assisted the resident back to his unit via a wheelchair. During a face-to-face interview on 05/05/21 at approximately 4:15 PM, Employee #1 (current Administrator) stated that the nursing supervisor and nurse who were working at the time of the incident was no longer with the company. During a face-to-face interview on 05/05/21 at 4:20 PM, 3 South's (secured unit), Employee #5 (Unit Manager), stated that she had worked with Resident #1 for approximately one year. She said that the resident was a wander and needed re-direction. Employee #3 also said that she could not remember when the resident was allowed to leave the unit (3 South -secured unit) without staff. During a face-to-face interview on 05/05/21 at 4:30 PM, 3 South's (secured unit), Employee #6 (Charge Nurse), stated that she had worked with Resident #1 for approximately a year and a half. She then said that the resident was an exit seeker and he was never allowed to leave the floor (3 South) by himself. Facility staff failed to adequately supervise Resident #1, who left the building unescorted, fell , and subsequently fractured his/her left ankle. On May 5, 2021, Employee #3 acknowledged the above findings and stated that Resident #1 was not allowed to go outside unescorted by staff. Past Non-compliance Information During an on-site survey on 05/05/21 at approximately 2:00 PM, Employee #1 (current Administrator) provided the State Agency with a Plan of Correction (POC) that had a completion date of 04/29/20. The POC included the following corrective actions: o The resident [Resident #1] was assessed on 04/22/20. The resident has been placed on one-on-one whenever he leaves the unit. o No other resident was affected by this deficient practice deficient practice. All residents with the risk of leaving the building unescorted will be identified and place on one-on-one monitoring whenever they leave the unit. The resident that were identified will continually be placed on one-on-one supervision. Unit managers will conduct weekly audit X 4, then monthly audits X3. All audits results will be forwarded to the DON (Director of Nursing). o The Staff Development Director will provide in-services to the nursing staff regarding residents at risk of leaving the Facility unescorted. o Hourly rounding will be conducted by the unit staff to identify resident recreation and activity. o The security also monitors the exit doors of the building via camera for the areas that the residents frequent for responses. o Security staff also completes frequent rounds on the unit to identify unusual activity. o One-on-one placement monitoring will be assigned to the resident identified when leaving the unit. o All residents with the risk of leaving the building unescorted will be added as a nursing quality indicator for review during the daily stand-up meeting sustained compliance until 3 months of greater than or equal to 90% compliance is achieved. Results of the findings will be reported to the daily Quality Assurance Improvement committee monthly for the next 3 months. The aforementioned Plan of Correction was implemented prior to the State Agency's on-site visit of 05/05/2021.

Based on observation, staff interviews and record review for two (2) residents, it was determined that facility staff failed to adequately supervise Resident #1 and Resident #2 who eloped from the secure unit on March 4, 2017. The findings include: According to the facility's policy no. 102, page 1 of 2, issued 3/17' with last update of February 2011, Wandering Resident Program under Policy: A Wandering Resident program is a necessary approach to the care plan of those residents assessed as being at risk due to a tendency to wander. The resident or responsible party will be informed that (facility) reserves the right to implement the elopement care plan at any time to prevent unauthorized exit by wandering residents. Wandering residents will be monitored by the use of an ankle/wrist bracelet which will automatically lock exits that are hooked up to the system. A staff member will be assigned to the secured unit to sit at the door for additional supervision. Under Application and Implementation: 1. The Clinical Nurse Manager will notify the unit social worker that the resident is being placed on the program. The social worker will notify the family or responsible party of the need for the resident to be on the program. 2. The Clinical nurse manager will request an ankle/wrist bracelet from the director of Facilities. 3. The Clinical nurse manager will explain to the resident that the bracelet is being applied for his/her safety. 4. An order is written to reflect the use of the Wander guard with ID# 5. Document on the MAR each shift that the correct bracelet is in place. Notify the nursing supervisor on duty if it is missing and request a replacement from Material Management. 6. An Elopement Binder is kept on unit and contains photographs of at risk residents 7. The Clinical Nurse Manager will notify Security when a resident is placed on, or removed from the program by placing a picture of the resident in the elopement binder at the front desk. 8. Licensed staff will evaluate on a daily and as needed basis or when the residents' conditions change, the need for continuance on the program. Documentation will be provided in the monthly summary/nurses notes. Elopement risk assessments will be updated quarterly, with significant change and as needed. An observation of the entrance/exit door to the secure unit was conducted at 8:00 AM on March 9, 2017. There was no visible or audible alarm to notify staff that the door had been opened. A facility employee was sitting at the door monitoring the activity of residents entering and leaving the secure unit. The middle doors (fire doors) are located approximately 35 feet from the entrance/exit door to the secure unit. Six (6) residents were identified on March 6, 2017 for being at risk for elopement. Wander guards were applied to the six (6) residents on March 7, 2017. On March 9, 2017 between 3:40 PM and 4:00 PM, all six (6) residents who were wearing the wonder guards walked or were rolled in their wheelchair to the entrance/exit door. The door locked in the presence of all six (6) residents. The wonder guards were functional on the day of the observation. Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) with an assessment reference date of December 24, 2016, Resident #1 scored 12/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14, a score of 8-12 suggests that the resident has moderately impaired cognitive skills for daily decision making. Resident #1 was assessed as requiring extensive assistance for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. A Elopement Risk Assessment was completed on January 3, 2017 for Resident #1. It was determined that the resident was not an elopement risk. There was no elopement care plan because the resident was identified as not being an elopement risk. An Elopement Risk Assessment was completed on March 6, 2017 which identified the resident as an elopement risk. An elopement risk care plan was initiated on March 5, 2017. A wander guard was placed on the resident's wrist on March 7, 2017. A nurse's note dated March 4, 2017 at 5:52 PM: Resident alert and verbally responsive. May be agitated sometime. He/she has AMS. He/she was given lunch about 1:30 (PM)as stated by the CNA. He/she received all medicine. He/she is ambulatory and sometime may make his/her needs known. He/she left the (unit) without no one knowing. The middle door (fire door) to the nursing station was closed. The security said that he/she went out through the employees time clock area to the employee parking lot when the alarm sounded. The (security) went out immediately and brought him/her back to the floor by 2:05 pm. I made MD aware and he/she said to put him/her on 1:1 until Monday (March 6, 2017). RP was called and I received answer call the facility and speak to the charge nurse. His/her name is .No injury noted on assessment. B/P 140/70, p 62, R 18, afebrile. March 5, 2017 at 3:30 PM: Resident alert verbal responsive no shortness of breath cooperative with treatment care. Pain management in progress no elopement noted at this shift. After am care resident was put to the nursing station for monitoring. No behavior problem noted. A review of Resident #1's record revealed no order for 1:1 monitoring. Through interviews with facility staff (Employee #1 and CNA#2) it was determined that the resident was not monitored 1:1 but placed at the nurse's station and checked hourly. According to the unit Monitoring Schedule dated March 4, 2017, there were no employees assigned to monitor the front door (unit entrance/exit door) from 7:00 AM through 10:00 AM. According to the assignment sheet for the secure unit dated March 4, 2017, there were three (3) CNAs assigned to work the day shift on the secure unit. CNA #1 was assigned to watch the front door from 10:00 AM to 11:00 AM and 1:00 PM to 2:00 PM. A face-to-face interview was conducted with CNA #1 on March 9, 2017 at 12:25 PM. He/she was asked about the schedule and stated, When we have only 3 CNAS we don't have enough help to have someone sit at the front door. In the morning, I had to get 10 residents up and I was doing resident care at ten o'clock. In the afternoon, I had three residents to feed. Lunch trays came up about quarter-to-one and I was assigned to the dining room so I had to stay there. I wasn't at the door even though I was assigned. When we have only three CNAs we shut the doors by the nursing station (fire doors). They are not locked and you can still go in or out. The residents don't usually go through the doors. According to the unit Monitoring Schedule CNA #2 was assigned to watch the front door from 11:00 AM to 12:00 PM and 2:00 PM to 3:00 PM on March 4, 2017. A face-to-face interview was conducted with CNA #2 on March 9, 2017 at 12:15 PM. CNA #2 was asked about the above situation and stated, When we have only three CNAs we don't sit at the door. We close the middle doors (fire doors) near the nursing station for safety, to keep the residents here on the unit close to the day room and the nurse's station. I didn't sit at the desk all day . I was doing resident care at the times I was assigned. I didn't see anyone sit at the front door all day According to the unit Monitoring Schedule CNA #3 was assigned to watch the front door from 12:00 PM to 1:00 PM on March 4, 2017. A face-to-face interview was conducted with CNA #3 on March 9, 2017 at 3:10 PM. He/she was asked about the above incident and stated, I was assigned to Resident #1. I helped him/her get dressed and assisted him/her into the wheelchair. There were only three CNAs and I didn't sit at the desk by the front door. I was getting residents to the dining room for lunch and then I had to feed residents. I gave Resident #1 the lunch tray. He/she likes to eat in his/her room. Then I went to the dining room. I thought he/she was in the room until one of the other CNAs told me that security had just brought him/her back from the parking lot. I have worked with Resident #1 before and I never knew he/she was an elopement risk. I took the vital signs and then he/she sat by the nurse's station. The nurse said the resident was supposed to be 1:1 but we didn't have enough staff so he/she was placed at the nurse's station. The (unit) Front Door Coverage sheet was developed by the facility and included date, time listed in one hour increments for the 24 hours, employee name and title. Employees sign the sheet for the time they sit by the front door and monitor it. The monitoring sheet was blank for March 4, 2017 except for an employee's signature in the 9:00 PM - 10:00 PM time slot. There was no evidence that facility staff implemented any interventions to ensure that subsequent elopements did not occur after Resident #1 eloped on March 4, 2017. Resident #2 was admitted to the facility on [DATE]. According to the hospital discharge summary dated March 3, 2017, under Attending progress notes was the following: Patient evaluated and deemed NOT to have capacity per psych - had been trying to leave the unit several times and Code Bert has been called several times this stay. An Elopement Risk Assessment was completed by Employee #1 for Resident #2 on March 3, 2017 (date of admission). The resident was identified as an elopement risk. A face-to-face interview was conducted with Employee #1 on March 9, 2017 at 3:30 PM. He/she was asked about the above concerns and stated, I assessed the resident as I always do and determined that he/she was an elopement risk. (The Resident) should have had a wander guard bracelet put on him/her. I didn't see any in the nursing office and I have access to central supply but all of the electronics are locked up. I would have put on one him/her if I had one. I didn't work the weekend and was going to follow up on Monday (March 6, 2017). He/she was very cooperative with the assessment and never said he/she wanted to go home. According to the facility's Wandering Resident Program there was no evidence that Employee #2 placed Resident #2's picture at the front desk or notified security that Resident #2 was an elopement risk as per facility policy. According to a nurse's note dated March 4, 2017 at 9:54 PM: Writer received call from evening clinical manager that they could not locate resident after searching the building. Writer notified (administrator) via phone. DON and Administrator arrived at the center to assist with the search with other staff members/Department Directors. Facility staff searched all rooms and bathrooms including basement and unable to locate resident. At 8 PM facility called police and officer arrived at center at 8:20 PM. Resident information and description provided to police. Officer called his team and dispatched them to his home address . Staff on the unit said resident was last seen between 5:26 PM before dinner, while taking all residents to the dining room. Staff last saw him/her with occupational therapist on the unit. Resident (family member) was called at home and said he/she was not with him/her. He/she gave me his/her friend's name and . all numbers checked on chart. Called (friend) and was given resident's cell phone number. Number called and resident picked the phone at 8:47 PM and writer introduced self, asked him/her where he/she is and resident stated home in his/her bed. Police asked resident how he/she got home and resident said didn't remember. DOH called at 8:38 pm, ombudsman called at 9:24 PM, adult protective services called at 9:37 pm. Physician notified at 8:19 PM. 3rd District police got to resident's house at .9:15 PM. Resident did not remember being at center but he/she agreed to go to the hospital. Police said they will drive him/her to the hospital. Adult protective services returned my call at 10:21 PM and was notified of occurrence. Officer (MPD) left facility at 10:10 PM. Police gave case number . According to a nurse's note dated March 5, 2017 at 12:22 AM: Resident was in the hallway with other residents. At about 5:45 PM resident was seen by the occupational therapist. Afterwards, at about 5:50 PM resident could not be located on the hallway. Writer located the therapist but denied being with the resident. Writer searched all the rooms within the facility to no avail. Writer also checked the surrounding streets and (stores) but resident could not be located. Metropolitan Police made aware by the supervisor. Resident was allegedly located in his/her home found by police. Resident is still not in the facility at this time. A face-to-face interview was conducted with CNA #4 on March 9, 2017 at 3:57 PM. CNA #4 was asked about the above incident and stated, I sat at the door from three to four. Then I had to get my residents ready for dinner. No one else was there after me. I didn't know the resident. I had never met him/her. The trays came up between five-thirty and quarter to six. The unit doors were closed. Everyone was in the dining room except the couple of residents who like to eat in their rooms. I answered a call light at five-thirty. Then I went to the dining room to help with the meal. When I went to the dining room I saw the resident standing by the nurse's station. There were only three CNAs scheduled to work so there is no one that sits at the front door except me a couple times during the shift. When I came to work at three o'clock, no one was at the door. After I left the door at four o'clock everyone was doing care and getting residents ready for dinner. No one was at the door. After I helped look for the resident, I went back to the door at nine o'clock. That was after the resident eloped. A review of the (unit) Front Door Coverage she for Saturday, March 4, 2017 revealed that CNA #4 signed on the sheet in the time block for 9:00 PM to 10:00 PM. There were no other signatures on the form. A face-to-face interview was conducted with CNA #5 on March 9, 2017 at 4:13 PM. He/she was asked about the above incident and stated, CNA #4 went to monitor the courtyard from three-thirty to four. At that time I sat at the door. I didn't sign the book. I forgot. At four o'clock CNA #4 returned and sat at the door. I went to get my residents ready for dinner. At about quarter to six I saw the OT take the resident to his/her room for the assessment. I thought that the resident was with him/her . The resident was wearing a coat. We tried to get him/her to hang it up but the resident refused. The trays came up and we went to the dining room to help feed the residents. Then they told us the resident was missing. A face-to-face interview was conducted with Employee #2 on March 9, 2017 at 3:00 PM. He/she was asked about the above incident and stated, When there are only three CNAs we shut the unit door and no one sits at the front door. We have to take care of the residents. I saw the OT (Occupational Therapist) take the resident to his/her room for the assessment. I thought the resident was with the OT. Then the trays came up and I was helping them pass trays and in the dining room to help feed the residents. When we couldn't find him/her I called all over the house looking for the OT but the resident wasn't with him/her. Then the supervisor notified the other administration people and the police. A face-to-face interview was conducted with Employee #3 on March 9, 2017 at 10:00 AM. Employee #3 was asked about the above concerns and stated, We were by the nursing station and I asked the resident to go to the room so I could evaluate him/her. The resident asked me if this was psych and I told him/her who I was and what OT was. We went to the room and the evaluation takes about 15 minutes. Then we walked back to the nursing station and I left the unit. Through staff interview and record review, it was determined that Resident #2 was last seen in the facility at approximately 6:00 PM on March 4, 2017. The resident was admitted on [DATE] and was assessed as being an elopement risk. There was no evidence that facility staff placed a wander guard bracelet on the resident, took his/her picture to be placed in the elopement risk binder on the unit and at the front desk, or notified Security that the resident was an elopement risk. Through staff interviews, it was determined that there were no employees sitting at the entrance/exit door to the secure unit on March 4, 2017 from 1:00 AM until 9:00 PM. Upon observation of the entrance/exit door to the secure unit, there was no visual or audible alarm to notify staff that the door had been opened. According to the (unit) Front Door Coverag sheet for March 3, 2017, there were no signatures present from 1:00 AM through 7:00 AM and 9:00 AM through 1:00 AM. There was a signature present for 7:00 AM to 8:00 AM and 8:00 AM to 9:00 AM. According to the Nurse Staffing Daily Roster three (3) CNAs were scheduled for the day and evening shifts for March 5, 2017. The (unit) Front Door Coverage sheet for March 4, 2017 was blank for 1:00 AM through 9:00 AM. The sheet was signed from 9:15 AM through 1:00 AM indicating that there was a person monitoring the entrance/exit door to the secure unit. There were no signatures for the (unit) Front Door Coverage sheet for Sunday, March 5, 2017 from 1:00 AM through 9:15 AM. Employees signed as monitoring the door from 9:15 AM through 1:00 AM (a total of 16 hours). An in-service was conducted by Employee #6 on the March 5, 2017 for day and evening shifts with nursing staff members. Topic included; The front door of (unit) must have a human being monitoring at all times - No Exceptions. Charge nurse - please complain and enforce on your shift. Any :questions/doubts please see your shift unit manager for clarification. A review of the March 6, 2017 (unit) Front Door Coverage revealed no signature on the form from 4:00 PM through 11:00 PM. The CNA assigned to those times was CNA #6. In a face-to-face interview conducted on March 9, 2017 at 2:000 PM, Employee #6 stated that the assigned CNA was an agency CNA. His/her name was not listed on the in-service sign-in sheet. A face-to-face meeting was conducted on March 9, 2017 at 4:45 PM with Employees #4 and #5 who acknowledged the above findings. Facility staff failed to adequately supervise two (2) residents who eloped from the secure unit on March 4, 2017.

Based on record review and staff interview for one (1) of 38 Stage 2 Sampled residents, it was determined that facility staff failed to accurately and consistently assess and/or monitor the skin integrity (surgical site) for Resident #262, which resulted in harm. The resident was admitted on [DATE], there was no evidence that the nursing facility identified and/or acted on any abnormalities with the wound; the resident was evaluated by an outside consultant during a routine follow-up appointment approximately 10 days post admission wherein the wound was determined to have deteriorated and required emergency management. The nursing facility's failure to assess the wound contributed to the wound deterioration requiring transfer to a local emergency department and same day urgent surgical intervention of the surgical wound The findings include: Res #262 was admitted to the facility on [DATE] status [REDACTED]. He/she was admitted with a surgical wound of the lower back for which a wound vac (negative-pressure wound therapy using a vacuum assisted drainage technique to remove blood or serous fluid from a wound or operation site) was administered for management of drainage from the lumbar surgical site during his/her hospital stay. During an evaluation of the resident's surgical site by an outside-of-the-facility consultant on [DATE] (10 days' post admission to the nursing facility) the resident was assessed with [REDACTED]. A review of the facility's assessments of the resident's altered skin lacked evidence of deterioration or lack of healing. Additionally, the documented assessments reviewed in the resident's medical record lacked evidence of accuracy, completeness and consistency as follows: According to the Discharge/Transfer Summary from the hospital dated January 27, 2017 15:48 (3:48 PM), the resident's discharge [DIAGNOSES REDACTED].Hospital Course . POD (Post-op day) #13 (1/25/17); The inferior aspect of (his/her) incision began to leak. (His/Her) incision was partially reopened at bedside, and a wound vac was placed. POD #15; .Subsequently deemed medically stable, and discharged to subacute rehab. (His/her) current wound vac was placed on 1/25. It will be clamped for transport to the facility. (His/her) wound vac should be changed twice weekly with small black granulofoam. Please keep (his/her) bulk off the lily pad. Decision can be made by wound care team at facility regarding when they feel it is appropriate to change to wet to dry dressings. The nursing admission note dated January 27, 2017 at 7:12 PM revealed Resident admitted to (skilled facility named) from (acute hospital named) at this time; resident arrived BIBA (brought in by ambulance) from (name hospital) this pm; resident has a medical history significant for [MEDICAL CONDITION] post op; [MEDICAL CONDITION] due to acute blood loss; acute post-operative pain; history of spinal fusion for scoliosis; [MEDICAL CONDITION]; presently resident presents as alert and oriented x (times) 3; . integumentary inspection reveals s/p (status [REDACTED]. MD gave wound care orders until wound vac to be implemented . The physician prescribed a wound vac to manage Resident #262's surgical wound as noted in the following admission order: January 27, 2017 1/27/17 (no documented per physician) Turn and position every 2 hours, chart by shift, OOB (Out of bed) with assistance, Reverse Trendelenburg when in bed, do not flex, OK to sit upright in chair, Current wound vac (negative-pressure wound therapy using a vacuum assisted drainage technique to remove blood or serous fluid from a wound or operation site) placed on 1/25/17, wound vac to be changed twice weekly with small black granulofoam, keep bulk off lily pad, wound care team to decide when appropriate to change to wet-dry dressing . The physician prescribed an alternate treatment to manage the resident's surgical wound after licensed nursing staff advised him/her of their inability to carry out the aforementioned order for the wound vac: January 27, 2017 (1/27/17)- 7:30 PM directed; . Wound care to back - Cleanse (with) DWC (Dermal Wound Cleaner), Apply [MEDICATION NAME] to surgical site, cover with Bordered Foam Dressing until wound vac placed . The physician's history and physical examination [REDACTED]. male/female with [MEDICAL CONDITION], Recent medical course . S/P (status [REDACTED]. A written statement dated February 8, 2017 ( no time indicated) written by Employee#21 (clinical manager - registered nurse) revealed; Resident arrived to (named skilled nursing facility) on 1/27/17 with wound vac dressing in place. I was informed by Director of Admissions that day that I was only to attach the wound vac device to the dressing on the resident. However, the wound vac device would not attach to the dressing due to differing connections/attachments. I then notified the Director of Nursing who instructed me to call the Medical Director. I then called the Medical director who gave wound care orders (wet-to-dry dressing until wound vac available). A review of Resident#262's clinical record revealed inconsistencies regarding the implementation of the wound vac. Licensed nursing staff recorded that the wound vac was initiated on January 27, 2017. However, according to interview and record review, the wound vac was not implemented until January 30, 2017 as evidenced by the following: Wound/skin sheet dated January 27, 2017: Date of Onset/Origin: January 27, 2017- Site/Location: Lower Back (Lumbar); Type of Wound: Surgical; Exudate Type: Serious; Odor: None; Exudate amount: Large; Wound Bed: Pink/Beefy Red, Comments: Wound vac applied . Nurse's entry: January 30, 2017- 04:31 PM- . Resident's wound vac in place and draining. Staples and surgical site intact with no sign of infection . Wound/skin sheet dated January 30, 2017: January 30, 2017 - Site/Location: Lower Back (open area); Type of Wound: Other: Surgical (wound vac); Size: 4cm x 2cm; Depth: 1 cm; Exudate Type: Serosanguineous; Odor: None; Exudate: Amount: Moderate; Wound Bed: Pink/Beefy Red, Date notified physician: 1/30/17, Comments: wound vac applied, functioning and draining well. The history and physical examination [REDACTED].sacral wound . There was no evidence of a comprehensive assessment regarding the characteristics of the resident's wound(s). Additionally, there were no successive notes recorded by the primary care physician. Subsequent to the physician's visit of January 29, 2017, the prescribed wound treatment orders were modified to include the use of a highly absorbent dressing as noted below: January 29, 2017 (1/29/17) - 5:00 PM- . (1) Please clean lower back (Lumbar) surgical wound (with) normal saline- Apply [MEDICATION NAME] Extra Alginate (highly absorbent dressing used for moderate to heavily drainage wounds) on wound area cover (with) Derma rite daily (times) 10 days . As noted above, the wound vac was applied on January 30, 2017 and according to nurse's notes, was draining as noted in the following nurse's entry: February 2, 2017 at 10:56 PM . wound vac in place draining serosanguinous, Staples and surgical site intact . The wound vac was 'dislodged' on February 3, 2017 (4 days post implementation of the wound vac) as noted by the following nurse's entry: February 3, 2017 at 6:49 PM While resident was having x-ray AP (Anterior-Posterior) lateral, T-spine ([MEDICATION NAME] Spine) and L-spine (Lumbar Spine). Wound vac became dislodged. (MD named) notified, new order to D/C (Discontinue) wound vac and restart previous dressing changes until wound Vac replacement arrives. Dressing applied as ordered . The nurses' notes lacked consistent documentation depicting the characteristics of the resident's surgical wound at the time of dislodgement, there was no information regarding the type of exudate as evidenced by the following wound/skin sheet dated February 3, 2017: February 3, 2017: Site/Location: Lower back (open area) surgical wound; Type of Wound: Other: Surgical; Size: 4 cm x 2cm; 0 depth; Exudate Type: no assessment recorded (space was blank); Odor: None; Exudate amount: Small; Wound Bed: Pink/Beefy Red; Plan of Care Updated: Wound vac dislodged when doing X-ray- 45 staples intact . Physician's wound treatment order post wound vac dislodgement: February 3, 2017 (no time indicated) - - Telephone order: D/C (Discontinue) wound vac- Clean surgical wound on lower back (with) NSS (Normal Saline Solution), Apply [MEDICATION NAME] Exra Alginate on wound Area-cover with Derma rite daily and PRN (as needed) . The medical record lacked evidence that the physician assessed and reevaluated the resident's wound(s) after the dislodgment of the wound vac. There was no evidence that staff consistently monitored the status of Resident #262's surgical site post dislodgement. Nurse's notes revealed wound treatments were performed daily, however; there was no evidence of comprehensive assessments of the characteristics of the surgical wound subsequent to the dislodgment of the wound vac. Nurse's notes read as follows: 2/3/2017- 11:18 PM . wound dressing intact. X-ray result was received no evidence of fracture reported . 2/4/2017- 06:54 AM . wound dressing intact . 2/4/2017-04:15PM . Tolerated dressing change to back surgical wound with minimal discomfort. 2/4/2017-11:27 PM . wound dressing intact . 02/5/2017- 06:41 AM . Spinal incision dressing intact with no drainage or odor . 02/5/2017-05:24 PM - Wound dressing intact. Serosanguineous drainage noted 02/06/2017- 12:05 AM . wound dressing intact with Serosanguinous drainage noted . 02/06/2017-06:40 AM- . spinal incision dressing is drained. Dressing is cleaned with normal saline and dressed. Resident is cleaned and made ready for (his/her) appointment this AM. SIC (written as documented) A review of the treatment administration record (TAR) for February 2017 revealed the nurse's initials in the slot for February 6, 2017 indicative that the wound treatment was performed prior to the resident's departure for an appointment outside to the facility. Note, as per physician's orders [REDACTED]. An assessment conducted by an out-of-facility consulting physician at approximately 10:48 AM on February 6, 2017 (within hours of leaving the facility) characterized Resident #262's wound as actively draining foul smelling purulence (exudate). The Neurosurgery (outside consulting physician) note dated February 6, 2017 read: . discharged from (hospital named) on 1/27/17 presenting to (MD named) clinic today for a postop check with signs and symptoms concerning for wound breakdown including a ~ 10 cm segment of wound breakdown in the lumbar and sacral region with actively draining foul-smelling purulence. (He/she) was sent to the ED (Emergency Department) for wound washout in the OR (Operating Room) today . Physical Exam . Incision with ~10cm region of wound breakdown in the lower lumbar and sacral area with actively draining foul-smelling purulence . Plan: Patient going to OR today as an add-on for wound washout and debridement . A review of the ED (Emergency Department) dated February 6, 2017 at 11:52 AM revealed; Pt (Patient) presented to ED .Pt reports (he/she) had back surgery in January 2017 . Pt unable to stand independently. Pt arrived in w/c (wheelchair); 4 staff members (plus) (patient's relative named), assisted patient to the bed from wheelchair. Serousanguinous fluid (large amount dripped on the floor. Patient wound is approx. (approximately) 10 cm (centimeters) in length, width unable to determine . Pt was transferred to OR (Operating Room) for wound vac placement. According to an Operative Report dated 2/6/2017 - 12:48 AM; Pre-operative Diagnosis: [REDACTED]. In summary, Resident #262 was admitted to the facility with an intent for management of his/her post-operative surgical wound with a wound vac. The wound vac was applied for a period of 4 out of 10 days that the resident resided in the facility. On the 10th day post admission, the resident was assessed by an outside consultant who identified the surgical wound as deteriorated and sent the resident to the hospital for emergency management and surgical intervention. There was no evidence that facility staff, who observed the resident's wound hours prior to the outside consulting physician, identified any abnormalities or failure of the resident's wound to heal. Staff failed to accurately assess and consistently characterize the resident's wounds and recorded inconsistencies in wound treatments. Additionally, the clinical manager identified that the resident was admitted with the vac dressing in place. However, he/she could not attach the tubing to create a negative vacuum pressure to assist with drainage of the surgical wound to promote healing. A face-to-face interview was conducted with the Director of Nursing on February 8, 2017 at approximately 2:30 PM regarding the date the wound vac was re-applied. He/she states that the wound vac was connected on January 30, 2017. Further stated, that she/he received a phone call (on January 27, 2017) from the Employee#21 (clinical manager - registered nurse) regarding his/her inability to connect the wound vac because of tubing issue. Employee#21 was instructed to inform the physician to get orders and document the concern/inability to connect tubing. When queried; what made the difference in the wound vac being applied three (3) days later; he/she stated that a new wound vac kit was used. After review of the clinical record, he/she acknowledged the aforementioned findings. The clinical record was reviewed on February 8, 2017. Based on observation, record review and staff interview for one (1) of 38 Stage 2 sampled residents, it was determined that facility staff failed to ensure that one (1) resident's Midline Inserted Catheter was flushed and monitored in accordance with the attending physician's orders [REDACTED]. The findings include: 1a. Facility staff failed to flush a midline catheter in accordance with the physician's order [REDACTED]. An interim physician's orders [REDACTED]. According to a physician progress notes [REDACTED].#221's chief complaint was UTI . Plan/Impression: . Complete course of antibiotic . A review of the Mid-Line Catheter Protocol dated and signed by the physician on January 25, 2017 revealed: Flushing Protocol: Use SASH (Saline, Antibiotic, Saline, [MEDICATION NAME]) Technique . Intermittent Meds, 5 Ml (millimeters) NSS (Normal Saline Solution) before med, 5 ml NSS after med; Then 5 ml 100 Unit/ml [MEDICATION NAME] Flush; Treatment Protocols: Change tubing q (every) 24 hours primary and secondary intermittent . The January, 2017 Central - Catheters flow sheets and the MAR (Medication Administration Records) lacked evidence (spaces left blank) that facility staff flushed the resident's mid line catheter on January 26, 27, 28 and 29, 2017. A face-to-face interview was conducted on February 7, 2017 with Employee #10 at approximately 10:30 AM. After review of the above he/she acknowledged the findings. The record was reviewed on February 7, 2017 1b. Facility staff failed to monitor Resident #221' s Midline Catheter in according to physician orders. A review of the Central-Line Catheters protocol signed by the physician on January 25, 2017 directed: Measure Arm Circumference 27 inches above insertion site on admission, PRN (as needed) and Q (every) 7 (seven) days with dressing change, Measure external catheter length on admission, with each dressing change and PRN, Q 7 days with dressing change The(external consultant's named) Vascular Access Patient Information sheet dated January 25, 2017 revealed; Side: Right; Vein: Branchial- External CM (circumference measurement) -0; Arm Circumference at Site: 27 cm (centimeters) . A nurse's note dated January 31, 2017 at 12:33 AM revealed; . Dressing change done for midline to right upper arm with central line kit. Resident tolerated procedure well. Area cleanse aseptically and new dressing placed, dated and initialed. Resident continues with current plan of care. A review of the Central-Line Catheters monitoring flow sheets, MAR (Medication Administration Record) and Nurses Notes from January 31, 2017 through February 2, 2017 lacked any evidence of measurements of the resident's upper arm circumference or the external catheter length according to the midline catheter protocol. A face-to-face interview was conducted on February 7, 2017 with Employee # 8 at approximately 10:30 AM. After a review of the above clinical record he/she acknowledged the aforementioned findings. The record was reviewed on February 7, 2017.

Based on staff interview and record review for one (1) of 33 sampled residents, it was determined that facility staff failed to ensure that necessary treatment and services were provided to promote wound healing, subsequently the resident ' s facility acquired pressure ulcer progressed to a Stage 3. Additionally, the resident ' s pressure sore risk was inaccurately assessed. Resident #42 The findings include: According to the Admission Nursing Evaluation dated September 11, 2015: Resident # 42 was [AGE] years old, wheel chair dependent, dependent for toileting, cognitively impaired, admitted from home. The evaluation included that the resident was incontinent of bowel / bladder, was dependent for toileting and wore adult briefs at all times. His/her and skin was moist with no areas of breakdown. A review of Resident # 42 's September 21, 2015 admission Minimum Data Set (MDS) revealed: In Section C, Cognitive Patterns, the resident was coded as moderately cognitively impaired with a score of 9 in the Brief Interview for Mental Status. According to the MDS 3.0 User ' s Manual page C-14, a score of 8-12 suggests that the resident has moderately impaired cognitive skills for daily decision making. Section G, Functional Status, was coded to reflect the resident required extensive assistance of one (1) person for bed mobility, total dependence of two (2) persons for transfer, total dependence of one (1) person for locomotion, limited assistance for eating and total dependence for toilet use. Item G0400, Functional Limitation and Range of Motion: impairment of lower extremities on one side. Section H, Bowel and Bladder always incontinent of bowels and bladder. Section I, Active [DIAGNOSES REDACTED]. Section M, Skin Conditions was coded under M0210, unhealed pressure ulcer(s) as 0, indicative that the resident was admitted without pressure ulcers. The successive (quarterly) MDS dated [DATE], revealed under Section M, Skin Conditions, M0300 current number of unhealed pressure ulcers at each stage was coded as B1 indicative that Resident #42 developed one (1) Stage 2 pressure ulcer. A review of the resident ' s record revealed that physician progress notes [REDACTED]. A physician's order [REDACTED]. This order was included in the monthly pre-printed orders signed by the physician on January 6, 2016. A review of the Treatment Administration Records (TARs) for December, 2015, revealed that the above cited order was transcribed onto the TAR. There was no evidence that facility staff followed up on the physician's order [REDACTED]. According to a physician ' s progress note dated December 16, 2015 at 3:00 PM: Sacral pressure ulcer, Stage 2, clean, ¿ (increase) pink tissue, minimal serous drainage, no odor . According to a physician ' s progress note dated December 23, 2015, Sacral pressure ulcer partial thickness fully re-epithelized . According to a physician ' s progress notes dated February 10, 2016: Sacral pressure ulcer re-opened, Stage 2, partial thickness, minimal serous drainage, no odor, peri-wound skin intact . There was no evidence that the order for the Roho cushion was transcribed onto the February 2016 pre-printed orders. However, there was no evidence that the physician intended to discontinue the Roho cushion and there was no evidence that the directive (December 14, 2015 order) to obtain the cushion was followed through. According to a physician ' s progress notes dated February 17, 2016 at 2:00 PM: Sacral pressure ulcer Stage 2 slowly healing, ¿pink tissue, minimal serous drainage no odor . February 24, 2016 at 6:00 PM: Sacral pressure ulcer now turned to Stage 3, + (positive) slough, + minimal serous drainage, no odor, + pink tissue . March 3, 2016 at 3:00 PM: Sacral pressure ulcer Stage 3 healing, ¿pink tissue, minimal slough, no odor, + slough . March 8, 2016 at 2:10 PM: Has sacral pressure ulcer Stage 3 got worse (larger) + slough, + pink tissue, minimal serous drainage, no odor. Poor oral intake/malnutrition . A physician's order [REDACTED]. According to a nurse ' s note date March 8, 2016 at 4:46 PM, Received Roho cushion from Rehab (rehabilitation) this AM and placed in resident ' s chair . A review of The Braden Scale for Predicting Score Risk revealed the following: The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development. Scale- (Low Risk 15-16 Moderate Risk 13-14 High Risk 12 or Less). <https://www.nlm.nih.gov/research/umls/sourcereleasedocs/2009AA/LNC_BRADEN/> A review of Resident #42 ' s Braden Scale assessments conducted by facility staff revealed the following: September 11, 2015: Sensory perception (ability to respond meaningfully to pressure related comfort) (4) No impairment Moisture (degree to which skin is exposed to moisture) (4) Rarely moist Activity (Degree of physical activity) (2) Chairfast Nutrition (Normal food intake) - (3) Adequate Friction and Shear - (2) potential problem Score 15 (15-16 indicates low risk) According to the resident ' s MDS with an assessment reference date of September 11, 2015, the resident was coded as always incontinent of bowel and bladder in Section H (See above). This would give the resident a score under always moist of One (1) and a total score of 12 indicating a high risk for pressure ulcer development. September 21, 2015: Sensory perception: (4) No impairment Moisture: (4) Rarely moist Activity: (2) Chairfast Nutrition: (3) Adequate Friction and Shear: (2) potential problem Score 15 (15-16 indicates low risk) According to the resident ' s MDS with an assessment reference date of September 21, 2015, the resident was coded as always incontinent of bowel and bladder in Section H (See above). This would give the resident a score under always moist of One (1) and a total score of 12 indicating a high risk for pressure ulcer development. Facility staff failed to accurately assess Resident #42 ' s risk for developing a pressure ulcer using the Braden Scale. Subsequently a Stage 3 pressure ulcer developed on the sacrum. A review of the most recent Nutrition assessment dated , September 22, 2015 revealed Resident would require 1800/2000 cc (cubic centimeter) fluid a day to maintain the goal of no signs/ symptoms (s/s) of dehydration. The plan was to follow nutrition plan of care. The Nutrition care plan initiated on September 22, 2015 revealed Approaches: monitor for monthly weights, skin condition, s/s (signs and symptoms) dehydration and food intake records. Goals: no significant changes, 75-100% food intake, no s/s (signs/symptoms) dehydration, maintain good weight status. The nutrition care plan updated December 30, 2015 revealed, Approaches: increase assistance with meals as needed continue present plan of care. There was no evidence of further nutritional assessments or interventions after September 22, 2015. There was no evidence that the dietician reviewed the resident ' s nutritional/hydration status when the resident developed a facility acquired pressure ulcer on December 16, 2015, after the resident ' s sacral wound re-opened on February 10, 2016 or when the pressure ulcer worsened to a Stage 3on February 24, 2016. Facility staff failed to obtain a pressure relieving cushion as ordered by the physician on December 14, 2015. The cushion was re-ordered on March 7, 2016 and obtained from the rehabilitation depart on March 8, 2016 after the wound had progressed to a Stage 3. The resident was transferred to a local hospital via emergency medical services (EMS) on March 8, 2016 at 4:00 PM as evidenced by the following physician's order [REDACTED]. A face-to-face interview was conducted on March 17, 2016 at approximately 9:30 AM with Employee # 8. He/she acknowledged that the resident was admitted without pressure sores, subsequently developed a Stage 2 which healed and re-opened to advance to a Stage 3. He/ she further stated the pressure relieving device was delayed and other than turning and repositioning no other measures were implemented to relieve pressure. After a review of the medical record, Employee # 8 acknowledged the aforementioned findings. The medical record was reviewed on March 17, 2016.

Based on observation, record review, staff and resident interviews for two (2) of 33 Stage 2 sampled residents, it was determined that facility staff failed to provide adequate supervision to ensure safety for one (1) resident who sustained second degree burns to the thighs after spilling coffee that was reheated in the microwave by facility staff. Additionally, there was no evidence that the facility had a policy in place to ensure the safe handling of reheated and/or microwaved beverages, such as coffee; staff failed to provide adequate supervision to one (1) resident with a history of repeated falls who sustained a fall with an abrasion injury and staff failed to ensure that the environment was free of potential accident hazards as evidenced by surge protectors that were in-use and unsecured in two (2) of 47 resident rooms observed and a janitor's closet that was accessible to residents and unlocked where hazardous substances were stored on one (1) of eight (8) resident care units. Residents #99 and #237. The findings include: 1. Facility staff failed to provide adequate supervision to ensure safety for Resident #99 who sustained second degree burns to the legs after spilling coffee that was reheated in the microwave by facility staff. Additionally, there was no evidence that the facility had a policy in place to ensure the safe handling of reheated and/or microwaved beverages, such as coffee. The microwaves used in the facility include the Sunbeam brand microwave. According to the Sunbeam User ' s manual: Microwaved water and other liquids do not always bubble when they reach the boiling point; they can actually get superheated and not bubble at all. Superheated liquid can bubble up when it is moved or when something like a spoon or tea bag is put into it. To prevent this from happening and causing injury, do not heat any liquid for more than 2 minutes per cup. Before removing the container from the oven, allow the container to stand in the oven for 30 to 40 seconds after the oven has shut off, <http://www.user-manual.info/ 3/microwave-oven/sunbeam/sbmw1109w-bl/4/>, (p.3). According to the American Burn Association Scald Injury Prevention Educator ' s Guide , Older Adults Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . Time and Temperature (temp) Relationship to Serious Burns: Water Temp Time Required for a 3rd Degree Burn to Occur: 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 52°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing Second-degree burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial thickness burns, (<https://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm>). A face-to-face interview was conducted on March 18, 2016 at approximately 9:00 AM with Resident #99. When queried regarding the burn, the resident stated I place the coffee cup between my thighs before I go down to smoke and drink my coffee in the morning. When asked how (he/she) sustained burns to thigh the resident stated, The coffee fell on it and I don ' t want to answer any more questions. A face-to-face interview was conducted with Resident #99 on March 18, 2016 at 11:12 AM. At this time, he/she explained that (he/she) was in the courtyard on (the morning of) March 17, 2016 and had (his/her) coffee cup was on top of the wall that (he/she) was sitting next to. The resident reached up to get the coffee cup and when (he/she) brought the cup down, the coffee spilled on (his/her) lap. A final face-to-face interview was conducted with Resident #99 on March 18, 2016 at 1:50 PM. The resident further explained that (he/she) takes (his/her) coffee down to the courtyard sometimes and (he/she) took it yesterday (March 17, 2016) After the nurse warmed it up for (him/her). (He/she) said that the nurse offered to carry (his/her) coffee to the courtyard for (him/her) but (he/she) told (him/her) No, I can make it. (He/she) stated, I was smoking, I reached for the coffee cup and when (he/she) brought it down it spilled on (him/her). It ' s nobody ' s fault but mine (he/she) said. An account of the burn injury sustained by Resident #99 was recorded in the following nurse's entry: March 17, 2016 at 4:43 PM, .at about (9:00 AM) resident reported to writer that, while (he/she) was drinking coffee this morning for breakfast, coffee spilled on (his/her) rt (right) thigh. On assessment blister noted. MD (medical doctor) made aware order give to apply Silvadene cream (an antibacterial cream used on burns) to blister area, writer apply the cream as ordered, Resident refused measurement at this time. No complaint of pain voiced . (sic) According to the Annual Assessment Form signed and dated by the physician on December 18, 2015, the Resident ' s [DIAGNOSES REDACTED].Surgical procedures: (status [REDACTED]. According to the quarterly Minimum Data Set (MDS) completed February 28, 2016, Resident #99 required limited assistance of one (1) person for transfers, locomotion on unit and off unit, dressing, eating, toilet use and personal hygiene under Section G (Functional Status). Under Section G0400 (Functional Limitation in Range of Motion) the resident was coded with impairment on both sides of the lower extremities and no impairment of the upper extremity (shoulder, elbow, wrist, hand). Resident #99 was observed seated in his/her room on March 18, 2016 at approximately 10:15 AM. He/she was seated in a standard sized wheelchair. There was no evidence that the resident ' s wheelchair was equipped with an apparatus such as a cup holder to safely store the coffee during transit or while seated away from a table. A cup of coffee was on the resident ' s bedside table. The resident agreed to permit facility staff to obtain the temperature of his/her coffee. The coffee was 87 degrees Fahrenheit and according to facility staff, it had been served with the breakfast meal. The temperature of the coffee obtained from stored in the coffee maker/dispenser located in dietary services was 172.1 degrees Fahrenheit at 11:02 AM on March 18, 2016. A face-to-face interview was conducted on March 18, 2016 at 10:40 AM with Employee # 27 Certified Nursing Assistant (CNA), caring for resident. He/she stated, I was working with (Resident #99). Breakfast came up and I delivered (his/her) tray. I guess (he/she) went to smoke. Later, I saw (him/her) coming off the elevator. I then assisted (him/her) to the room. (He/she) asked to stop at the charge nurse. We stopped and (he/she) asked to have something for (his/her) leg. I then assisted him to (his/her) room. I wouldn't have known anything about the burn if (he/she) hadn't stop to ask the nurse. I assist (him/her) with care. (He/she) moves from the bed to the wheelchair by (him/herself). (He/she) likes to eat in (his/her) room and does (his/her) own tray setup. A face-to-face interview was conducted on March 18, 2016 at 10:45 AM with Employee # 25 charge nurse caring for resident. Employee #25 stated, (Resident #99) went downstairs and came back upstairs. The CNA/Employee #27 was pushing (him/her) towards me. (He/she) said, let me show you something. (He/she) said I was drinking and the coffee) spilled on my thigh. (He/she) refused for the area to be measured. A face-to-face interview was conducted on March 18, 2016 at 10:50 AM with Employee # 26. He/she stated, I was on the unit at the time. I called Employee# 8 (a nurse manager covering the 2 North unit). We both went into the room to assess (him/her). We looked at the coffee cup and it was empty. Employee # 8 asked (him/her) was it hot when (he/she) got the coffee. The resident replied, Don't ask me no more (expletive used) questions. (He/she) declined the treatment and said that (he/she) was not taking (his/her) pants off. Employee #8 interviewed the CNAs to see if anyone warmed (his/her) coffee up. They said No. They (the CNAs) all wrote statements. (Resident #99) stated, (he/she) is not telling you anything, you are too nosey and (he/she) is tired of people coming to (him/her). A face-to-face interview was conducted on March 18, 2016 at 2:47 PM with Employee # 1, Administrator and Employee #28, CNA. In response a query to review the facility's policy related to the method that staff use to safely heat beverages in the microwave. They both stated, If they (the resident) want their coffee warmed up, we warm it up. Employee # 1 stated, Yes, we have microwaves to warm up the residents' food when they ask (for the food to be warmed). Everyone likes their coffee hot. Both employees were queried as to how they measure the temperature of the coffee and/or food being served to the resident that is reheated in the microwave. Employee #28 gave an example of another resident that likes his/her coffee reheated and stated, (resident's name) will tell you to warm (his/her) coffee for 20 seconds . Employee #1 did not respond to the question. Through interview it was determined that the facility ' s practice is to use the microwave to reheat residents' beverages and food when asked. However, there was no protocol, procedure or policy in place to ensure that beverages reheated via microwave are done so safely as to avoid burn hazards. Through interview it was determined that Resident #99 transported his/her coffee off of the residential unit and throughout the facility in an uncovered coffee cup placed between his/her thighs, as the resident is a bilateral lower extremity amputee and uses his/her hands to propel the wheelchair. There was no evidence that facility staff assessed the resident's needs to determine if he/she could benefit from an adaptive device such as a cup holder or a covered cup to ensure safe handling of the hot beverage. There was no evidence that facility staff provided adequate supervision to Resident #99 who moved about the facility with an uncovered cup of coffee served at an unknown temperature. The resident alerted staff of the burn injury upon his/her return to the unit from the outside courtyard smoking area, as it was not identified by staff supervising activities in the courtyard. There was no evidence that the facility had a protocol in place to ensure safe heating of hot beverages such as coffee in the microwave. Subsequently, the resident spilled the hot coffee onto him/herself and sustained second degree burns to the thighs. The record was reviewed on March 18, 2016. 2. Facility staff failed to provide adequate supervision for Resident #237 who had a history of [REDACTED]. Staff responding to a loud noise observed the resident lying on the floor with the wheelchair atop him/her. A review of Resident #287 ' s admission Minimum Data Set (MDS) dated [DATE] under Section I, Active [DIAGNOSES REDACTED]. in Range of Motion was coded as A2 and B2 indicative of impairment on both sides of the lower and upper extremities. Section C, Cognitive Patterns revealed the resident was coded as severely cognitively impaired with a score of 6 in the Brief Interview for Mental Status (BIMS). Section E, Behavior was coded as having verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred 4 to 6 days, but less than daily. Section J (Health Conditions) - Resident was coded as having one (1) fall with no injury prior to admission. A review of Resident #237 ' s clinical record revealed the resident sustained [REDACTED]. A low bed and bedside floor mat was one (1) of the interventions initiated to manage the resident ' s falls. The resident sustained [REDACTED]. A nurses ' note detailing the fall sustained by Resident #237 on January 5, 2016 read as follows: 01/5/2016 - 7:19 AM- At 5 AM, resident found on the floor by the nursing station lying on her back. AAOX# (Awake, Alert and Oriented (times) three (3). Resident denies hitting (his/her) head and denies pain. PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) - (bilateral) arm grasp equal in strength to both arms. resident sustained [REDACTED]. Areas cleansed??? with normal saline and ice applied. V/S (Vital Signs) - 140/76 (blood pressure) - 78 (pulse), 18 (respirations), Temp- 97.3 and FS (finger stick)-108. Resident assisted (times) 2 (two) from the floor. Resident denies pain. AROM (Active range of motion) WNL to all extremities. (MD named} and RP (responsible party named) notified. MD ordered x-ray of mid back and bilateral hips. Neuro (neurological) check initiated (times) 72 hours . A review of the facility ' s incident report titled, Incident Report Form , documented by nursing staff, dated January 5, 2016, (Time of Incident- not indicated- left blank). Read as follows: Exact Location of Incident: Other: Nursing Station . Type of Injury: Abrasion (and) Bruise . Describe Exactly What Happened (What you saw, who reported the incident, what the resident slid) - At 5:00 AM assigned CNA (Certified Nursing Assistant) reported to writer that resident fell out of the w/c (wheelchair) at the nursing station. Resident observed on the floor lying on (his/her) back. Noted to sustained abrasion/bruise (at) mid back. Helped back to w/c. Ice pak applied to midback. Denies pain. ROM (Range of Motion) to all extremities WNL (within normal limits) . SIC A review of the comprehensive care plan for Resident #237 revealed the interdisciplinary team (IDT) identified falls as a problem with a goal that the resident would be free from injury. The plan was initiated November 4, 2015 and updated November 30, 2015, December 12, 2015 and January 5, 2016. The falls care plan included (but was not limited to) the following: Problem Start Date - 11/4/2015- Category: Falls- Resident observed on the floor (mat) at bedside. Goal Target Date: 02/4/2016- Resident will remain free from injury. Approach: Avoid use of restraints, Give resident verbal reminders not to ambulate/transfer without assistance, Keep RP (responsible party) updated, Observe frequently and place in supervised area when out of bed, Provide resident an environment free of clutter . Problem Start Date: 11/30/15- Category- Falls- Resident observed on the floor (floor mat) at bedside. Goal Target Date: 03/01/2016- Resident will remain free from injury . Problem Start Date: 12/12/2015, Category: Falls- Resident observed on the floor (floor mat) at bedside; Goal Target Date: 03/12/2016- Resident will remain free from injury; Approach: 1:1 monitoring through 12/14/2015 . Problem Start Date: 01/5/2016- Category: Falls- Resident observed on the floor at nursing station. Goal Target Date: 4/5/2016- Resident will remain safe and injury free (times) 90 days. Approach: Ensure resident ' s chair equipped with device that monitors rising when OOB (Out of bed). Check for placement and functionality (every) shift. Monitor for pain (every) shift . Obtain PT/OT (Physical Therapy/Occupational Therapy) consult. - Resident currently on caseload. PT/OT made aware. Pharmacy Consultant to review medications. Follow up with recommendations to MD (Medical Doctor). Resident #237 sustained a fall without injury on December 27, 2016 (fall not recorded in care plan as others listed above) as recorded in the following nurse's entry: 12/27/2015 2:03 PM, Writer was on the unit to assess (Resident #237) that was observed on the floor mat by (his/her) bed in a sitting position, on assessment (he/she) is alert but confused A face-to-face interview was conducted with Employee #35 on March 23, 2016 at approximately 9:00 AM. When queried regarding Resident #237's fall on January 5, 2016 at the nurse ' s station; he/she stated, The resident fell out of the Geri chair. Further stated, the assigned CNA (Certified Nursing Assistant) reported that, Resident #237 was becoming agitated and was trying to get out of the bed. He/she informed the CNA, to get (him/her) out of the bed and put (him/her) at the nurses ' station. The resident was placed at the nurse ' s station before (CNA) went on break. Employee #35 was asked how often Resident #237 was placed at the nurse ' s station. He/she stated about one (1) to two (2) times a week. A face-to-face interview was conducted with Employee #32 on March 30, 2016 (interview was conducted after survey exit due to employee ' s availability). at approximately 10:00 AM. He/she acknowledged that the resident was observed lying on the floor at the nurses ' station. The resident had been restless all night. When queried, if the resident was observed seated at the nurses ' station unsupervised; Employee #32 stated, I was in another room caring for a resident, when I heard a loud noise. He/she proceeded to the door and went to the nurses ' station. After walking over to the nurses ' station desk, (he/she) looked over the desk and observed Resident #237 face down on the floor and the wheel chair was on top of (him/her). Further stated; that (he/she) called out for help and there was no staff at the nursing station. The clinical record was reviewed on March 18, 2016. Resident #237 sustained a fall from the wheelchair with an abrasion injury. Through interview, it was determined the resident was placed at the nurse ' s station when he/she was identified as restless, agitated and attempting to get out of bed. The care plan intervention identified by the IDT on November 4, 2015 included, Observe frequently and place in supervised area when out of bed. There was no evidence that staff implemented measures to promote safety for Resident #237 who demonstrated restlessness, had a history of [REDACTED]. 3. During observations made during on March 10, 2016 at approximately 10:00 AM and on March 15, 2016 at approximately 11:30 AM, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible as evidenced by: surge protectors were in-use and unsecured to the wall in two (2) of 47 resident rooms and an open, accessible janitor ' s closet on one (1) of eight (8) resident care units. A. Two (2) of two (2) surge protectors were observed in use and unsecure on the floor of resident room #215A, one (1) of 47 resident rooms surveyed. B. A surge protector was stored on top of a dresser in room #111, one (1) of 47 resident rooms surveyed. C. The entrance door to the janitor's closet located on 2 South was left completely open for approximately 30 minutes, from 11:55 AM to 12:25 PM on March 16, 2016. Jugs of floor cleaning chemical solutions were accessible to residents, staff and visitors. These observations were made in the presence of Employee #22 and/or Employee # 23 who acknowledged the findings.

Based on record review and staff interview for one (1) of 30 admission sampled (Stage 1)residents, it was determined that facility staff failed to ensure that one (1) resident who entered the facility having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent a new pressure sore from developing. This was a closed record review. The findings include: Facility staff failed to consistently assess Resident #64 ' s skin integrity to prevent a facility acquired pressure ulcer on the left buttock. Subsequently, a Stage 3 pressure ulcer was identified on the left buttock 16 days admission to the facility. According to the facility ' s policy, Pressure Ulcer Prevention Protocol Policy No. 104; issued 2011; stipulates: Procedure: I. Risk Assessment: A risk assessment is done to determined the resident ' s risk for the development of pressure ulcers. The risk assessment scale that will be utilized is the Braden Scale . II. Skin Assessment: 3. Inspect skin for signs of redness, change in temperature of skin ., VI. Support Surfaces: 1. Use a higher-specification mattress rather than standard facility mattress for residents at risk. According to the hospital discharge summary dated November 15, 2014 at 8:51 AM under the section special instructions included: Left heel: Heel Eschar. Apply santyl to eschar on heels and redistribute the pressure of the affected area, R (Right) hand blisters/open areas/necrotic areas: [MEDICATION NAME], dry dressing to R hand, esp (especially) black or necrotic areas BID (twice a day), R LE (Right Lower Extremity) wounds: Santyl to both RLE wounds with dry dressing (Allevyn) on top BID (twice a day) and Sacral Wound: NS (Normal Saline) WTD ( Wet to Dry) dsg (dressing) changes to sacral wound BID. The physician Admission Assessment Form dated November 17, 2014 revealed that Resident #64 ' s chief complaint/reason for admission was skilled services for: Multiple wounds, Decline in ADL (Activities of Daily Living). [DIAGNOSES REDACTED]. The Admission Order Sheet and Physician Plan of Care form revealed that Resident #64 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Admission Nursing Evaluation form dated November 15, 2014 revealed the skin condition section identified that the resident was admitted with a Stage IV Sacral Ulcer, Two (2) Stage 2 ulcers of the right lower extremity, and a left heel unstageable pressure ulcer. All the identified ulcers were depicted on an anatomical anterior and posterior body diagram. Resident #64 ' s Braden Scale-For Predicting Pressure Sore Risk was scored 8 on admission which indicates the resident was at High Risk for developing a pressure ulcer. According to the Admissions MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of November 21, 2014 indicated in Section G- Functional Status; resident was coded as total dependence with two+ (plus) persons physical assist for bed mobility. Section G0400- Functional Limitation in Range of Motion- Resident had upper extremity impairment on one side and impairment on both sides for lower extremities. Section H0300- Resident was always incontinent of bowel and urine. Section M: A Skin condition, resident was coded as being at risk of developing pressure ulcers. A review of Resident #64 ' s care plan initiated on November 15, 2014 included: Alteration in skin integrity related to multiple hospitals acquired pressure ulcers. Approaches included: Conduct a systematic skin inspection weekly. Report any signs of further skin breakdown keep clean and dry as possible. Minimize skin exposure to moisture, obtain a dietary consult and use moisture barrier product to perineal area. The Admission Order Sheet and Physician Plan of Care dated November 15, 2014 directed; Pressure Ulcer Prevention: Moisture barrier cream to buttocks every shift and as needed after each incontinence episode, turn and position every 2 (two) hours, chart by shift; Magnesium Chloride, 64mg po (by mouth) daily for supplement According to the Interim Order Form dated November 15, 2014 at 6:00 PM directed the following: (1) Wet to dry dressing to Sacral Ulcer (2) Wet to dry dressing to (R) (right) forearm stitches (3) Wet to dry dressing to Stage II ulcers (R) right calves (4) Wet to dry dressing to left heel pressure ulcer (5) Wet to dry dressing to (R) right hand necrotic blisters (6) Continue wet to dry dressing daily until seen by the WOCN (Wound Ostomy Care Nurse) (7) Wound Care Consult. A telephone interim order dated November 24, 2014 at 10:00 AM directed, Please provide air mattress to relieve pressure to sacral area and prevent further skin or tissue breakdown. A Nutritional Assessment dated November 22, 2015 revealed Resident has multiple wounds, treatment started. Resident is being turned every two hours, resident is very heavy is unable to assist staff in turning self. Resident is assisted with all meals. PO (by mouth) intake about 50-75%. 30 ml (milliliters) Prosource TID (three times a day) for nutrition support and to promote wound healing. The resident was noted to be receiving Mag 64 po daily, Prosource Liquid -30 mls po three times a day and Vitamin D3 50,000 units ' po one day per week for 12 weeks. Further review of the Medication Administration Records (MAR) from November 15, 2014 to December 31, 2014 revealed that facility staff signed in the allotted spaces, indicating that moisture barrier cream treatments were administer to Resident #64 ' s buttocks as needed after each incontinence episode every shift as per the physician's orders [REDACTED].>According to a Daily Skilled Nurse ' s Note dated December 1, 2014 revealed: Comments/Concerns Day Shift) revealed; T&R (Turned and positioned) (every) 2 (two) hours. Treatment to wounds done as ordered . Reddened area on left buttocks opened- 3 ½ x 1 ½ cm(centimeters). MD (Medical Doctor) and RP (Responsible Party) made aware. Comments/Concerns Evening Shift - Resident remains alert and responsive- Seen by wound team. New orders given . A review of the clinical record lacked evidence that any alteration in skin integrity to the left buttock was identified and documented prior to December 1, 2014. The Physician Wound Notes revealed the following: December 1, 2014- 4PM- Patient seen today, was admitted to (facility named) with multiple pressure ulcers and open wounds. 1. Rt (Right) hand open wound (non -pressure) . 2. Left heel eschar- Unstageable, Plan: Monitor, Float, Skin prep daily 3. Rt lower extremity ulcers pressure type- Stage 4 - + (positive) slough, + tendon, Plan: Xeroform Dressing. 4. Sacral pressure ulcer- Stage 4- + slough, undermining, moderate serous drainage, No odor, Santyl on wound bed, Pack with AMD (Antimicrobal Dressing) gauze, Dermarite bordered, for plain x-ray - R/O ( Rule out) [DIAGNOSES REDACTED]. 5. Left buttock pressure ulcer- Stage 3- Full thickness, Xeroform dressing daily. (Newly identified wound). Initial visit of the wound care team, identified a stage 3 pressure ulcer of the left buttock. There was no documented evidence in the clinical record that the resident was admitted with a left buttock pressure ulcer. MD (Medical Doctor) Notes Continued: December 10, 2014- 1 PM- Patient seen today has multiple wounds on different sites (hospital acquired) 1. Rt. Hand open wounds (non-pressure) . 2. Rt lower extremity pressure ulcers (two), Stage 4- Full thickness, + slough, (increased) pink tissue, moderate serous drainage. Plan: Xeroform dressing 3. Sacral pressure ulcer- Stage 4, + undermining, + slough, moderate serous drainage. Plan: Santyl and Solofite Phalt Packing. 4. Left heel eschar- Unstageable, Float, Skin prep daily December 17, 2014- 1PM- Patient seen today, has multiple wounds on different sites. 1. Rt hand necrotic wounds (non-pressure) 2. Sacral Pressure Ulcer- Stage 4, + slough- minimal, moderate serous drainage, (increased) Pink tissue, undermining, Plan: Santyl + Solosite Sheet packing, Plan: x-ray- (No) osteo. 3. Rt lower extremity pressure ulcers (two), Stage 4, Size (decreasing), healing slowly, (increased) Pink tissue - minimal slough, periwound skin intact. Plan: Xeroform dressing daily. 4. Left heel eschar- Unstageable, Plan: Float, Skin prep daily. December 31, 2014- 3PM- Patient seen today, has multiple wounds on different sites 1. Rt hand open wounds healing . 2. Sacral pressure ulcer- Stage 4- (increased) pink tissue, minimal slough, periwound skin- open Wound (pressure type), moderate serous drainage, no odor, Plan- Estim, Santyl, Pack with Solosite Sheet 3. Rt Lower extremity pressure ulcers- Stage 4- slowly healing, (increased) pink tissue, minimal slough, moderate serous drainage. Plan: Xeroform dressing daily. Pressure relief. The physician failed to consistently assess Resident #64 ' s wounds as evidenced by the following: December 1, 2014 - Five (5) wounds identified December 10, 2014 - Four (4) wounds identified; left buttock wound not identified December 17, 2014 - Four (4) wounds identified; left buttock wound not identified December 31, 2014- Three (3) wounds identified; left buttock wound and left heel not identified. The Nurse ' s Admission Notes dated November 15, 2014 at 8:15 PM, indicated that the resident had multiple wound sites, which included; Left heel unstageable wound measuring 8.6 cm x 7cm and bilateral wound site on right lower leg. The nurse ' s admission progress notes documentation did not include the sacral ulcer- Stage IV that was identified on the admission assessment form. According to the facility's Weekly Wound Healing Record identified the following wound assessments: Date of Onset/Origin: November 15, 2014- Sacral Pressure Ulcer- (Hospital Acquired) - Stage 4- Size: 8.0 cm ( centimeters) x 6.0 cm; depth- 2 cm; Exudate Type: Sero-sanguineous; Wound Bed- Granulation Tissue; Underming (cm)- 7 cm. Date of Onset/Origin: November 15, 2014- Right Lower Leg Pressure Ulcer (6A) - (Hospital Acquired) - Stage 3- 7.5cm x 4.5 cm; depth- 0.5 cm; Exudate Type: Sero-sanguineous, Wound Bed- Granulation Tissue, Slough. Date of Onset/Origin: November 15, 2014- Right Lower Leg Pressure Ulcer- (Hospital Acquired) - No stage identified- Size- 7.5 cm x 4.5 cm; 0 depth; Exudate Type: Serious, Wound Bed- Pink/Beefy Red. Date of Onset/Origin: November 15, 2014- Left heel Pressure Ulcer (Hospital Acquired) - Unstageable- Size: 8.6 cm x 7 cm; 0 depth; Exudate Type: None; Wound Bed- Black/Brown (Eschar) Date of Onset/Origin: December 1, 2014- Site/Location: Left Buttock Pressure Ulcer- Stage 3- 3 ½ x 1 ½ cm, 0 depth, Exudate Type: None, Wound Bed- Pink/Beefy Red A review of the clinical record for Resident #64 revealed an alteration in skin integrity to the left buttock identified on December 1, 2014, sixteen (16) days after admission to the facility. No left buttock pressure ulcer was identified on admission. Facility staff failed to consistently assess Resident #64 ' s skin integrity to prevent a facility acquired Stage 3 pressure ulcer to the left buttock. Resident was identified as a high risk for the development of a pressure ulcer. A face-to-face interview was conducted with Employee #1 on May 6, 2015 at approximately 4:15 PM in regards to the left buttock pressure ulcer. Employee #1 stated that the resident was admitted to the facility from the hospital with the left buttock pressure ulcer. Further stated that the smaller one (left buttock pressure ulcer) was adjacent to the sacrum pressure ulcer at the margin. A face-to-face interview was conducted with Employee # 14 on May 6, 2015 at approximately 4:17 PM; he/she stated that when the left buttock pressure ulcer was assessed on December 1, 2014, there were two (2) different depths; therefore he/she had to document it as a left buttock ulcer and a sacrum ulcer. Further stated, that on December 10, 2014; the left buttock wound had probably healed or was getting better, that ' s why there was no documentation on the left buttock on December 10, 2014 and subsequent visits. The clinical record was reviewed on May 6, 2015.

Based on observations, record and staff interview for three (3) of 43 sampled residents, it was determined that facility staff failed to assess and manage pain as evidenced by: a failure to recognize signs and symptom of pain demonstrated by one (1) resident during a wound treatment; assess and treat abdominal pain for one (1) resident and consistently assess and monitor left knee pain expressed by one(1) resident who was later determined to have a patellar fracture. Residents #109, #123 and #130. The findings include: 1. Facility staff failed to assess and address Resident #109's complaint of right foot/toe pain. A face-to-face interview was conducted with Resident #109 at approximately 10:30 AM on [DATE] after the completion of a dressing change. The resident responding to a query of how his/her foot felt responded, " Real bad. It feels real bad. It hurts 24 hours a day. In response to another query regarding whether he/she receives pain medication, he/she responded " Yes, but it doesn ' t help. I told them six (6) months ago to tell the doctor that the pill don't work but they didn't do anything. They keep giving it to me." A face-to-face interview was conducted with Employee #25 at approximately 11:00 A M on [DATE]. The employee was queried whether the resident had received pain medication prior to the dressing change. He/she responded, " Yes. I gave (him/her) something at 9:00 o ' clock " and added, " (He/she) usually lets me know when (he/she) is in pain. (He/she) usually asks for pain medication. (He/she) did not ask for anything today but I gave (him/her) some (pain medication) before I started (his/her) dressing. " Employee #25 was queried about the open area at the tip of the resident ' s right great toe. The employee responded, " I did not see it. I did not know it was there. The podiatrist saw him yesterday. I will call the doctor. " A review of the podiatrist ' s documentation in the Physician ' s Progress Notes dated [DATE] revealed a note which included the following: " Slight bleeding from ..right great toe nail where it impinges on 2nd (second) toe with slight surrounding hematoma. All mycotic nails> (greater than) ,[DATE] with thickening ..., irregularity - All debrided on preventive basis. " The attending physician ' s note from the Physician ' s Progress Notes dated [DATE] at 3:45 PM revealed the following, " Rt (right) great toe open area S/P (Status/Post) toe nail removal. Minimal serous drainage. Local wound care. Severe [MEDICAL CONDITIONS]. Emperic antibiotic. " According to the documentation in the nurse ' s notes a nurse notified the physician of the open area on the resident ' s right great toe at 3:00 PM on [DATE]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the record revealed no evidence that the resident was assessed and/or medicated for pain between 9:00 AM and 5:00 PM on the said date A face-to-face interview was conducted with Employees # 1, 2, 11, and #19 at approximately 11:00 AM on [DATE]. During the interview the employees were queried regarding the facility's staff assessment and treatment of [REDACTED].#2 both stated that the resident despite (his/her) [DIAGNOSES REDACTED]. Employee #19 stated that because of the resident ' s [DIAGNOSES REDACTED]. The employee added that the resident was previously on [MEDICATION NAME]es (for pain) which were discontinued due to lethargy and he/she (Employee #19) is planning to prescribe another medication which will relieve the pain without the side effect of lethargy. A review of the Physicians ' Progress Notes on the clinical record failed to reveal a plan for the new medication. A review of the Pain Management Policy #82 with a date of issue of ,[DATE] revealed the following: under the heading of Procedure: 1. " Upon admission, readmission, return from hospital and any new onset of pain as claimed by the resident or as observed shall be assessed by a licensed nursing staff using the standard assessment form attached and plan of care will be completed. 2. Assessment elements that must be included are: a. Location of pain b. Intensity of pain (use attached intensity scale as applicable) c. Quality of description of pain d. Onset, duration e. Activity that precipitated or increases the pain f. What relieves the pain g. Description of behavior when in pain. " A review of the nurse ' s notes from [DATE], through [DATE] failed to reveal a consistent reference to the absence/presence of pain although the resident received daily dressing changes and that between February 16 and February 29, 2012 the resident received daily dressings to the sacrum and the toe. Four (4) Weekly/Monthly Summaries were retrieved from the clinical record. The summary of February 14, 2012 was checked as weekly and pain was assessed as rarely present. A summary dated February 15, 2012 was checked as weekly and monthly and pain was also assessed as rarely present. The next assessment was dated [DATE] and pain was assessed as occasionally present. This summary was neither checked for weekly or monthly. The fourth summary on the record was dated [DATE]. Pain was assessed as rarely present and the summary was neither checked for weekly or monthly. Facility staff failed to assess and address one (1) resident ' s complaint of right foot/toe pain. The record was reviewed on [DATE]. 2. Facility staff failed to assess and treat one (1) resident who complained of abdominal pain. Resident #123 A review of the history and physical dated [DATE] revealed that the resident has the following diagnosess: DM (Diabetes Mellitus),[MEDICAL CONDITION](Hypertension), [MEDICAL CONDITION] s/p (Status/Post) Resection, [MEDICAL CONDITION], Urinary Incontinence, and Depression. A review of nurses note dated for [DATE] at 5:00 PM reads, " Complained of abdominal pain and generalized weakness ... vital signs T (temperature)95.4, P (pulse) 64, Resp. (respiration) 20, B/P (blood pressure) ,[DATE], SpO2 97% (oxygen saturation) in room air and FS (finger stick) 151mg/dl. MD (Medical Doctor) was notified who ordered a transfer resident to (area hospital) emergency room for pneumonia and abdominal pain resident refuse transfer stating "I am not going anywhere", MD was made aware who ordered continue antibiotic and administer O2 (Oxygen) 2 liters via NC (nasal canal) ... resident representative was notified. Resident received vital signs T96.5, P68, Resp. 18, B/P ,[DATE], SpO2 98% on O2, normal saline 2 liters " A review of physician order [REDACTED]. A review of April, 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the " Pain assessment record form " on [DATE] at approximately 11:00 AM revealed that a pain assessment form for resident #123 complains of abdominal pain on [DATE] was not done. A face to face interview was conducted on [DATE] at approximately 11:05AM with Employee #23 concerning the process used to assess residents complaints of pain. He/she stated that " for residents who can complain of pain, they will tell us they are in pain, the resident on routine pain medication are ask when administering medication if they are in pain, some resident are on routine pain meds, some on PRN (as needed) pain medications and others on PRN narcotics. If a resident say (he/she) is in pain we ask level ,[DATE], where it hurt, and what the pain is like, and those who have pain every other week or when they complain of pain we assess using the pain assessment form and give medication per physician order. " The resident clinical record lack evidence that facility staff assessed and treated Resident #123 who complained of abdominal pain on [DATE] after resident refused to go to the emergency room . A further face-to-face interview was conducted on [DATE] at 11:10 AM with Employee #8 concerning Resident #123, who was not assessed or treated for [REDACTED]. He/she reviewed the chart and was unable to find further pain assessment forms for the resident abdominal pain. He/she acknowledge the findings. The record was reviewed [DATE] 3. Facility staff failed to stop a wound care treatment to the left shoulder and reassess for pain when Resident #130 demonstrated non-verbal indicators of pain.. During an observation of a wound care treatment for [REDACTED].#6 was going to perform a dressing change to the resident ' s left shoulder pressure ulcer. Resident #130 was turned on his/her right side. Employee #6 proceeded to remove the old dressing from the left shoulder. After the DWC (Dermal Wound Cleaner) Solution was applied to the wound bed, Employee #6 proceeded to clean the wound bed with a 4 X 4 gauze. Resident #130 began to present with facial expressions of grimaces, furrowed brow and a tensed posture with movement. Immediately, Employee #6 asked, " Are you OK? " There was no response from the resident. He/she continued to clean the wound. Resident #130 still continued with some facial grimaces through the process. The nurse failed to assess the resident for his/her tolerence of the treatment. Employee #6 applied Santyl Hydrogel to the wound bed and covered the shoulder wound with gauze. Afterwards, Employee #6 was queried, " When was the resident medicated for pain? He/she stated, " It was given 30 minutes prior to the dressing change. When Employee #26, who administered the pain medication, was queried when the pain medication was given; he/she stated, " It was given at 9:00 AM; because the order does not indicate to give 30 minutes before the dressing change. So, I gave it at 9:00 AM. " Employee #6 proceeded to call the (Attending Medical Doctor) to obtain an order for [REDACTED]. A second observation was conducted on [DATE] at approximately 1:20 PM. Employee #6 was going to perform a dressing change to the resident ' s left shoulder wound. Also, Employee #2 was present for the wound care. Employee #6 started the process of setting up for the wound treatment. Resident #130 was lying on his/her left side/shoulder facing the wall. Employee #6 repositioned resident on right side so he/she could remove the old dressing from the left shoulder. He/she informed the State Surveyor that the resident was medicated with Tylenol at 9:30 AM. Proceeded to ask Resident #130, " (Resident ' s Name) are you having any pain? " There was no response from the resident. Employee #6, " stated he/she appears comfortable,and he/she is not having any facial grimaces; so I can proceed with during the treatment. " At that point, Employee #1 entered the room. Employee #6 informed him/her that she/he was going to do Resident #130 ' s left shoulder wound care and resident was medicated for pain at 9:00 AM with Tylenol. Employee #1 immediately stated, " , No, it has been four (4) hours since his pain medication, so the wound care will not be done now. You need to medicate the resident for pain and call the state surveyor(s) when we are ready to proceed with the wound care. " Additional observations were conducted [DATE] through 7, 2012 during the hours of 9:30 AM to 4:00 PM; the resident was lying in his/her bed. Upper and lower extremities were contracted. There were no grimaces, restlessness or other distressed behavior(s) demonstrated at the time of the observations. Employee #6 failed to recognize Resident 130 ' s onset/presence of pain and reassess during his/her wound treatment. Resident #130 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Advance Directives: No CPR (Cardio-Pulmonary Resuscitation) ; Healthcare Decision: Hospice. According to the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], Section C (Cognitive Patterns) indicated that the " Brief Interview for Mental Status " was not conducted secondary to resident is rarely/never understood and his/her cognitive skills for daily decision making is severely impaired. Section J (Health Conditions) -J0100-Pain Management- indicated that resident is on a scheduled pain medication regimen. The care plan last updated [DATE] revealed: " Resident is at risk for pain and or discomfort related to multiple wounds - Approach: Nurse will observe resident for signs and symptoms of pain and or acute discomfort; facial grimacing, restlessness, moaning, crying and agitation. Pain management will apply as ordered- Nurse will reposition and turn resident for comfort. " A review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s order dated February9, 2012. The " Weekly Wound Healing Record " sheet dated [DATE] revealed, " Site/Location: Left Shoulder Pressure ...Stage 4 ...Size 2.5 cm x 3.4 cm ...No depth indicated ...Exudate Type: Serious ...Odor-None; Moderate ...Exudate Amount- Moderate; Wound Bed-Normal for skin; Surrounding Skin Color- Normal for skin; Surrounding Tissue/Wound Edges- Normal for Skin. " The interim telephone order dated [DATE] ( No Medical Doctor Signature) directed, " Left Shoulder Pressure Ulcer- Stage 4; Cleanse wound with DWC ( Dermal Wound Cleanser)- apply Santyl and Hydrogel on wound bed- Cover with 4 X 4 AMD Gauze- cover with coversite (every day) (times) 14 days. " A review of the [DATE] Treatment Administration Record revealed that Resident #130 received a treatment/dressing changed to his/her left shoulder area once daily from [DATE]-7, 2012. Although Resident #130 was medicated for pain at 9:00 AM prior to the dressing change at approximately 10:15 AM, the facility staff failed to stop the wound care treatment and reassess the resident for pain when he/she demonstrated non-verbal indicators of pain; while cleaning the wound bed. A face-to-face interview was conducted with Employee #6 on [DATE] at approximately 10:25 AM. He/she stated the resident was nonverbal," I looked at his/her face; and he/she did not have any grimaces on his/her face". A second face-to-face interview was conducted on [DATE] at approximately 4: 35 PM with Employees #1, #2, #6, and #11. When queried about the facility ' s pain management assessment for nonverbal resident (s); Employee #2 stated, the residents who cannot talk , we look for movement, grimaces, restlessness and withdrawing. If the resident has any of these symptoms, they will be given pain medications per physician's order [REDACTED].