Every finding on record at Washington CTR for Aging SVCS

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, the facility staff failed to: 1) post the results of its most recent survey in a place readily accessible to residents, family members, and resident representatives and 2) have reports from the three preceding years, including certification surveys, complaint investigations, and any plan of correction in effect with respect to the facility available upon request for any individual to review. The findings included: During an observation on 08/03/25, upon entrance into the facility at approximately 6:00 AM, the surveyor observed a sign posted on the window at the front security desk that read: [Name of Facility] Survey Book Available Upon Request. During a telephone interview on 08/11/25 at 2:09 AM with [Name of Resident 199#s Representative/President of Family Council] stated that on 08/24/24, when she was visiting the Resident, she asked the Employee # former front desk security guard staff for the most recent survey results, she was handed a binder that contained a 2567 report from 06/21/22. [Resident# 199's representative] also emailed a picture of the binder to the state agency on 08/19/25. During an observation and a face-to-face interview on 08/20/25 at approximately 9:16 AM, the surveyor observed a sign posted on the window at the front security desk that read: [Name of Facility] Survey Book Available Upon Request. Sitting at the front desk was Employee # Front Door/Entrance Security Officer. The surveyor asked the Employee # for the facility's survey book. The Employee searched the security front desk area, and after checking several binders at the front desk. The Employee stated he could not locate the survey book. He then asked the surveyor to check with the Administrator. During a face-to-face interview on 08/20/25 at 9:35 AM, Employee #1 (Administrator) stated that the 2024 survey report was located at the front desk. When asked if the facility had any reports, including certification surveys, complaint investigations, and any plan of correction in effect with respect to the facility from the three preceding years available, the Administrator acknowledged that the facility did not have the reports available at that moment, but stated that the staff could look for them and provide them. During the time of the observations and staff interviews, there was no evidence that the facility had posted in a place that was readily accessible to residents, family members, and resident representatives, the results of its most recent survey. In addition, the facility failed to have available upon request its survey reports, including certification surveys, complaint investigations, and any plan of correction in effect from the three preceding years available for review by any individual, and failed to have the reports in areas that were easily accessible to the public. On 08/20/25 at approximately 9:39 AM, Employee # provided a binder to the surveyor. A review of the binder revealed that it contained only the survey report for 2024. On 08/20/25 at 1:31 PM, Employee #, (Administrator Liaison), provided a binder that included reports from 2022, 2023, and 2024 and stated that moving forward, one binder with the reports will be kept in the Administrator's office and another at the front entrance security desk.

Number of residents sampled: Number of residents cited: Based on record view, staff interview and family interview, the facility failed to implement its discharge planning process to ensure a safe discharge for one (1) of three (3) sampled residents that were discharged home. (Resident #221)The findings included:Resident #221 was admitted to the facility on [DATE] multiple diagnoses including Chronic Respiratory Failure, Morbid Obesity, and Sleep Apnea.A policy titled, Discharge Planning with an Interdisciplinary Team review date of 01/03/24 documented, The social worker (discharge planning coordinator) will counsel resident and family about available .services. An admission Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 15 indicating the resident had an intact cognitive status. The resident was coded for using a wheelchair, requiring substantial to maximum assistance with upper body, total assistance for lower body, partial to moderate assist with mobility, total assist with bathing, and incontinent of both bowel and bladder. The resident was also coded for receiving physical therapy, occupational therapy, and oxygen therapy. A nursing Discharge summary dated [DATE] documented in part, Resident completed rehab therapy successfully and is scheduled for discharge on Saturday 06/07/25. Resident will continue to receive Physical Therapy/Occupational Therapy/Home Health services in the community. Resident continues on oxygen therapy at 2 liters per minute via nasal cannula for shortness of breath. A discharge nursing progress note dated 06/07/25 at 3:37 PM documented, Resident discharge home this morning at 12 noon. She was signed off by her daughter. Medication and discharge teaching provided patient verbalized understanding of teaching. She went home with facility oxygen cylinder daughter promise to return cylinder. A District of Columbia complaint intake dated 06/24/25 documented in part, My mother [Resident #221's name] was discharged from rehab. The rehab didn't even have operable transport oxygen for her to go home with. The social worker.stopped answering our call after my mom was discharged . She assured us that she would have wrap around services to help with our mom after discharge. During a telephone interview at 1PM on 08/07/25, the complainants stated that because Employee #41 did not coordinate home care services, physical therapy services, and occupational therapy services prior to their mother's discharge on [DATE]s. The employee told them she would make sure the resident receives those services. However, the services were never provided. They also stated they called the employee several times, but she failed to return their calls. The complainants said that they were using an oxygen concentrator that their mom had from 2 years ago. Additionally, the complainants stated that their mother needed the services because the family member that was providing care for her was wheelchair bound, and the mother has had a couple of falls without injury since discharge. During a face-to-face interview at 12:09 PM on 08/11/25, Employee #41 (Social Worker/Discharge Coordinator) stated that she verbally requested home care services with a local home care agency that frequently comes into the facility. However, she did not have documented evidence of that correspondence or if the homecare agency accepted or denied services for the resident. Additionally, the employee stated that she did not coordinate continuous oxygen therapy services because she was not aware the resident needed oxygen. During a telephone interview at 2:57 PM on 08/11/25, the representative from the local home care agency stated that he verbally informed Employee #41 that his agency could not provide services for the resident, but he could not remember the specific date. Additionally, the representative stated that he did not have documented evidence of the denial of services.

Based on observations, record reviews and staff interviews for six (6) residents and one (1) of three (3) of the six (6) residents with an active diagnosis of Dysphagia, it was determined that the facility's staff failed to ensure that Resident #1 was provided with adequate monitoring during meals, had a physician order to provide close supervision while eating, ensured speech documentation contained accurate information related to diet and liquid consistency, completed speech recommendations following a Modified Barium Swallow Study that showed laryngeal aspiration and failed to implement special dietary instructions for the resident whose diagnoses include oropharyngeal dysphagia. Subsequently, these failures resulted in the resident choking on food while eating alone in his room.During this survey an Immediate Jeopardy (IJ) was identified on July 2, 2025, at 2:14 PM at 42 CFR 483.25 (d)(2), F684, for Resident #1, with an active diagnosis of Oropharyngeal Dysphagia, who choked on food while eating alone in his room on June 25, 2025, at approximately 5:00 PM. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on July 2, 2025, at 11:02 PM. The Survey Team verified implementation of the corrective plan while onsite and the Immediate Jeopardy was lifted on July 10, 2025, at 6:45 PM.The findings included:An undated facility policy titled ‘Out of Facility Guidelines' documented, in part: To protect and safeguard the safety and health state of the resident during out of facility activities and Give necessary instructions for special care such as dietary restrictions, fluid requirements.An undated facility policy titled ‘Gastrostomy Tube (GT) Feeding for Resident on Pureed, Mechanical or Regular Diet' documented, in part: GT feeding and oral diet will be administered per physician/dietitian orders and under close interdisciplinary monitoring and Monitor for signs of aspiration (coughing, choking, wet voice) or difficulty chewing/swallowing.An undated facility policy titled ‘Communication With Physicians' documented, in part: When a resident returns from consultation, the nurse will inform the attending physician or NP (Nurse Practitioner) of the recommendation for validation. Based on the validated recommendation, new orders are transcribed into the resident's medical record and a progress note is created to document the consultation, the recommendations, and physician's/NP's validation. A follow-up appointment is scheduled by the unit secretary if indicated.A review of the Resident #1's medical record revealed:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Oropharyngeal Dysphagia, Gastrostomy on Tube Feeding, Aphasia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Congestive Heart Failure and Gastroesophageal Reflux Disease.A care plan dated 03/15/24 documented in part, Focus: The resident requires tube feeding r/t (related to) Dysphagia, Swallowing problem. Goal: The resident will remain free of side effects or complications related to tube feeding through review date. Interventions: Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of: Aspiration.A care plan dated 03/26/24 documented in part, Focus: [Resident's name] is at risk for Ineffective Airway Clearance Hx (history) of Dysphagia Oropharyngeal phase.Goal: Resident will maintain airway patency. Interventions: Evaluate secretions; Monitor for signs/symptoms of dysphagia; Monitor Resident's ability to expectorate secretions; Position Resident upright.A care plan dated 03/26/24 documented in part, Focus: The resident has nutritional problem r/t (related to) Dysphagia. Goal: The resident will comply with recommended diet for weight reduction daily through review date. Interventions: Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Appears concerned during meals.A care plan dated 03/26/24 documented in part, Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t Stroke. Goal: The resident will maintain current level of function in (Specify) through the review date. Interventions: Assess functional level, Therapy referrals . Note changes in functional level; Eating: Setup; The resident requires assistance to [from] staff to eat.A care plan dated 04/23/24 documented in part, Focus: The resident has GERD (Gastro-Esophageal Reflux Disease) r/t poor cardiac sphincter control. Goal: The resident will remain free from discomfort, complications or s/sx related to dx (diagnosis) of GERD through review date. Interventions: Avoid lying down for at least 1 hour after eating. Keep HOB (head of bed) elevated. Encourage to stand/sit upright after meals. Avoid overeating. Provide small frequent meals rather than 3 large ones. Encourage the resident to take their time eating. Encourage resident to avoid [NAME] [sodas]. Monitor/document/report PRN s/sx of GERD: increased salivation, swallowing problems, Dysphagia.A care plan dated 06/13/24 documented in part, Focus: The resident has Congestive Heart Failure. Goal: The resident will verbalize less difficulty breathing (Dyspnea) and be more comfortable through the review date. Interventions: Offer small frequent feedingsA Dietitian progress note dated 01/21/25 at 22:06 (10:06 PM) documented in part, Resident will frequently order takeout meals or purchase snacks from the facility gift shop, as well.A Nurse Practitioner Health Status Note dated 01/21/25 at 21:47 (10:47 PM) documented in part, Seen and examined at the request of nursing team to address clinical change noted today-he appeared weak, unable to swallow. Assessment: Dysphagia, Generalized Weakness.Plan: he was sent out 911 (emergency number for police, fire or medic) to R/O (rule out) CVA (Cerebrovascular Accident).A Modified Barium Swallowing study dated 01/24/25 at 11:58 AM performed at a local hospital documented in part, Impression: Intermittent silent versus sensate aspiration of mildly thick liquids demonstrated. Penetration seen with moderately thick liquids. Please see the speech pathology report for full details.A Hospital Discharge summary dated [DATE] documented in part, Suspected TIA (Transient Ischemic Attack)/Stroke, with baseline dysarthria and dysphagia (uses PEG (Percutaneous Endoscopic Gastrostomy tube) but can tolerate some [food and drink] PO (by mouth/oral). SLP (Speech Language Pathology) evaluation: Must repeat MBSS (Modified Barium Swallow Study) in 6 weeks. Can start regular diet w (with) moderately thick liquids, will keep tube feeds a reduced rate to ensure optimal caloric intake. For PO Diet; Regular diet/no dietary restrictions, Food/Fluid: moderately thick liquids, Avoid: Large sips/bites, Patient must utilize single sips or about 10cc (cubic centimeter, equivalent to one milliliter). No straws, sit upright, small bites, slow pace. Follow up Modified Barium Swallow study in 6 weeks (~ (around) 03/07/2025).A physician's order dated 01/25/25 documented, Aspiration Precautions every shift.A physician's order dated 01/25/25 documented, Lovaz Oral Capsule 1 GM (gram) Give 2 capsule by mouth two times a day for Hypertriglycerimia Please Provide liquid if available.It should be noted that Resident #1's medical record revealed 11 additional medications that could be administered by mouth, but were ordered on 01/25/25 by the physician to be administered via the resident's G-Tube as documented below: Acetaminophen 30 ML (milliliter) oral liquid, Atorvastatin Calcium 80 MG (milligram) oral tablet, Calcium Plus Vitamin D3 600-10 MG-MCG (microgram) oral tablet, Eliquis 5 MG oral tablet, Famotidine 20 MG oral tablet, Gabapentin 100 MG oral capsule, Jardiance 10 MG oral tablet, Metformin HCl (Hydrochloride) 1000 MG oral tablet, Metoprolol Succinate ER (extended release) 50 MG oral tablet, Polyethylene Glycol 17 GM 3350 powder and Spironolactone 25 MG oral tablet. A physician's order dated 01/25/25 documented, Repeat Modified Barium Swallow Study (MBSS) in 6 weeks. A physician's order dated 01/27/25 documented, Modified Barium Swallow Studies on 3/7/25 at 9:30 AM @ (at) [Hospital's name] Radiology Dept (Department). It should be noted that the repeat MBSS was scheduled as ordered and the appointment was documented in the resident's record. A physician's order dated 01/27/25 documented, Regular diet Regular texture, Honey/Moderately Thick consistency, No dietary restrictions. A physician's order dated 01/27/25 documented, No straw, sit upright, small bites and slow pace while eating and drinking every shift. It should be noted that Resident #1 was ordered a Regular Diet, no dietary restrictions, while medications that could also be taken orally were ordered to be administered through his Gastrostomy Tube.A physician's order dated 01/27/25 at 11:15 AM documented, Speech Consult.A care plan dated 01/27/25 documented in part, Focus: The resident has a swallowing problem r/t difficulty with thin liquids. Goal: The resident will have no choking episodes when eating through the review date. The resident will have clear lungs, no signs and symptoms of aspiration through the review date. Interventions: All staff to be informed of resident's special dietary and safety needs. Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Assistive device (i.e. (such as) Sippy cup) for liquids. Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Monitor shortness of breath, choking. Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Appears concerned during meals. Refer to Speech therapist for Swallowing Evaluation.A Nurse Practitioner Late Entry Health Status Note dated 01/28/25 at 22:15 (10:15 PM) documented in part, readmission visit following a brief hospitalization where he was admitted to r/o (rule out) CVA (Cerebrovascular Accident). He underwent work up and was found to have possible silent aspiration on thin liquid and was instructed to [have] moderately thickened all liquids but was cleared for regular meals.A Speech Therapy Evaluation and Plan of Treatment with a Certification Period of 02/05/2025-05/05/2025 revealed an Initial Assessment note dated 02/05/25 that documented in part, Gastrointestinal Disrupted Swallow = 7, that indicated Resident #1 had a high level of disruption or difficulty with swallowing. The Speech Therapy treatment note also documented the reason for therapy was Pt (patient) presents deficits in cognitive linguistic and swallowing deficits and Diagnosis: Dysphagia, oropharyngeal phase and Treatment of swallowing dysfunction and/or oral function for feeding; Eval (evaluation) of oral and pharyngeal swallow function; Recommended: Thin liquids (No modifications).It should be noted that the findings from the Modified Barium Swallow Study completed on 01/24/25 revealed Intermittent silent versus sensate aspiration of mildly thick liquids, subsequently Resident #1 was ordered to drink only liquids with moderately thick consistency.A Nurse Practitioner Skin/Wound Note dated 02/03/25 at 22:17 (10:17 PM) documented in part, I addressed the issue of Dysphagia and reiterated to the staff that all meds and supplemental meal - should be given via (through) feeding tube, all liquids should be moderately thickened.Further review of the facility's Speech Therapy Evaluation and Treatment notes from 02/06/25 - 04/01/25 revealed that the Speech Therapist documented in part, Pt is on mech (mechanical) soft textures with nectar thick liquids and Current Drinks = Thin Drinks; Current Foods/Solids = Regular/Easy to Chew Foods.It should also be noted that nectar-thick liquid has a level of thickness between thin liquid like water, but not as thick as honey-thick liquid which was ordered for the resident as of 01/27/25 due to his difficulty with swallowing.A Nurse Practitioner Skin/Wound Note dated 02/17/25 at 22:58 (10:58 PM) documented in part, All liquids ‘MUST' be thickened moderately, only regular meals should be taken by mouth, this has been discussed with the resident and staff at bedside.A Diagnostic Radiology Exam dated 03/06/25 at 12:29 [PM] documented in part, [Resident #1's name]. Reason for Exam: XR (x-ray) Modified Barium Swallow MBS w (With) SCT (Swallowing Competence Test) NK (Not Known), Report/Clinical Indication: Dysphagia. History of silent aspiration. Technique: Thick, pureed and solid consistencies of barium were administered to the patient in the upright/lateral position. Fluoroscopic images were videotaped for imaging assistance provided to the speech pathologist. Findings: Silent laryngeal aspiration was noted with mildly thickened, thick nectar barium utilizing a cup, straw and or chin tuck. Note, thin consistency barium send was not trialed. Impression: Laryngeal aspiration. Please refer to speech pathology for further evaluation.A [Skilled Nursing Facility's Name] Consultation Form dated 03/06/25 and signed by the consultant Speech Therapist documented in part, [Resident #1's name], Report Requested Regarding: Modified Barium Swallow, Findings: Silent Aspiration of mildly thick liquids. [NAME] tuck intermittently helped with silent aspiration; thin liquids not trialed. Continue to recommend a regular diet with moderately thick liquids. Recommend speech therapy to complete swallow exercises and practice chin tuck. Follow up MBSS (Modified Barium Swallow Study) in 8 weeks. May have thin liquids (water) via spoon for effortful swallows.It should be noted that effortful swallows is a swallowing exercise used to strengthen the muscles involved in swallowing and improve swallowing efficiency. It involves consciously squeezing the throat muscles and swallowing with more effort than usual, often imagining a bolus (food or liquid) getting stuck and needing to be cleared).A Dietitian progress note dated 03/07/25 at 18:27 (6:27 PM) documented in part, Per recent consultation on 3/9/25 regarding MBS (Modified Barium Swallow) for this resident, the following recommendations were made: 1. Con't (continue) Regular diet with moderately thick liquids 2. SLP to complete swallow exercises & chin tucks 3. F/u (follow-up) MBSS in 8 weeks; Current diet: Regular with honey/moderately thickened liquids.A Nurse Practitioner Health Status Note dated 04/24/25 at 22:14 (10:14 PM) documented in part, The resident is known for drinking multiple cans of sodas.A care plan dated 04/25/25 documented in part, Focus: The resident refuses to eat/resists feeding r/t does not like [the] food [offered at the facility], dysphagia. Goal: The resident will not have weight loss. Interventions: Encourage the resident's family members to bring in favorite food items from home or favorite restaurant items; The resident needs encouragement/support to be independent with eating. Allow the resident to feed self if desired, regardless of skill; The resident needs privacy as meal time is messy.A physician's progress note dated 05/18/25 at 10:26 (10:26 AM) documented in part, Patient is aphasia [aphasic]. Oropharyngeal phase dysphagia. Aspiration precaution.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of ‘13,' indicating the resident was cognitively intact. Eating- 09 that indicated the resident did not perform this activity; Swallowing/Nutritional Status- none of the above that indicated the resident had no signs or symptoms of possible swallowing disorder.A care plan dated 05/31/25 documented in part, Focus: [Resident's first name] has potential for alteration in nutrition r/t: 1. h/o (history of) swallowing difficulty, oropharyngeal dysphagia per diagnosis. Interventions: Monitor intake, tolerance of diet.A Dietitian progress note dated 05/31/25 at 04:16 (4:16 AM) documented in part, Diet Order Type: regular, regular texture, thin liquids.It should be noted that according to the result of the Modified Barium Swallow Study completed on 03/06/25 and the recommendation of the consultant Speech Language Pathologist, the resident was ordered a regular diet with moderately thick liquids.A Treatment Administration Record (TAR) dated 06/01/2025 - 06/25/2025 documented in part, No straw, sit upright, small bites and slow pace while eating and drinking every shift and revealed the facility's nursing staff indicated with their electronic signature that they were monitoring Resident #1 during all meals to ensure he had no straw, was sitting upright, had small bites at a slow pace while eating and drinking.A nursing progress note dated 06/25/25 at 16:14 (4:14 PM) documented in part, Resident received in bed in good spirit watching TV (television) at 3:40pm, alert and verbally responsive no acute distress noted.A physician's order dated 06/25/25 at 5:45 PM documented, Transfer resident to ER (Emergency Room) for Unresponsiveness.A nursing incident note dated 06/25/25 at 18:05 (6:05 PM) documented in part, Around 5:10PM, Supervisor was called to the unit due to change in one of the resident's conditions. Upon arrival the resident was met on the chair at the nursing station being assisted by other nursing staff. Resident was not fully responding, presented with some difficulty breathing. Charge nurse reported that resident came out of the room pointing to his mouth like something was stuck in his throat. Charge nurse reported that Heimlich Maneuver was done but no pieces came out of resident's mouth. Upon assessment, no object was seen in resident's mouth, but resident was noted with some drooling. Call was placed to 911 (emergency number for police, fire or medic) at 5:11PM and Code blue (facility's emergency announcement) was called . 911 instructed [facility staff] to lay [the] resident on the floor. CPR (cardiopulmonary resuscitation) continued until paramedic arrived on the unit at 5:20PM and took over the CPR. Upon assessing the resident's room, an open box of [fast food restaurant's name] chicken with remains [remaining] chicken pieces was [were] found at resident bedside, on the bed and on the floor.It should be noted that documentation revealed that Resident #1 was last seen by facility staff at 3:40 PM watching TV then not seen again until suddenly appearing in the hallway running towards the nurse's station at approximately 5:10 PM, after choking on food while eating alone in his room.An SBAR (Situation, Background, Appearance, Review/Notify) Communication Form dated 06/25/25 at 19:47 (7:47 PM) documented in part, The change in condition, symptoms, or signs observed and evaluated is/are: Altered level of consciousness, Unresponsiveness, Swallowing difficulty, Labored or rapid breathing.A nursing progress note dated 06/25/25 at 20:11 (8:11 PM) documented in part, Resident was observed coming down the hallway to the nursing station pointing to his mouth and holding his stomach around 5:10PM. When writer asked the resident what happened[,] the resident was unable to answer, but keep [kept] pointing to his mouth. Upon assessing resident['s] mouth nothing was seen. Writer immediately initiated Heimlich Maneuver with nothing coming out of the mouth.A nursing incident note dated 06/25/25 at 20:30 (8:30 PM) documented in part, Around 8:18pm, call was received from the detective, [Detective's name and telephone number], informing resident just expired at the hospital.A Nurse Practitioner's note dated 06/25/25 at 22:23 (10:23 PM) documented in part, I was called urgently to come to [nursing unit] earlier this evening to asses[s] the resident who was unresponsive, I arrived on the unit around 5:15pm and found the resident lying on the floor in front of the nurse station, he was unresponsive and had no pulse. A review of a DC (District of Columbia) And EMS (Emergency Medical Services) Department's Patient Care Record dated 06/25/25 documented in part: [Resident #1's name], Pick Up: Nursing Home, Destination: [Hospital name], Dispatched as: ALS (Advanced Life Support)-Cardiac Arrest; Patient initially complained of choking and fell uncon (unconscious)/unresponsive. Two attempts made for intubation - unsuccessful. Patient airway is filled with bolus of food. Suctioning is only moderately useful. Airway patency unable to be obtained due to excessive boluses of food in trachea and throughout airway. A DOH (Department of Health) Notice of Discharge Transfer or Relocation Form dated 06/26/25 at 9:18 AM documented in part, [Resident #1's name] was transferred to [Hospital Name] due to choking/shortness of breath.A Facility Reported Incident [Intake Number: DC00013792] received by the State Agency on 06/27/2025 at 15:08 (3:08 PM) documented the following in part: History of CVA ([DATE]) w/ aphasia, dysphagia. Resident is taking all his medications via G-tube; however, his diet is regular texture, Honey/Moderately Thick consistency. On 06/25/2025, around 5:10 PM, the resident was noted by one of the CNA (Certified Nursing Assistant) in the hallway pointing at his mouth and holding his stomach; charge nurse was immediately called to address his concern. The Evening nurse stated that the resident was unable to answer any of her questions but kept pointing at his mouth. During her assessment, nothing was seen in the resident mouth. Heimlich Maneuver was immediately initiated, still no substance was coming out of the resident mouth, except drooling, and resident became unresponsive. Code Blue was called O2 (oxygen) and CPR (cardiopulmonary resuscitation) initiated and 911 called. The resident was transferred to [Hospital name] at 5:50 PM for further evaluation. Upon assessing the resident's room, an open box of [fast food restaurant's name] chicken with remaining pieces of chicken was found at resident bedside, on the bed and on the floor. During a telephone interview conducted on 06/30/25 at 2:15 PM, Employee #6 (Speech Language Pathologist, SLP) stated that, He (Resident #1) was being seen for dysphagia. He had a feeding and a modified barium swallow that cleared him for his swallowing.It should be noted that the findings from the MBSS completed on 03/06/25 documented in part: Silent Aspiration of mildly thick liquids. Continue to recommend a regular diet with moderately thick liquids. Laryngeal aspiration.During a face-to-face interview conducted on 06/30/25 at 2:35 PM, Employee #5 (Director of Dietary/Dietitian) stated that, He was recently upgraded to regular texture, but cannot have thin liquids. There are four (4) types of Liquids: thin liquid, nectar thick, honey thick and pudding thick, which is the thickest. Honey is a little bit thicker than nectar. If [the order] just say moderately thick, [the] Speech Therapist will determine if nectar or honey then we would order from our vendor. I think we ordered nectar for him.It should be noted that Resident #1's prescribed liquid diet order was Honey/Moderately Thick consistency.During a face-to-face interview conducted on 06/30/25 at 2:42 PM, Employee #21 (Registered Dietitian) stated that, He was evaluated and in January was upgraded with precautions with little amounts at a time, chew properly and swallowing with honey consistency thickened liquid. But it's my understanding that the resident had food stuck in his airway which caused his demise and some chunks of food in his mouth. He may have been eating larger amounts of bites at a time.During a face-to-face interview conducted on 06/30/25 at 3:15 PM, Employee #22 (Licensed Practical Nurse, LPN) confirmed what she documented in her written statement during the facility's investigation stating that, Resident #1 was observed coming down the hallway to the nurse's station pointing to his mouth and stomach around 5:10 PM [on 06/25/25]. [The] resident was unable to answer when asked what happened but kept pointing to his mouth. I immediately performed the Heimlich [technique used to dislodge an object blocking a person's airway], but nothing came out of his mouth. We started CPR. They (other nursing home staff) said he was eating [fast food restaurant's name] chicken. He eats by himself, in his room all the time. He supposed to eat with thickener and small bites. I've never seen him when he's eating.During a face-to-face interview conducted on 06/30/25 at 3:27 PM, Employee #4 (Registered Nurse (RN), Unit Manager) confirmed what she documented in her written statement during the facility's investigation stating that, she was the evening nurse supervisor and received a call from [Unit name] that something was going on with [Resident #1's name]. I saw him at the nurse's station in a chair. The resident was not responding to name and presented with some difficulty breathing. The charge nurse reported that [the] resident came out of the room pointing to his mouth like something was stuck in his throat. He was on a regular diet with thickened liquids. Later after he left [the nursing home facility with paramedics] I saw a little piece of chicken in the hallway. Upon assessing the resident's room, an open box of [fast food restaurant's name] chicken that was almost finished, just maybe a little crumbs and bones left [was] found at the bedside, on the bed and on the floor [in the resident's room].During a follow-up face-to-face interview conducted on 07/01/25 at 10:10 AM, Employee #6 (Speech Therapist) stated that, I looked at swallowing, but it was not a concern. I know he was cleared for a regular diet. He did have coughing sometimes [when eating]. Honey [thick] versus Nectar [thick] is sometimes used interchangeably, but it is not the same thing. The recommendation from the Modified Barium Swallow Study on 03/06/25 for the chin-tuck [exercises], I never saw that recommendation. A chin-tuck is very vague because it's dozens of swallowing exercises. I didn't work with him on that; I really didn't see that there was a need for that [chin-tuck swallowing exercises].During a face-to-face interview conducted on 07/01/25 at 10:50 AM, Employee #24 (Licensed Practical Nurse, LPN) stated that, He was on tube feeding and he was [also] eating by mouth soft foods, regular diet and thickener for all the liquids - sometimes comes up on [meal] tray already thick like Nectar. He would eat by himself, he can set up his tray and did everything by himself.Employee #24 was asked about any special instructions for Resident #1 while eating and she stated that, Watch close because sometimes he would choke. He never ate in the Solarium (multipurpose/dining room), always in his room. We (facility staff) would just pass by his room when eating. His meds were crushed because I think he had swallowing problems, I don't know the reason; he had [an] order for it and was on a regular diet. I'm not aware of any swallow studies or recent stroke. It should be noted that Employee #24 was unsure why and was unaware that Resident #1 had the following instructions during meals: No straw, sit upright, small bites and slow pace while eating and drinking every shift. During a follow up interview conducted on 07/01/25 at 11:14 AM, Employee #4 (RN, Unit Manager) was asked about any special feeding instructions for Resident #1 and she stated that, He was [required] supervision to oversee. He received a regular tray (regular diet) and he just wanted you to put the tray in front of him. He always ate in his room, he didn't socialize. He preferred his medications through his feeding tube. He had a Stroke some time ago in January and we sent him out [to the hospital]. He can have regular meals with thickened liquids, no straw. For the Modified Barium Swallow Study, we called but they said it was too early to schedule, and we called back. The unit clerk has her own book to track appointment scheduling, I don't know where she keeps it [resident appointment book]. For the consult recommendations, we hand deliver a copy of the Speech Therapy consult recommendations, but not sure if that was done. The chin-tuck (swallowing exercises) is done by the Speech Therapist, not by the nursing staff.During a face-to-face interview conducted on 07/01/25 at 11:25 AM, Employee #25 (Certified Nursing Assistant, CNA) stated that, Resident #1 would feed himself and we would make sure food was warm. He would always eat in his room alone. He needed thick liquids but sometimes would buy his own Coke soda and I saw [had seen] him drinking it recently.During a face-to-face interview conducted on 07/01/25 at 11:30 AM, Employee #26 (CNA) stated that, He could feed and eat by himself. You can put the food there [at his bedside], but he wouldn't eat right away. He stayed in his room most of the time, so I never watched him eat. Sometimes we would find sodas and milk in his room.During a face-to-face interview conducted on 07/01/25 at 11:40 AM, Employee #23 (Registered Nurse, RN) confirmed what she documented in her written statement during the facility's investigation that stated, At 5:10 PM the resident from [room number] was noted to be running down the hallway pointing at his mouth. Upon assessment, nothing was noted in the [resident's] mouth. Heimlich maneuver was performed; nothing came out. 9-1-1 [was] called, Code Blue was initiated. We followed the instructions provided by the 9-1-1 operator, and started CPR until Paramedics arrived. Employee #23 was asked if there were any special instructions ordered for the resident while eating and she stated, He was on a regular diet. When I checked [entered the order for] moderate thick, [the word] honey came up [was selected]. I don't remember if I saw an option for nectar, that would mean the consistency should've been thick [like honey consistency].During a face-to-face interview conducted on 07/01/25 at 11:53 AM, Employee #3 (Nurse Practitioner) was asked about follow-up consult appointments and consult recommendations and he stated that, The nurse review the consult recommendations and let me know about it. I read the instructions, signed off and it goes back to the nurse. I agreed with the recommendations from the Modified Barium Swallow Study (MBSS) from 03/06/25 that Speech Therapy [should be] doing the chin-tuck (swallowing exercises). The unit clerk schedules the [follow-up] appointment. There's no new order because there was already a recommendation to have the follow-up [MBSS] done in eight (8) weeks, but I don't know if this [follow-up MBSS scheduled] was done. If it wasn't done, we would go off of what's already in place and the most recent assessment. Potentially the new follow-up [MBSS] could provide new information but wouldn't know if we don't have the new MBSS results. Diet orders are very specific so should be followed and goes specifically by what was written from the hospital discharge note and we would not change it.During a face-to-face interview conducted on 07/01/25 at 12:10 PM, Employee #27 (LPN) stated that, He was on a regular diet, fed himself, would eat in his room. We would leave the tray there for him. No special instructions for eating.During a face-to-face interview conducted on 07/01/25 at 1:15 PM, Employee #7 (Director of Rehab/Occupational Therapist) stated that, It's up to the [nursing home facility's] Speech Therapist to make a determination of what to assess based off of the consult recommendations.During a face-to-face interview conducted on 07/01/25 at 1:57 PM, Employee #13 (Unit Clerk) stated that, It [Modified Barium Swallow Study] was scheduled for July 21, 2025, at 9:00 AM. I started calling for that appointment on March 7, 2025. They said it was a little too early [to schedule] because they didn't have their schedule. The next call was placed on April 22, 2025, and they said they would give me a call back. I made the Unit Manager [Employee #4's name] aware. I finally got the appointment scheduled a week or two weeks ago.A review of Employee #13's resident appointment book revealed a handwritten entry on 07/21/25 that documented, [Resident #1's name], B. (Barium) Swallow [Hospital name] 9:45 [AM].During the same interview with Employee #13 (Unit Clerk), Employee #4 (Unit Manager) stated that, I knew there was a delay, the unit clerk mentioned it to me that she was having problems getting the appointment. I docume

Based on record review and staff interviews, for one (1) of 1 sampled residents who had an outside speech-language pathologist consultation, the facility failed to have documented evidence that they discussed with the resident's physician: (1) they were not able to schedule a Modified Barium Swallow Study (diagnostic test) in 8 weeks, as recommended by outside speech therapist on 03/06/25 and approved the facility's nurse practitioner on 03/07/25; and (2) the resident not provided swallowing exercises, chin tucks, and effort swallow techniques as recommended by an outside speech-language pathologist on 03/06/25 and approved the facility's nurse practitioner on 03/07/25. (Resident #1)The findings included: Resident #1 was admitted on [DATE] with multiple diagnoses including Dysphagia (oropharyngeal phase), Gastrostomy, Gastroesophageal Reflux Disease and Hemiplegia.A policy titled, Communication with Physicians with a reviewed and approve date of 01/03/24 documented in part, When a resident return from a consultation, the nurse will inform the attending physician or nurse practitioner of recommendations for validation. Based on validated [approved] recommendations, new orders are transcribed into the resident's medical record and a progress note is created to document the consultation, the recommendations, and they physician's/nurse practitioner's validation. A follow-up appointment is scheduled by the unit secretary if indicated.1. A review of a consultation document from an outside speech-language pathologist dated 03/06/25 revealed the following but not limited to, Report Requested Regarding- Modified Barium Swallow. Findings-Silent aspiration of mildly thick liquids.Follow up -Modified Barium Swallowing Study (MBSS) in 8 weeks [April 17, 2025] . Continued review of the consultation document revealed Employee #3's (nurse practitioner) initials indicating that he reviewed the consultation form and validated (approved) the recommendations listed in the form on 03/07/25. Employee 4's [RN/Unit Manager] progress note dated 03/06/25 at 4:38 PM documented, Resident alert and oriented x 3, no acute respiratory distress noted. Resident went for modified barium swallow study today and returned with recommendation to continue a regular diet with moderately thick liquids, speech therapy to complete swallow exercises and practice chin tuck intermittently to help with aspiration. Follow up with MBSS in 8 weeks. MD and RP made aware.A review of progress notes, medication administration records, and treatment administration records from 03/07/25 to 06/30/25 lacked documented evidence that the resident was scheduled for a repeat MBSS.During a face-to-face interview on 07/01/25 at approximately 11 AM, Employee #3 stated that on 03/07/25 he reviewed and approved of the recommendations listed on the consultation form. The employee said that he did not write the recommendations as a physician order because he informed a nurse that he approved the recommendations. He then said that the nurse was responsible for instructing the unit secretary to make the appointment for the MBSS. Additionally, the employee said that he was not made aware that the resident did not have the MBSS done. During a face-to-face interview on 07/01/25 at 1:58 PM, Employee #13 (Unit Secretary) stated that she attempted several times to get appointment for the MBSS in the eight weeks, but she was unsuccessful. She did, however, to get an appointment for 07/21/25 [19 weeks]. The employee also said that she informed Employee #4 (RN/Unit manager) of the resident appointment date. During a face-to-face interview on 07/01/25 at 2:10 PM, Employee #4 (RN/Unit manager) said she was made aware of the resident's MBSS appointment date of 07/21/25. The employee then said that she made Employee #3 (NP) and the resident's physician aware of the 07/21/25 date, and she documented the date she informed them in the resident's record. At the time of the interview, the employee reviewed the resident's record and said that she could not find the progress note where she documented when she informed the NP or MD of the date the resident's MBSS was scheduled. During a telephone interview on 07/02/25 at 8:40 AM, the resident's physician stated that he was not made that the MBSS was done in 8 weeks as approved. The physician said that he was also not informed that the resident's MBSS was scheduled for 07/21/25. He said that if he had been informed of the delayed date, he would've intervened to get an earlier appointment date. 2. A review of a consultation document from an outside speech-language pathologist dated 03/06/25 revealed the following but not limited to, Recommend speech therapy to complete swallow exercise, practice chin tuck.May have thin liquids (water) via spoon for *effortful swallows. *Effortful swallow (ES) is a widely used technique in dysphagia management, believed to strengthen oropharyngeal muscles and enhance swallowing safety and efficiency. https://[NAME].com/fpl/article-abstract/77/1/28/906843/Effortful-Swallow-Maneuver-and-Modifications-on?redirectedFrom=fulltext. A review of speech therapy notes from 03/12/25 to 03/27/25 lacked documented evidence that the resident was provided with swallowing exercises, chin tucks, or effort swallowing technique. Please note the resident was discharged from speech therapy services on 03/27/25. During a face-to-face interview on 07/01/25 at 10:11 AM, Employee #6 (assigned Speech Pathologist) stated that she was not aware of the consultation from the outside speech pathologist. At the time of the interview, the employee reviewed the outside speech pathologist consultation and stated that she had been working with the resident since February [2025] and did not feel the resident needed the recommendations listed in the consultation form. During a face-to-face interview on 07/01/25 at approximately 11 AM, Employee #3 (NP) stated that on 03/07/25 he reviewed and approved of the recommendations listed on the outside speech pathologist consultation form. The employee said that he did not write the recommendations as a physician order because he informed a nurse. He said that the nurse was responsible for making the rehab department aware of the speech therapy recommendations. Additionally, the employee stated that he was not made aware the recommendations for speech therapy were not provided. During a face-to-face interview on 07/01/25 at approximately at 2PM, Employee #7 (Rehab Director) showed the surveyors a copy of the outside speech-language pathologist form dated 03/06/25. The employee said that he made Employee #6 aware of the recommendations from the outside speech-language pathologist, but he did not have documented evidence of when he made her aware. During a telephone interview on 07/02/25 at 8:40 AM, the resident's physician stated that he was not made aware that the approved speech therapy recommendations from the outside speech-language pathologist were not provided. Cross Reference: 483.25 Quality of Care F684

Based on an observation, record reviews, and staff interviews, the facility failed to ensure Comprehensive Assessments contained accurate information for two (2) of six (6) sampled residents. (Residents #1 and #5)The findings included: 1.Resident #1 was admitted on [DATE] with multiple diagnoses including Dysphagia (oropharyngeal phase), Gastrostomy, Gastroesophageal Reflux Disease and Hemiplegia.A physician order dated 01/27/25 instructed, Regular texture, honey/moderately thick consistency, No dietary restrictions.A review of certified nursing assistants (CNAs) task sheets from 02/17/25 to 02/23/25 documented that the resident required set-up or clean up assistance with eating. A Minimum Data Set (MDS) assessment dated [DATE] documented in part that the resident had a Brief Interview for Mental Status summary score of 13 indicating that the residents had an intact cognitive status. Additionally, the resident was coded as not applicable for eating indicating that resident was not eating. A review of certified nursing assistants (CNAs) task sheets from 05/17/25 to 05/23/25 documented that the resident required set-up or clean up assistance with eating. A MDS assessment dated [DATE] documented in part the resident had a Brief Interview for Mental Status summary score of 13 indicating the residents had an intact cognitive status. Additionally, the resident was coded as not applicable for eating indicating that the resident was not eating. During a face-to-face interview on 07/01/25 at 10:50 AM, Employee #9 (LPN) stated that the resident was on a regular diet with thicken liquids. The resident fed himself alone in his room. And staff would supervise him by walking by the door and asking him if he was ok. During a face-to-face interview on 07/01/25 at 4PM, Employee #10 (CNA) stated that the resident was on a regular diet and fed himself. During a face-to-face interview on 07/01/25 at approximately 10 AM, Employee #6 (MDS Coordinator) stated that she documented in error that Resident #1 eating status was not applicable. The employee then said that the resident was able to feed himself at the time of the assessments dated 02/23/25 and 05/23/25. Cross Reference: 483.25 Quality of Care F6842.Resident #5 was admitted on [DATE] with multiple diagnoses including Dysphagia, Adult Failure to Thrive, and Dementia. A review of certified nursing assistants (CNAs) task sheets dated 03/08/25 to 03/14/25 documented that the staff provided the resident with partial/moderate assistance (staff does less than half the effort) or total assistance (staff does all the effort) with eating (meals). A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident did not have a Brief Interview for Mental Status summary score indicating the resident was not able to complete the test. Additionally, the resident was coded for requiring staff assistance to set-up or clean-up with eating (meals). A review of certified nursing assistants (CNAs) task sheets dated from 06/08/25 to 06/14/25 documented that staff provided the resident with total assistance (staff does all the effort) with eating (meals).A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident did not have a Brief Interview for Mental Status summary score indicating the resident was not able to complete the test. Additionally, the resident was coded for requiring staff assistance to set-up or clean-up with eating (meals). An observation on 07/07/25 at approximately 12:50 PM showed the resident sitting in the day room sitting in a Geri-chair watching tv. The resident was alert and oriented to name. At the time of the observation, Employee #16 (CNA) holding a cup of water to the resident's mouth for the resident to drink. During a face-to-face interview on 07/07/25 at approximately 1PM, Employee #16 (assigned CNA) and Employee # 17 (assigned LPN) stated the resident requires total assistance from staff for all activities of daily living to include eating. Additionally, the employee said that the resident is unable to feed herself. During a face-to-face interview on 07/08/25 at approximately 9:30 AM, Employee #8 (LPN/MDS Coordinator) and Employee #9 (RN/MDS Director) stated that the resident's eating status documented in the quarterly assessments dated 03/14/25 and 06/14/25 were not accurate. The resident required total assistance from staff for all meals.

Based on observation, record review, and staff interview, for one (1) of six (6) sampled residents, the facility failed to develop a care plan to address the resident's need for staff assistance with eating. (Resident #6)Resident #5 was admitted on [DATE] with multiple diagnoses including History of Dysphagia, Adult Failure to Thrive, and Dementia. An observation on 07/07/25 at approximately 12:50 PM showed the resident sitting in the day room sitting in a Geri-chair watching tv. The resident was alert and oriented to name. At the time of the observation, Employee #16 (CNA) holding a cup of water to the resident's mouth for the resident to drink. A review of the care plan lacked documented evidence of goals and interventions to address the resident's need for total assistance from staff with eating and drinking.During a face-to-face interview on 07/07/25 at approximately 1 PM, Employee #16 stated that the resident required total assistance from staff with eating and drinking.During a face-to-face interview on 07/08/25 at 9:04 AM, Employee #18 (RN/Unit Manager 3 Green) stated that resident had a history of dysphagia and the resident is totally dependent on staff assistance with eating and drinking. Additionally, the employee said that she would develop a care plan to address the resident's need for staff assistance with meals.

Based on record reviews and interviews, facility staff failed to have documented evidence that the IDT team reviewed residents care plans or held care plan conferences with the resident and/or the resident's family after each Minimum Data Set (MDS) assessment for two (2) of six (6) sampled residents. (Residents #1 and #5)The findings included: 1. Resident #1 was admitted on [DATE] with multiple diagnoses including Dysphagia (oropharyngeal phase), Gastrostomy, Gastroesophageal Reflux Disease and Hemiplegia.A review of a Minimum Data Set (MDS) assessment submission sheet revealed that the facility completed quarterly assessments for the resident on 02/23/25 and 05/23/25.A review of the resident's record lacked documented evidence that the IDT reviewed the resident's care plan or held a care plan conference with the resident and/or his family after the MDS assessments dated 02/23/25 and 05/23/25.During a face-to-face interview on 07/08/25 at 1:26 PM, Employee #14 (Social Worker) who was responsible for scheduling care plan conferences to review the resident's care plan, stated that she believed the IDT team reviewed care plan and conferences were held with the resident and his family after the assessments dated 02/23/25 and 05/23/25. However, after reviewing her notes during the interview, the employee said that she did not have documented evidence that the IDT reviewed the resident's care plan or held care plan conferences after 01/28/25. The employee offered no further explanation. 2. Resident #5 was admitted on [DATE] with multiple diagnoses including History of Dysphagia, Adult Failure to Thrive, and Dementia. A review of the Minimum Data Set assessment submission sheet revealed that the facility completed quarterly assessments for the resident on 03/14/25, and 06/14/25. However, review of the resident record revealed the last time the IDT reviewed the resident care plan and held a care plan conference with the resident's family was on 09/23/24.During a face-to-face interview on 07/07/25 at approximately 2 PM, Employee #19 (assigned SW) and Employee #20 (SW/Interim Director) stated that they could not find documented evidence that the IDT reviewed the resident's care plan or conducted a care plan conference with the resident or the resident's family after 09/23/24. Cross Reference: 483.25 Quality of Care F684

Based on record reviews and staff interviews, for one (1) of six (6) sampled residents, the facility failed to ensure that the resident's speech-language pathology treatment notes and care plan contained accurate information. (Resident #1). The findings included: Resident #1 was admitted on [DATE] with multiple diagnoses including Dysphagia (oropharyngeal phase), Gastrostomy, Gastroesophageal Reflux Disease and Hemiplegia.A physician order dated 01/28/25 instructed, Regular diet, regular texture, honey/moderately thick consistency [liquids].1a.A review Employee #6 (Speech-Language Pathologist) treatment encounter notes dated from 02/05/25 to 03/27/25 [consisted of 32 treatments] documented the following but not limited to, Precautions.Pt (patient) is on a mech (mechanical soft) texture [diet] with nectar thick liquids.Oral intake- current drinks/liquids=thin drinks.Current Foods-Regular/Easy to chew foods.A review of the resident dietary meal ticket documented that the resident's was on a regular texture diet and honey thick liquids. During a face-to-face interview on 07/01/25 at 10:11 AM, Employee #6 stated that the resident the documentation from 02/05/25 to 03/27/25 was incorrect. The employee said that the resident was on a regular diet with regular texture and honey consistency liquids. Additionally, the employee stated that she entered the information into the resident's electronic health incorrectly. During a face-to-face interview on 07/01/25 at approximately 2PM, Employee #5 (Dietician/Director of Dietary) stated that the resident was on a regular texture diet with honey consistency liquids. Additionally, the employee said that Employee #6 informed the dietary department of Resident #1's diet order. 1b.A review of the resident's care plan dated 04/25/25 documented the following but not limited to, Focus- The resident refuses to eat/resist feeding r/t does not like food, dysphagia.Interventions-The resident needs privacy as [at] mealtime is messy.During a face-to-face interview on 07/01/25 at 10:50 AM, Employee #10 (assigned LPN) stated that the resident preferred to eat alone in his room. He was able to feed himself independently. During a face-to-face interview on 07/01/25 at 4 PM, Employee #15 (CNA) stated that the resident preferred eating alone in his room, so he always serve the resident his tray in his room. During a face-to-face interview on 07/10/25 at approximately 4 PM, Employee #4 (RN/Unit Manager) stated the care plan was incorrect. The resident was not a messy eater. He preferred eating alone in his room. Cross Reference: 483.25 Quality of Care F684

Based on observations, record reviews, staff and resident interviews for one (1) of 59 sampled residents, facility staff failed to ensure that adequate supervision was provided to Resident #21, as evidenced by documentation in the residents medical records of staff observing Resident #21 smoking and possessing smoking paraphernalia while using supplemental oxygen continuously and the surveyor observing the facility staff failing to provide one to one monitoring of Resident #21 as instructed by physician orders on multiple occasions during the survey. Resident #21. Due to these failures, an immediate jeopardy situation was identified on July 9, 2024, at 4:36 PM. The facility submitted a plan of action to the survey team that was onsite at 1:12 AM on July 10, 2024, and the plan was accepted. The survey team validated the facility's plan of removal on July 12, 2024, and the immediate jeopardy was lifted on July 12, 2024, at 3:59 PM. After removal of the immediacy, the deficient practice remained at a potential for more than minimal harm for the residents at a scope and severity of D. The findings included: According to the National Center on Aging and the American Lung Association, .While oxygen itself is not flammable, it can make flammable materials ignite faster and burn more rapidly. While using supplemental oxygen, always stay at least five feet away from an open flame or heat source. You should also never smoke (cigarettes, vape pens, or otherwise) while using oxygen, and prohibit smoking nearby. https://www.ncoa.org/adviser/oxygen-machines/home-oxygen-safety/ A review of the facility's policy titled Oxygen Administration-Nasal Cannula that was undated [#NSD04-12] documented in part, Oxygen is administered according to the physician's orders and in observance of all safety precautions . post No smoking sign on the door and in the resident's room-oxygen is highly combustible. A review of the facility's policy titled One-to-One Monitoring for Residents was undated and documented the following: One-to-one monitoring is a type of care that can be provided to residents at (facility name abbreviation) to ensure their safety whenever they are alone especially in their room. One-to-one monitoring can help staff prevent falls, redirect residents from harmful actions. A review of the facility's policy titled Smoke Free Environment with a review date of 01/03/24 documented the following: Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with signs that read No Smoking or with the international symbol for no smoking. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses including, Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath, Heart Failure, and Bipolar Disorder.On 07/02/24 at 10:54 AM Resident #21 was observed in her room lying in bed with oxygen in use. At the time of the observation, Resident #21 stated I do smoke, but I haven't been outside to smoke. I don't smoke in the room. It should be noted that there was no one-to-one (1:1) staff monitoring Resident #21 at the time of the Surveyor observation. Review of Resident #21's medical record revealed the following: A Smoking assessment dated [DATE] indicated that the resident was an unsafe smoker. A physician order dated 03/01/24 directed, Oxygen at 2 liter per minute via nasal cannula continuously every shift for COPD (chronic obstructive pulmonary disease) A nursing progress note dated 03/27/24 at 5:10 PM documented Social worker was informed by security staff that [Resident #21] was smoking in the facility on 3/23/2024 and on today 3/27/2024 .it appeared she was in the crystal room in a corner smoking with an oxygen tank on the back of her chair. A nursing progress note dated 03/28/24 at 11:25 PM documented, [Resident #21] came to unit twice with cigarettes. Charge nurse took the cigarettes from her. Security police reported her twice that she was trying to smoke in the living room. Resident educated that she is on oxygen and the risks explained to her. Continue on O2 (oxygen) therapy at 2L (liters) via (by) nasal cannula with SPO2 (Saturation of peripheral oxygen) 96%. Continue on hourly monitoring, resident propel herself throughout the building. There was no documented evidence in the resident medical record of new interventions or orders after these incidents. A social services progress note dated 04/19/24 at 10:32 AM documented, SW (social worker) smelled the odor of smoke around 10:12 AM, coming from the far-left corner of the [NAME] room and observed [sitting] in her wheel chair smoking a cigarette. Resident had lighter and plastic bag with portions of other cigarettes. Resident agreed to give the smoking items to the social worker, and was counseled on the dangers of smoking and jeopardizing the health and safety of all persons in the building. A health status progress note dated 04/20/24 at 10:21 PM documented, At around 10:10 PM the writer was alerted by security guard that the resident was seen downstairs smoking a cigarette while on oxygen. A nursing progress note dated 04/24/24 at 3:25 PM documented, [Resident #21- who resides in room ## A] assisted with care, out of bed and propel self around unit. Continue on oxygen at 2liters, [Resident #21] was found in another resident bathroom in room ## trying to smoke. Writer found three cigarettes and a lighter with resident, took it to social worker. And later [Resident #21] went to another resident room ##, the resident in ## gave [Resident #21] another cigarette and was asking for lighter and in the process writer took the cigarette and made social-worker aware . It is important to note that following the unsupervised smoking incidents reported on 04/19/24, 04/20/24, and 04/24/24, staff began documenting on an hourly log that the resident was on one-to-one monitoring as of 4 PM on 04/26/24. A care plan dated 04/29/24 documented in part, Focus-[Resident #21] has a behavior on oxygen . Interventions- Resident on One-to-One monitoring, involve psych[iatric services] and psycho-therapy, resident was transfer room . closer to nursing station A social services progress note dated 04/29/24 at 3:28 PM documented, Resident continues to violate regulatory and facility smoking policies. Resident acknowledges she is unable to control urges to smoke, even around her oxygen . Staff reported she continued to smoke . Due to persistent involvement with smoking, resident is currently monitored by a 1:1 staff assigned as of April 26, 2024. Smoking observed . on 4/25/2024, 4/23/2024, 4/19/2024, and 3/27/2024. A physician order dated 05/06/24 directed, Resident is on one-to-one monitoring Q (every) shift to prevent resident from smoking while on oxygen. A review of the Quarterly Minimum Data (MDS) assessment dated [DATE] revealed that the facility staff coded the following for Resident #21: intact cognition, rejected an evaluation or care occurred 1-3 days, has no impairment in the upper or lower extremity, and receives oxygen therapy. A physician order dated 05/02/24, directed Target behavior: 1) Monitor for refusal of medications. 2) Refusal of care. #) Smoking while on continuous oxygen. A nursing progress note dated 05/2/24 at 1:25 PM documented, Resident was noted with cigarette stick on her and the CNA (certified nursing assistant) monitoring her retrieved it and gave it to the charge nurse, but she did not have lighter or matches on her . During an observation on 07/03/24 at 09:10 AM, Resident #21 was observed in her room without staff present or in proximity. The resident was lying in bed with oxygen in use. During a face-to-face interview on 07/03/24 at 9:10 AM, Employee #4 (Unit Manager 3 Blue) acknowledged there was no one-to-one staff present with Resident #21. During a face-to-face interview on 07/03/24 at 9:24 AM, Employee #2 (Director of Nursing) was made aware that the resident was observed without a one-to-one monitor. The employee then said that one-to-one monitoring means for resident safety we have to monitor the resident. The employee failed to explain why the one-to-one was not in place at the time of the surveyor's observation. Based on these findings, July 9, 2024, at 4:36 PM an Immediate Jeopardy (IJ) situation was identified. On July 10, 1:09 AM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: F-689 Immediate Jeopardy - Removal Plan 1. Immediate Action Taken - Resident # 21 was reassessed (smoking assessment) by the social worker as it pertains to smoking on 7/9/24 I. DON. ADON. and managers conducted rounds on all residents on oxygen for no smoking signs on 7/9/2024. All these residents who utilized oxygen have no smoking signs posted on the door and/or in room. II. The Care plan for resident #21 was updated by the manager and social worker on 7/9/2024. Based upon the smoking reassessment and her use of oxygen the resident #21 was on one-to-one monitoring, the care plan was updated to reflect (a)consistency of one- to - one monitoring (b)new smoking. Assessment completed 7/9/2024 (c)new smoking contract on 7/9/2024(d)Oxygen sign completed 7/9/2024. The Evening shift staff on the unit and the security on duty have been re-educated by DON, ADON regarding the one-to-one monitoring on 7/9/2024. The resident is to always have assigned staff on one to one. The monitoring nurse will document that she is on one to one on the treatment administration record. The individual assigned will sign the one to one hourly log in the room. Staff member must be monitoring one to one at all times. Resident #21 was re-educated by the DON regarding the danger of smoking when on oxygen 7/9/2024. She has signed a contract in the past; however, the contract has been updated and she has signed the contract dated today, 7/9/24 that she will not have any smoking paraphernalia on her person. III. The evening shift security staff have been re-educated by the DON on 7/9/2024 regarding smoking and the danger of smoking when on oxygen. Further they were instructed that if someone is observed smoking and on oxygen, they will contact the nursing supervisor immediately and ensure residents have no smoking items. All other security officers will be instructed on 7/10/2024. Any smoking paraphernalia found will be removed immediately. IV. DON, ADON, Nurse managers including all other supervisors will ensure that one to one monitoring is in place while performing their shift rounds starting on 7/10/2024. V. The roommate of Resident #142 who uses oxygen was relocated to another room on 7/9/2024 (room [ROOM NUMBER]) per resident request. All residents with oxygen were identified and none shared a room with a smoker. 2. Immediate Action Taken - Residents who smoke I. All residents who smoke are on a smoking list and have been advised on 7/9/2024 that while there are designated smoking areas the facility is a smoke free facility. Staff found no smoking items on residents #131, #1 and 167. Resident #142, turned in an empty pack of cigarettes. II. A review of the care plan conducted on 7/10/2024 for all residents who smoke will be updated to include residents will not have any smoking paraphernalia on their person or in their room. These items will be maintained at the security desk. III. The nursing staff who are on units with residents that smoke were re-educated on 7/9/24 by the DON, ADON on the smoking policy. All disciplines will be re-educated on the smoking policy by 7/10/2024. All other staff not on schedule to work will be re -educated prior to returning to work. IV. List of smokers will be updated to reflect current residents that smoke cigarette on 7/10/2024.The smoking list will be kept by the unit managers, security, social workers and administration. V. Each resident will be assigned a zip lock clear bag that would contain their cigarettes and lighters. Starting on 7/10/2024, these bags will be kept at the security desk. Assigned smoking aides/monitors will hand out one cigarette at a time and ensure that no resident keep/store smoking paraphernalia. Education will be provided by DON, ADON, and social worker on 7/10/2024. Assigned staff will light the cigarettes and keep the lighter. VI. To mitigate future smoking deficiency, the social worker will ensure that smoking policy is shared during the next schedules resident council and family council meetings. Robocall, letters or email will be used to inform family members of smoking policy on 7/10/2024. With resident permission, nursing managers, nurses, security will make random weekly rounds on residents that smoke cigarettes to ensure no smoking paraphernalia are kept in the rooms. Additional posting signs will be placed in the facility regarding smoking policy on 7/10/2024. A meeting will be held with residents 7/10/2024 reminding each of them of the contract they signed indicating discharge from the facility for smoking policy infraction. Corrective action completion date: 07/10/2024 Verification of the removal of the immediacy was performed by the survey team onsite on July 12, 2024, at 3:59 PM. Cross Reference- 22 B DCMR Sec 3211.1(d)

Based on record review and interview, the facility staff failed to have documented evidence that the residents or their representative were made aware that their accounts were above the maximum limit of $4000 for 16 of 16 sampled residents. The findings included: A review of the facility's trial balance dated 05/16/24 showed that Resident #28, #36, #25, #95, #12, #24, #67, #81, #87, #129, #94, #39, #105, #63, #90, and #32's accounts were above the $4000 limit. During a face-to-face interview conducted on 07/10/24 at 3:00 pm, Employee #24 (Resident Finance) stated that she sent letters to the residents' representatives regarding their accounts, but she did not keep track of when the letters were sent. In addition, the employee said she did not have a system for tracking correspondence with families.

Based on observation, record review and staff interviews for six (6) of 59 sampled residents, facility staff failed to ensure each resident received an accurate assessment reflective of the resident's status at the time of the assessment for a resident: with a history of falls; who requires repositioning assistance; with weight loss; on prescribed psychotropic medications; with a surgical wound; and who is prescribed use of supplemental oxygen. Residents' #496, #501, #95, #45, #133, and #21. The findings included: 1.Resident #496 was admitted to the facility on [DATE] with multiple diagnoses that included: Squamous Cell Carcinoma of Skin, Secondary Malignant Neoplasm of Inguinal and Lower Limb Lymph Nodes, Malignant Neoplasm of Prostate, Malignant Neoplasm of Lung, Muscle Weakness, and Difficulty Walking. A review of Resident #496's medical record revealed: An admission Summary Progress Note dated 05/21/24 at 8:13 pm documented, He can only ambulate in a wheelchair. A Nursing Progress Note dated 05/21/24 at 9:21 PM documented, limited ROM (range of motion) on left leg. A Physician Progress Note dated 05/23/24 at 11:24 PM documented, generalized weakness and difficulty ambulating for 2 weeks prior to presentation. A Fall Risk Evaluation dated 06/04/24 at 1:41 AM documented, Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Gait / balance: Decreased muscular coordination. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Gait / balance: Balance problem while standing. Fall Risk Score: 13.0 (Moderate Fall Risk). A Post Fall Evaluation dated 06/04/24 at 2:04 AM documented, Fall Details: Fall was not witnessed. Fall occurred bedside. Resident was attempting to self-toilet at time of the fall. A Facility Reported Incident (FRI) received by the State Agency on 06/04/24 at 9:09 AM documented, resident stated he went to the bathroom and [was] coming back to sit on his bed. A Discharge Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '11,' indicating the resident was moderately impaired. Section GG - Functional Abilities and Goals: Supervision for Sit to stand, Walk 10 feet, Walk 50 feet with (2) two turns, Walk 150 feet and Toilet transfer. Section J - Health Conditions: Has the resident had any falls since admission/entry or reentry or the prior assessment? No. It is noted that the Discharge Minimum Data Sete (MDS) assessment failed to accurately document the residents recent fall. During a face-to-face interview conducted on 07/03/24 at 1:00 pm, Employee #16 (MDS Coordinator-Manager) acknowledged the findings and stated, That was an error on the MDS. 2. Resident #501 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Chronic Kidney Disease, and Failure to Thrive. A review of Resident #501's medical record revealed: A Physician Order dated 06/07/2022 at 1:24 PM documented, Turning and repositioning every 2 hours every shift for to maintain skin integrity. A Physician Order dated 06/07/22 at 4:45 PM documented, Hourly rounding conducted for the Resident using the four P's every shift for fall prevention (3) Positioning: Resident re-positioned while sitting on the chair or lying in bed to prevent fall and maintain skin integrity. A Health Status Note dated 03/03/24 at 6:25 AM documented, ADL (Activities of Daily Living) care done, turn and reposition every two [hours] and as needed for skin integrity and pressure relief. An Orders - General Note from eRecord (electronic record) dated 03/03/24 at 11:07 am documented, Resident turned and repositioned per facility protocol for pressure relief and skin integrity. A Quarterly MDS assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score as Severely Impaired. Section M - Skin Conditions documented C. Turning/repositioning program was unchecked for Skin and Ulcer/Injury Treatments. During a face-to-face interview conducted on 07/03/24 at 1:00 pm, Employee #16 (MDS Coordinator-Manager) acknowledged the findings and stated, That was an error on the MDS. 3. Resident #95 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia with Intermittent Behavioral Problems, Psychotic Disorder with Delusions, and Anxiety Disorder. A review of Resident #95's medical record revealed: A Weight Summary dated 04/10/24 at 2:19 pm documented, 141.0 Lbs (pounds) Standing. A Physician Order dated 04/27/24 at 6:52 am documented, Weight monthly every day shift every 1 month(s) starting on the 10th. A Weight Summary dated 05/10/24 at 12:14 pm documented, 129.0 Lbs Standing. A Quarterly MDS assessment dated [DATE] documented: facility staff coded '0' for Loss of 5% or more in the last month or loss of 10% or more in last 6 months, indicating No. During a face-to-face interview conducted on 07/02/24 at 1:15 pm, Employee #12 (Dietitian) stated, There was a 6.9% weight loss while in the hospital because she weighed 141 pounds before she was admitted to the hospital. The MDS should've stated Yes for weight loss of 5% or more in last 30 days because my calculation show that she had a 6.9% weight loss over 3 weeks in the hospital, so that was an error on the MDS. 4. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Paranoia and Delusional Disorder, Major Depressive Disorder, Dementia, and Bipolar Disorder. A review of Resident #45's medical record revealed: A Physician Order dated 09/30/2023 documented, Ativan (lorazepam) - Schedule IV (four) solution; 2mg/ml (milligram per milliliter); amt (amount): 2mg/ml; injection, for agitation Every 6 hours PRN. A Medication Regimen Review dated 11/03/23 at 11:58 am documented, Patient has a PRN (as needed) Ativan for agitation. Recommend discontinue at this time due to non-use. As a PRN psychotropic, if need to continue, please re-evaluate and document clinical rationale. Then, please write a new order with a set number of days. A Physician Order dated 11/06/2023 at 5:00 pm documented, D/C (Discontinue) PRN Ativan. A Quarterly MDS assessment dated [DATE] documented: No for Active Diagnosis of Anxiety Disorder and Yes for use of Antianxiety medications. During a face-to-face interview conducted on 06/28/24 at 1:00 pm, Employee #16 (MDS Coordinator-Manager) acknowledged the findings and stated, For Section N, we look at the eMAR (electronic medication administration record), to capture the medication that was actually ordered and administered to the resident. I looked at the eMAR and it doesn't show she was getting an antianxiety medication, so that was a documentation error on the MDS. 5.Resident #133 was admitted to the facility on [DATE] with multiple diagnoses including Chronic Kidney Disease, Anemia, Hypertension, Peripheral Vascular Disease, Hyperlipidemia, and Anorexia. Review of Resident#133 medical record showed the following: 3/1/2024 16:38 [4:38pm] admission summary: Resident is [AGE] year-old female re-admitted from [NAME] Hospital center at 1:15 pm. She arrived via stretcher accompanied by paramedic. Resident was hospitalized on [DATE] for failure to thrive, significant weight loss, left sided abdominal mass. During hospital course she was noted with hematoma in left abdomen s/p aspiration of hematoma 2/15/24 due to purulent drainage and completed antibiotics, she came with negative pressure to left abdomen Prevenar plus 125 mmhg seting draining and functioning well. Per discharge summary palliative care was discuses with RP to transition to hospice care at facility. Resident new code status is DNR/DNI/DNH/Comfort care. NP in house had phone conversation with RP to come to the facility to sign Molst form, she agrees to come Saturday. DXx CKD, UTI, hematoma, Hyperglycemia, septic shock, Hypercalcemia, abscess, Leukocytosis. Resident alert and verbally responsive no distress/ discomfort voices denied pain when asked. lung sounds clear to bilateral upper and lower lobes, no wheezing no crackles. Heart rate regular. Abdomen rounded, obese, bowel sounds active on all four quadrants. Resident has multiple skin issues: Skin note: Left flank wound with negative pressure dressing. Sacrogluteal wound measure 19x11xUN. Right breast full thickness 100% eschar measure 11x9x0.2 cm Left breast full thickness 10x10xUN 100% epithelia. Right elbow pressure area measure 2 x1.5 x 0.1 100%epitheali. Bilateral heels DTPI 5 x5 xUN Perineal/inner thigh -IAD Bilateral arms, abdomen and under breast extensive ecchymosis. Bilateral leg edema Generalized pitting edema entire body. Medication reconciliation done by PA [Physician Assistant name]. RP [Responsible Party] made aware. Vital sign Bp 124/72, HR 79, RR 18, Temp 98.0, Spo2 98% RA. Review of the Physician order note dated 03/01/2024 at 22:25 [10:25 pm] showed. Left flank: Surgical wound w [with]/ wound with negative pressure dressing Treatment: Negative pressure, monitor device and dressing every shift and PRN [as needed] Review of the Annual (MDS) Minimum Data Set, dated [DATE], showed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 06, indicates severe cognitive impairment. In Section M (Skin Conditions), M1200 under other F. Surgical Wound care box was not checked for resident indicating not coded. The MDS lacked documented evidence that the facility staff accurately coded the MDS to reflect Resident #133 Surgical wound care. During a face-to-face interview conducted on 07/03/2024 at 1:14 PM, Employee #16 (MDS Coordinator) stated, He reviewed the MDS assessment and agreed it was missed. 6. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath, Heart Failure, and Bipolar Disorder. A review of Resident #21's medical record revealed the following: A review of a State Optional Minimum Data Set (MDS) assessment dated [DATE], showed that the facility staff did not code that the resident uses supplemental oxygen. A physician order dated 03/01/24 directed, Oxygen at 2 liter per minute via nasal cannula continuously every shift for COPD (chronic obstructive pulmonary disease). It is noted that the surveyor observed the resident on supplemental oxygen via Nasal cannula on 07/02/24 and 07/03/24. During a face-to-face interview conducted on 07/03/24 at 1:36 PM, Employee #13 (MDS Coordinator) stated that not coding that the resident receives supplemental oxygen was an oversight and human error. Cross Reference -22B DCMR Sec 3231.11

Based on observation, record review and staff interviews for two (2) of 59 sampled residents, facility staff failed to develop and implement a comprehensive person-centered care plan that included measurable goals and interventions for a resident who was prescribed psychotropic medications and a resident on one-to-one monitoring to prevent the resident from smoking while using supplemental oxygen. Residents' #92 and #21. The findings included: 1.Resident #92 was admitted to the facility on [DATE] with multiple diagnoses that included: Paranoid Schizophrenia, Psychotic Disorder with Delusions, Malignant Neoplasm of Lung and Malignant Neoplasm of Parotid Gland. A review of Resident #92's medical record revealed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented, facility staff coded Active Diagnoses - Psychotic Disorder and Schizophrenia and is taking Antipsychotic and Antidepressant medications during the last (7) seven days or since admission/entry or reentry. A Medication Administration Record (MAR) dated 4/1/2024 - 4/30/2024, 5/1/2024 - 5/31/2024 and 6/1/2024 - 6/30/2024 indicated that facility staff administered the following psychotropic medications as ordered by the physician: Trazodone, Depakote and Haloperidol. A review of an Order Summary Report dated 07/01/2924 at 12:25 pm documented the following active orders: --Depakote ER (extended release) Oral Tablet 24 Hour 250 MG (milligram) (Divalproex Sodium) Give 1 (one) tablet by mouth two times a day for Mood. Order Date 03/13/2023. --Haloperidol Oral Tablet 1 MG (Haloperidol) Give 1 tablet by mouth two times a day for Psychotic Disorder. Order Date 06/01/2021. --Trazodone HCl (Hydrochloride) Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to Insomnia. Order Date 03/16/2021. It should be noted that Resident #92's care plan did not show any documented evidence that facility staff implemented a comprehensive care plan with goals and interventions, including medication side effects, for her prescribed psychotropic medications. During a face-to-face interview conducted on 07/01/24 at 11:15 am, Employee #14 (1 Blue Unit Manager) was about the resident's care plan and he stated, Those things (care plans) are updated when we do the IDT (Interdisciplinary Team) meeting. I do all the assessments for the residents on 1 Blue and [Employee #4's name] (Unit Manager, 1 Blue/3 Blue) does all of the care plans for 1 Blue. During a face-to-face interview conducted on 07/01/24 at 11:28 am, Employee #4 (Unit Manager, 1 Blue/3 Blue) acknowledged the findings and stated Ok, we have to do one for Psychotropic medications. 2. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath, Heart Failure, and Bipolar Disorder. A review of the facility's policy titled Nursing Services Resident Care Plan dated revised on 03/21/24, documented the following: There shall be a written care plan for each resident. It shall contain information of importance concerning resident needs. The care plan shall include (1) problem list (2) measurable goals, (3) Approaches to address the problem. The problem list shall include but not be limited to: The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well being as required. A review of Resident #21's medical record revealed the following: A care plan dated 04/29/24, documented in part, Focus- (Resident #21) has a behavior of smoking while on oxygen .Interventions Resident is on one-to-one monitoring Q (every) shift. A physician order dated 05/06/24 directed, Resident is on one-to-one monitoring Q (every) shift to prevent resident from smoking while on oxygen. On 07/02/24 at 10:54 AM Resident #21 was observed in her room lying in bed with oxygen in use. At the time of the observation, Resident #21 stated I do smoke, but I haven't been outside to smoke. I don't smoke in the room. It should be noted that there was no 1:1 staff monitoring Resident #21 at the time of the Surveyor observation. On 07/02/24 at approximately 3:30 PM, Resident #21 was observed in her room laying in bed while receiving supplemental oxygen via nasal cannula. There were no staff present in the resident's room or near the doorway. During a face-to-face interview conducted on 07/02/24 at approximately 3:55 PM, Employee #4 (Unit Manager) stated that all the staff is monitoring the residents, and the resident has not been observed smoking since being placed on monitoring. The surveyor asked how all staff monitor the resident if they cannot see the resident and Employee #4 made no further comment. Cross Refrence-22B DCMR Sec 3210.4 Based on record review and resident and staff interviews for two (2) of 59 sampled residents, facility staff failed to develop a care plan that addressed a resident who was visually impaired and had glaucoma and failed to implement the approaches on a resident's care plan that addressed the resident's need for follow-up with audiology, resulting in the resident obtaining an appointment nine months after staff documented hearing as a concern. Residents #112 and #162. The findings included: 1)Resident #112 was admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus with Hyperglycemia, Partial Amputation of Left Foot, and Chronic Angle -Closure Glaucoma, Right Eye, Stage Unspecified. A review of the Resident #112's medical record revealed: A physician's order dated 02/03/24 directed: Consult: Ophthalmology consult eval (uation) and treat as needed. A physician's order dated 04/02/24 that directed: Azopt Ophthalmic Suspension 1% (Brinzolamide) [eyedrops] Instill 1 drop in right eye two times a day/ Place 1 drop into the right eye 2 times daily for glaucoma. A physician's order dated 04/02/24 that directed: Combigan Ophthalmic Solution 0.2-0.5 (Brimonidine Tartrate-Timolol Meleate) [eyedrops]. Instill 1 drop in right eye two times a day for glaucoma. A physician's order dated 04/02/24 that directed: Latanoprost Ophthalmic Solution 0.005 (Latanoprost) [eyedrops]. Instill 1 drop in the right eye at bedtime for glaucoma. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #112 had a Brief Interview for Mental Status (BIMS) summary score of 13 indicating intact cognition, required setup for eating and oral hygiene, and was dependent on staff for assistance with all other activities of daily living (toileting, personal hygiene, bathing, and dressing. During an observation and a face-to-face interview on 06/24/24 at 4:04 PM, Resident #122 was observed awake, laying in her bed supine (on her back). To the left side of the resident's bed, was a bedside table. A lunch tray was sitting on top of the bedside table. When asked if she liked the food served at lunch, the resident replied that she did not see or know that her lunch tray was sitting there. The surveyor observed that during the entire interview, the resident kept her right eye closed. When asked if she could see from the right eye, she stated, Not really, it is blurry. I get drops for dry eyes, but it doesn't seem to help. When asked if she had an appointment with the eye doctor the resident stated that she was not aware of one and she had never had an appointment scheduled since she got to the facility. During a face-to-face interview on 07/15/24 at 1:45 PM, Employee #20, (Unit Manager of 2 Blue), stated that care plans are reviewed and updated quarterly and prn (as needed). She then reviewed Resident #112's comprehensive care plan and acknowledged that the care plan did not address the resident's visual impairment. She also stated that she would check to see if the Resident had an ophthalmology appointment since her admission. Of note, there was no documented evidence that facility staff had initiated a care plan that addressed the resident's visual impairment/glaucoma. At 3:30 PM the Employee returned with an updated care plan implemented on 07/15/24 that documented: Focus:[Name of Resident #112] has impaired visual function r/t (related to) glaucoma on the right eye; Goal: The Resident will show no decline in visual function through the review date .Ophthalmology Appointment scheduled for March 7th, 2025 .Report to MD (Medical Director). Sudden visual loss. Pupil dilated, gray or milky, c/o (complaint of) halos around lights, double vision, tunnel vision, blurred or hazy vision. 2)Resident #162 was admitted to the facility on [DATE] with diagnoses that included: Acute Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Tobacco Use, and Generalized Muscle Weakness. A review of the resident's medical record revealed: A review of a Quarterly admission Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #162 had a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognition. A review of a physician's order dated 08/01/23 at 3:30 PM, directed: Clarification order for Debrox otic [ear] solution: Debrox otic solution. Apply 5 drops to bilateral ears twice daily x 4 days for cerumen impaction, Flush with lukewarm water with a bulb syringe twice on the 5th day. A review of a Nurse Progress Note dated 08/02/2023 04:57 PM documented: Resident S/P (status post) in house transfer was seen by [Name of Physician Assistant] during doctor's rounds on 8/1/23. Debrox otic solution was ordered. Order clarified today .Resident has been notified of the new order. Resident's sister [Name of Sister/resident's representative] was notified . A review of a care plan implemented on 08/02/23 documented: Cerumen impaction .Approach(es) created 08/02/23: Debrox otic solution. Apply 5 drops to bilateral ears twice daily x 4 days for cerumen impaction; Flush with lukewarm water with a bulb syringe twice on the 5th day; Follow-up with Audiology, if recommended. Monitor for changes in hearing and report to physician . Of note the care plan showed a reviewed and revision date of 07/01/24, after the surveyor asked for a copy of the resident's care plan. A review of a Physician's Note dated 09/26/23 at 06:57 PM documented, Patient has multiple medical problems and is hearing impaired and reports numbness in both lower limbs after taking a certain medication . A review of a physician's order dated 02/06/24 directed: Audiology consult for hearing loss/difficulty-possible hearing aid -evaluate and treat. A review of a Nursing Note on 05/30/24 at 4:27 PM documented: Resident had an audiology appointment today at [Name of Local Hospital], hospital called to reschedule the appointment for September 6th2024, at 1:30 PM. Resident/RP (representative /PMD (primary medical doctor) made aware. Of note, there was no documented evidence that facility staff monitored the resident's hearing and reported it to the physician from 08/02/23 to 02/06/24 (6 months). In addition, there was no documented evidence that the care plan was revised or reviewed again until 07/01/24 at 2:11 PM, after the writer asked for a copy of Resident #162's comprehensive care plan. During a face-to-face interview on 06/24/24 at 3:13 PM, Resident #162, stated, They [facility staff] get on me, because I talk loudly. I can hardly hear sometimes and asking people to repeat themselves makes me upset. I have asked to see the doctor. I think I may need hearing aids or something to help me hear. I told the charge nurse, so they know about it. During a face-to-face interview on 07/03/24 at 4:12 PM, Employee #19, (Former Unit Manager of 2 Blue), that care plans are reviewed and updated quarterly and as needed. When asked about the when asked about the interventions on the care plan, the Employee stated that the nurses should have documented that they were monitoring for changes to the resident's hearing in the progress notes and, they should have let the physician know. The Employee had no response when asked what delayed the resident from obtaining an appointment from 02/06/24 to 05/30/24, and she had no explanation for not reviewing the interventions on the care plan until 07/01/24 when the survey was ongoing.

Based on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to treat a resident with respect, dignity, and care, as evidenced by administering advanced life support measures to a resident who was not a Full Code. Resident #498. The findings included: Resident #498 was admitted to the facility on [DATE] with multiple diagnoses that included: Malignant Neoplasm of Breast, Respiratory Failure, Congestive Heart Failure, and Chronic Kidney Disease. A review of Resident #498'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 '13,' indicating the resident was cognitively intact; Functional Abilities an Goals coded as '02-Substantial/maximal assistance' with Sit to Stand position, Lower body dressing and Putting on/taking off footwear; '03-Partial/moderate assistance with Toileting hygiene, Shower/bathe self, Personal hygiene and Upper body dressing. A Nursing re-admission Note dated [DATE] at 7:08 pm documented, The resident code status is DNR (Do not Resuscitate) and pre-arrest limitation-ordered: DO NOT Intubate. A Physician Order dated [DATE] documented, Advance Directive Set/Code Status. Special Instructions: Resident is DNR/DNI (Do Not Resuscitate/Do Not Intubate)/DO NOT HOSPITALIZE COMFORT CARE. A Nursing Progress Note dated [DATE] at 12:10 am documented, [Resident's son's name] visited today and told the writer that the hospital told the family that sending the resident to the hospital will cause her more pain and will not change her medical condition. He said they have been advised to put the resident [on] end of life care. The writer explained the comfort and hospice care to him. Asked if he would like CPR (Cardiopulmonary Resuscitation) to be initiated and to be transferred to the hospital and he responded no to the questions asked. He said he would prefer her to be in comfort care. [Physician Assistant's name] was contacted and notified of family's desire to have the resident on comfort care. Telephone order was given for DNR/DNI/DO NOT HOSPITALIZE COMFORT CARE. Resident's son was notified that the resident's code status is now DNR/DNI/DO NOT HOSPITALIZE COMFORT CARE before he leaves the unit today. A Care Plan Problem dated [DATE] documented, Category: End of Life Program DNR/DNI/DO NOT HOSPITALIZE COMFORT CARE. Goal-Resident will experience death with dignity and physical comfort and resident's wishes in the Advanced directive will be honored in the next 90 days. Approach-Manage pain and other uncomfortable symptoms, Provide basic comfort measures (e.g. (such as), touch, oral care, back massage). A Nursing Progress Note dated [DATE] at 7:45 am documented, [Resident's name] was observed lying bed without pulse and without respiration. Resident code status: Full Code. CPR was initiated immediately and 911 called and The EMS (Emergency Medical Services) took over the CPR. At around 6:25 AM, the resident left the unit via (by) stretchers with the EMS to [Hospital name]. A Nursing Progress Note dated [DATE] at 10:00 pm documented, Resident expired at [Hospital name]. A Complaint [#DC00012509] received by the State Agency on [DATE] at 12:00 pm documented, I am an EMS Captain with DC (District of Columbia) Fire and EMS. At 0535hrs (5:35 am) 01-02-2024 we were dispatched for a Cardiac Arrest. At time of arrival, only chest compressions were being done with no assisted ventilation nor was an AED (automated external defibrillator) in place. My crews and I took over the arrest and were given paperwork for the patient. We proceeded to actively work this cardiac arrest for 51 minutes, including transporting to [Hospital name] where we were notified that the facility failed to provide us with valid DNR documentation on scene (at the facility). We provided full advanced life support measures for this patient against their wishes because the facility failed to provide us with appropriate documentation. During a telephone interview conducted on [DATE] at 8:00 am, Employee #17 stated, I don't know if the order was in place or embedded somewhere in the chart, but we always supposed to look first. So, if it (resident's code status) was carried out as Full Code maybe the Pulse Form (Advance Directive Form) was not changed yet. During a telephone interview conducted on [DATE] 8:06 am, the (EMS Captians complainant) stated, The patient was pulseless and apneic (not breathing) on our arrival. We were given paperwork that stated the patient was a full code, but upon arrival to [Hospital name] they were notified that the patient was in fact a DNR after we worked this patient up for a very long time. It's important to honor the requests and decisions for patients.

Based on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to ensure that a resident was free from physical restraint not required to treat the resident's medical symptoms, as evidenced by a siderail up at the foot of the resident's bed. Resident #105. The findings included: Resident #105 was admitted to the facility on [DATE] with multiple diagnoses that included: Blindness Both Eyes, Psychotic Disorder with Delusions, Hallucinations, Morbid Obesity and Muscle Weakness. A review of Resident #105's medical record revealed: A review of the facility's policy titled 'Restraint Usage 00 - 008' with a review and revised date of June 7, 2024, documented, Definition and Philosophy of Use: The RAI (Resident Assessment Instrument) User's Manual defined restraint as Any manual method of physical or mechanical device, material or equipment attached or adjacent to resident's body that the individual cannot remove easily, which restricts freedom or normal access to one's body (Chap. 3 p P-1). And In 42 CFR (Code of Federal Regulations) 4183-18(a) under Resident behavior and center practices (a) it is recognized that the resident has the right to be free of any physical or chemical restraints imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. Restraints will not be applied without first obtaining an order from the resident's physician. A Physician Order dated 05/15/2021 documented, Bilateral quarter side rails up in bed every shift for enhancement of turning and repositioning. Monitor every shift. A Care Plan Problem dated 05/17/2023 documented, Category: ADLs Functional Status/Rehabilitation Potential, Self care deficit; Approach: Half side rails when in bed to enhance turning and repositioning. A Physician Note dated 05/14/2024 at 11:35 pm documented, The resident at baseline is debilitated, bedbound and dependent with all ADLs (Activities of Daily Living). A Discharge Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 11, indicating the resident was moderately impaired; coded 0 for Restraints and Alarms, indicating there were no bedrails used in bed as a form of restraint. During an observation of Resident #105's room that was conducted on 06/26/24 at 10:30 am and 07/16/24 at 11:45 am, the resident was lying in bed with (3) three siderails in the upward position - there were (2) two siderails up at the head of the bed, one on each side; and one siderail that was up at the foot of the resident's bed on the left side. During a face-to-face interview conducted on 07/16/24 at 2:32 pm, Employee #2 (Director of Nursing/DON) stated, Only persons who are able to reposition themselves have quarter side rails in place at the head of the bed. No resident should have siderails up at the foot of the bed. Cross Reference 22B DCMR Sec 3216.1

Based on record reviews and staff interviews for one (1) of 59 sampled residents, the facility staff failed to implement its policies and procedures for reporting and conducting investigations into potential allegations of neglect and or abuse. Resident #128. The findings included: A review of the facility's policy titled Incident and Accident dated revised on 01/03/24 documented the following: When actual incident occurs: Complete head to toe nursing assessment must be completed by the licensed nurse for both witnessed and unwitnessed incidents. Perform neurological assessments for all if appropriate Incident will be reviewed by the clinical team. Notification of physician and responsible party. Incident report must be sent to Department of Health (DOH) for all incidences. Investigation using the incident and accident form. Witness statement if appropriate. A review of the facility's policy titled Prohibition of Abuse that was undated directed Staff will complete an incident /accident form for any unusual occurrences and submit it to the director of nursing or designee All alleged violations, substantiated incidents; corrective actions depending on the results of the investigation are reported verbally within 8-72 hours and in writing within 5 working days to the State Agency. Resident #128 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Diabetes Mellitus Type 2, Opioid Dependence, and Acquired Absence of Right Leg above the Knee. A review of a Facility Reported Incident (FRI) DC# 00012281, submitted to the State Agency on 09/08/23 documented the following: Around 9:25 PM today 9/7/2023, nursing supervisors were called to the 2 Blue unit by the charge nurse, informing them that the resident had called 911. Upon arrival, 911 had already left the unit. According to the charge nurse, the resident reported that he had a bump on his forehead and a scratch on his chest. Resident also verbalized that he had an encounter with the staff earlier today. 911 offered to take him to the hospital, but he declined. Upon assessment, the resident was noted with a small bump on his mid forehead and a scratch on his chest. The resident was offered pain medication, but he refused. When asked for further information about the encounter, the resident became agitated and loud. Nursing supervisors calmed the resident down and left the room. A review of a Facility Reported Incident (FRI) DC# 00012448, submitted to the State Agency on 11/14/23, documented the following: At about 5:00 PM the charge nurse called the writer to resident's room. On arrival the resident was observed in bed unresponsive to name call or tactile stimuli. Resident has a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing have a palpable pulse but unresponsive. Blood sugar was checked it was 231mg/dl(milligram deciliter), T (tempreature) 98.5 P (pulse) 98 R (respirations) 22 B/P (Blood Pressure) 132/76. Assessment findings communicated to PA-C (Physician Assistant Certified) ordered was given to transfer the resident to the nearest ER (Emergency Room) via 911 for further evaluation of unresponsiveness. EMS was immediately activated. Resident continue to breathe and have a palpable pulse until the arrival of 911 at about 5:15PM that takes over the care the resident. Additional Narcan was given by 911 and the resident regained consciousness though he was very drowsy. Resident initially refused to be transferred but later he agreed to go with the emergency crew. A review of a Facility Reported Incident (FRI) DC#00012735 submitted to the State Agency on 03/05/24, documented the following: At about 8:00PM the charge nurse called the writer to the resident's room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. He is diabetic blood sugar was checked and it was 370mg/dl (milligram deciliter). T (Tempreature) 98.5 P (pulse) 97 R (Respirations) 02 B/P (Blood Pressure) 136/76. Assessment findings communicated to MD (medical doctor) ordered to transfer the resident to the nearest ER via 911 for further evaluation of unresponsiveness. EMS (emergency medical services) was immediately activated at about 8:10 PM. A review of a Facility Reported Incident (FRI) DC# 00012736, submitted to the State Agency on 04/10/24, that documented the following: Resident propels himself in and out of his unit on his wheelchair independently. He was closely monitored during the day shift for signs of drug overdose. No signs of drug overdose were noted during the day shift. At about 8:00PM the charge nurse called the writer to the resident?s room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. He is diabetic blood sugar was checked and it was 370mg/dl (milligram deciliter). T (tempreature) 98.5 P (pulse) 97 R (Respirations) 02 B/P (Blood Pressure) 136/76. Assessment findings communicated to MD (medical doctor) ordered to transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. EMS (emergency medical services)was immediately activated at about 8:10PM. Resident continued to breathe and had a palpable pulse until the arrival of 911 at about 8: 20 PM A) The facility staff failed to follow the facility's policy to thoroughly investigate an incident in which Resident #128 was found unresponsive on 11/14/23. A review of Resident #128's medical record revealed the following: A transfer progress note dated 11/14/23 at 6:25 PM, documented in part On arrival the resident was observed in bed unresponsive to his name or tactile stimuli. Resident have (sp) (Has) a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to but (sp) (Both) nostrils immediately. Resident was breathing has a palpable pulse but unresponsive. ordered to transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A review of the facility's investigation of the incident involving Resident #128 on 11/14/23 consisted of a handwritten form titled For (facility name) Personnel Use. It is noted that there is no documented evidence of witness statements, statements from Resident #128 once he returned to the facility, updated care plan or any other follow up investigations to the incident that occurred on 11/14/23. B. The facility staff failed to follow the facility's policies to thoroughly investigate the incident that occurred on 03/05/24 in which the resident was found unresponsive and Narcan (Opiate Antagonist) was administered. A review of Resident #128's medical record revealed the following: A physician order dated 06/06/22, documented Narcan Nasal Liquid 4mg/0.1ML (Naloxone HCL) 1 spray in each nostril as needed for signs of opioid overdose Administer 1 time. A nursing progress note dated 03/05/24, documented He (Resident #128) was closely monitored during the day shift for signs of drug overdose. No signs of drug overdose were noted during the day shift. At about 8:00 PM the charge nurse called the writer to the residents room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. MD (Medical Doctor) ordered transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A physician order dated 03/05/24 at 8:15 PM, directed Transfer resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A care plan initiated on 03/05/24 documented in part (Resident #128) has a history of substance abuse hence potential for ineffective Health Maintenance and risk for injury related to substance intoxication or withdrawal as evidenced by opioid/narcotics overdose. Interventions/tasks Monitor resident for safety each shift, Give medication as ordered Narcan (Nasal Naloxone). A review the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the facility staff coded that Resident #128 as having a Brief Interview for Mental Status Summary Score of 15 indicating intact cognition, being independent in eating and using a manual wheel chair 150 ft (Feet) once seated, required supervision for toileting, shower bath, Upper and lower body dressing and personal hygiene, and receives antidepressant medication. A review of the facility's investigation dated 03/05/24, showed that it consisted of 4 handwritten statements from the facility's staff, a handwritten form titled For (Facility Name) Personnel Use, and an updated care plan submission dated created on 03/05/24. It is noted that the facility's investigation did not contain any of the following: statements from Resident #128 or other residents, visitor logs, physical or neurological assessments of Resident #128 and there was no follow up investigation submitted to the State Agency. There was also no follow up Interdisciplinary Team Meeting or notes from the social worker. During a face-to-face interview conducted on 07/16/24 at 4:03 PM, Employee #1 (Administrator) acknowledged the findings and asked Do we need to write an incident report and do an investigation for a resident who is unresponsive and has a history of drug abuse? C. The facility staff failed to follow the facility's policy to report a follow up investigation to the State Agency within 5 working days following an incident in which Resident #128 was found on the floor with a bloody nose and an alteration in behavior which was documented on 04/10/24. A review of Resident #128's medical record revealed the following: A review of an incident progress note dated 04/10/24 at 8:45 am documented the following: Around 7:30 AM CNA (certified nursing aide) caring for the above resident reported that resident was observed in a sitting position on the floor in his room. Upon assessment, resident was observed with minimal amount of blood dripping from his nostrils. An open area was noted on his nose bridge about the size of a pin head. He was agitated screaming, yelling and banging his face with his open palms. He was fighting off staff attempting to clean the blood dripping from his nostrils. He refused vital signs to be checked. MD (medical doctor) notified of assessment findings and ordered the resident to be transferred to the nearest ER (emergency room) via 911 for further evaluation. A review of nursing progress dated 04/11/24 at 4:19 AM, ER (emergency room) documented the following: ER (emergency room) discharge summary indicated drug abuse as complaint. While in hospital, there was no medical intervention provided. Resident was diagnosed with final diagnosis 1: Altered mental status and final diagnosis 2 Nasal Bone fracture and there was no treatment while in the ER. Resident to follow up at (hospital Abbreviation clinic and address) Resident was educated on the danger of taking illicit drugs and noncompliance with medication regimen. A review of a nursing progress note dated 04/11/24 at 10:32 AM, documented the following: Resident returned from (hospital name) @ (at) 8 AM via stretcher with two paramedics. Resident refused assessments and vital sign was encourage (sp) and educated still refuse. Review of the facility's investigations showed that no follow-up investigation was completed and submitted to the State Agency within the required 5 working days. During a face-to-face interview conducted on 07/15/24 at 4:29 PM, Employee #2 (Director of Nursing) Acknowledged the findings.

Based on record reviews and staff interviews for one (1) of 59 sampled residents, the facility staff failed to show documented evidence that the facility reported the results of a follow up investigation to the State Agency within 5 working days of incidents in which Resident #128 was found unresponsive on 11/14/23, 3/5/24 and found with an injury of unknown origin and change in behavior on 4/10/24. Resident #128. The findings included: A review of the facility's policy titled Prohibition of Abuse that was undated directed, Staff will complete an incident /accident form for any unusual occurrences and submit it to the director of nursing or designee All alleged violations, substantiated incidents; corrective actions depending on the results of the investigation are reported verbally within 8-72 hours and in writing within 5 working days to the State Agency A review of a Facility Reported Incident (FRI) DC~00012281, submitted to the State Agency on 09/08/23 documented the following: Around 9:25 PM today 9/7/2023, nursing supervisors were called to the 2 Blue unit by the charge nurse, informing them that the resident had called 911. Upon arrival, 911 had already left the unit. According to the charge nurse, the resident reported that he had a bump on his forehead and a scratch on his chest. Resident also verbalized that he had an encounter with the staff earlier today. 911 offered to take him to the hospital, but he declined. Upon assessment, the resident was noted with a small bump on his mid forehead and a scratch on his chest. The resident was offered pain medication, but he refused. When asked for further information about the encounter, the resident became agitated and loud. Nursing supervisors calmed the resident down and left the room. A review of a FRI DC~00012448, submitted to the State Agency on 11/14/23, documented the following: At about 5:00 PM the charge nurse called the writer to resident's room. On arrival the resident was observed in bed unresponsive to name call or tactile stimuli. Resident has a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing have a palpable pulse but unresponsive. Blood sugar was checked it was 231mg/dl(milligram deciliter), T (tempreature) 98.5 P (pulse) 98 R (respirations) 22 B/P (Blood Pressure) 132/76. Assessment findings communicated to PA-C (Physician Assistant Certified) ordered was given to transfer the resident to the nearest ER (Emergency Room) via 911 for further evaluation of unresponsiveness. EMS was immediately activated. Resident continue to breathe and have a palpable pulse until the arrival of 911 at about 5:15PM that takes over the care the resident. Additional Narcan was given by 911 and the resident regained consciousness though he was very drowsy. Resident initially refused to be transferred but later he agreed to go with the emergency crew. A review of a FRI DC~00012735 submitted to the State Agency on 03/05/24, documented the following: At about 8:00PM the charge nurse called the writer to the resident's room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. He is diabetic blood sugar was checked and it was 370mg/dl (milligram deciliter). T (Tempreature) 98.5 P (pulse) 97 R (Respirations) 02 B/P (Blood Pressure) 136/76. Assessment findings communicated to MD (medical doctor) ordered to transfer the resident to the nearest ER via 911 for further evaluation of unresponsiveness. EMS (emergency medical services) was immediately activated at about 8:10 PM. A review of a FRI DC~12736, submitted to the State Agency on 04/10/24, that documented the following: Resident propels himself in and out of his unit on his wheelchair independently. He was closely monitored during the day shift for signs of drug overdose. No signs of drug overdose were noted during the day shift. At about 8:00PM the charge nurse called the writer to the resident?s room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. He is diabetic blood sugar was checked and it was 370mg/dl (milligram deciliter). T (tempreature) 98.5 P (pulse) 97 R (Respirations) 02 B/P (Blood Pressure) 136/76. Assessment findings communicated to MD (medical doctor) ordered to transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. EMS (emergency medical services)was immediately activated at about 8:10PM. Resident continued to breathe and had a palpable pulse until the arrival of 911 at about 8: 20 PM Resident #128 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Diabetes Mellitus Type 2, Opioid Dependence, and Acquired Absence of Right Leg above the Knee. A) The facility staff failed to submit a follow up investigation to the State Agency within 5 working days following an incident in which Resident #128 was found unresponsive on 11/14/23. A review of Resident #128's medical record revealed the following: A transfer progress note dated 11/14/23 at 6:25 PM, documented in part On arrival the resident was observed in bed unresponsive in bed unresponsive to his name or tactile stimuli. Resident have (sp) (Has) a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to but (sp) (Both) nostrils immediately. Resident was breathing has a palpable pulse but unresponsive. ordered to transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A review of the facility's investigation of the incident involving Resident #128 on 11/14/23 consisted of a handwritten form titled For (facility name) Personnel Use. It is noted that there is no documented evidence that a follow up investigation was submitted to the State Agency following the incident that occurred on 11/14/23 in which Resident #128 was found unresponsive. B. The facility staff failed to Submit a follow up investigation to the State Agency within 5 working days following an incident that occurred on 03/05/24 in which the resident was found unresponsive and Narcan (Opiate Antagonist) was administered. Review of Resident #128's medical record revealed the following: A physician order dated 06/06/22, documented Narcan Nasal Liquid 4mg/0.1ML (Naloxone HCL) 1 spray in each nostril as needed for signs of opioid overdose Administer 1 time. A nursing progress note dated 03/05/24, documented He (Resident #128) was closely monitored during the day shift for signs of drug overdose. No signs of drug overdose were noted during the day shift. At about 8:00 PM the charge nurse called the writer to the residents room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. MD (Medical Doctor) ordered transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A physician order dated 03/05/24 at 8:15 PM, directed Transfer resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A care plan dated initiated on 03/05/24 documented in part (Resident #128) has a history of substance abuse hence potential for ineffective Health Maintenance and risk for injury related to substance intoxication or withdrawal as evidenced by opioid/narcotics overdose. Interventions/tasks Monitor resident for safety each shift, Give medication as ordered Narcan (Nasal Naloxone) A review the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the facility staff coded that Resident #128 as having a Brief Interview for Mental Status Summary Score of 15 indicating intact cognition, being independent in eating and using a manual wheel chair 150 ft (Feet) once seated, required supervision for toileting, shower bath, Upper and lower body dressing and personal hygiene, and receives antidepressant medication. A review of the facility's investigation dated 03/05/24, showed that it consisted of 4 handwritten statements from the facility's staff, a handwritten form titled For (Facility Name) Personnel Use, and an updated care plan submission created on 03/05/24. It is noted that there was no follow up investigation submitted to the State Agency within 5 working days after the incident that occurred on 03/05/24 in which Resident #128 was found unresponsive. C. The facility staff failed to submit a follow up report/investigation within 5 working days to the State Agency following an incident in which Resident #128 was found on the floor with a bloody nose and an alteration in behavior which was documented on 04/10/24. Review of Resident #128's medical record revealed the following: A review of an incident progress note dated 04/10/24 at 8:45 am documented the following: Around 7:30 AM CNA (certified nursing aide) caring for the above resident reported that resident was observed in a sitting position on the floor in his room. Upon assessment, resident was observed with minimal amount of blood dripping from his nostrils. An open area was noted on his nose bridge about the size of a pin head. He was agitated screaming, yelling and banging his face with his open palms. He was fighting off staff attempting to clean the blood dripping from his nostrils. He refused vital signs to be checked. MD (medical doctor) notified of assessment findings and ordered the resident to be transferred to the nearest ER (emergency room) via 911 for further evaluation. A review of nursing progress dated 04/11/24 at 4:19 AM, ER (emergency room) documented the following: ER (emergency room) discharge summary indicated drug abuse as complaint. While in hospital, there was no medical intervention provided. Resident was diagnosed with final diagnosis 1: Altered mental status and final diagnosis 2 Nasal Bone fracture and there was no treatment while in the ER. Resident to follow up at (hospital Abbreviation clinic and address) Resident was educated on the danger of taking illicit drugs and noncompliance with medication regimen A review of a progress note dated 04/11/24 at 10:32 AM, documented the following: Resident returned from (hospital name) @ (at) 8 AM via stretcher with two paramedics. Resident refused assessments and vital sign was encourage (sp) and educated still refuse Review of the facility's investigations showed that no follow-up investigation was completed and submitted to the State Agency within the required 5 working days. During a face-to-face interview conducted on 07/15/24 at 4:29 PM, Employee #2 (Director of Nursing) Acknowledged the findings and stated she would check to see if a follow up investigation was submitted.

2.Facility staff failed to conduct a thorough investigation after Resident #159 sustained an injury while in the facility's dialysis center. Resident #159 was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease (ESRD), Dependence on Dialysis, Left-Sided Weakness and Left Femur Fracture. A review of Resident #159's medical record revealed: A physician's order dated 03/01/24 at 7:30 AM directed, Hemodialysis with [Name of Dialysis Center] in the basement under [Dialysis Physician's name] on Mondays, Wednesdays, and Fridays secondary to ESRD every day shift every Monday, Wednesday and Friday for dialysis schedule. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident as having a Brief Interview for Mental Status Summary Score of 15, indicating intact cognition and used a wheelchair for locomotion. A review of a Facility Reported Incident (FRI) DC# 00012907, submitted to the State Agency on 06/20/24 at 11:10 AM, documented the following: On 6/17/2024, the resident left the facility for dialysis in stable condition. On 6/18/2024, the resident told the unit manager, 'I was [in] dialysis yesterday in my wheelchair and the nurse accidentally pushed my wheelchair while my left leg was on the floor instead of the footrest, I heard [a] cracking sound.' Upon assessment, the left knee was noted slightly swollen and warm to touch. The resident complaint [ed] of pain with touch on a scale of 5/10. Tylenol 500 mg (milligram), 2 tabs were administered per order which relieved the pain about an hour later. Physician Assistant (PA) [Name of PA] notified, ordered X-ray 2 views of left knee and Lasix 20 mg po (by mouth) daily x 2 weeks for localized edema. The result of the X-ray showed, 'Angulated fracture of distal femur with displacement.' [Name of radiology service] was called for clarification of the X-ray result, as the resident was admitted with similar diagnosis in 2023. An addendum impression was sent to the unit as 'Fracture is subacute. There are no previous films for comparison.' PA made aware, ordered Orthopedic consult with recommendation for hospital transfer if no close appointment date. Resident will be transferred to the hospital for evaluation . An email from Employee #26, Administrator Liaison, to the [Dialysis Center's Administrator's name] on 06/21/24 at 11:55 AM documented: .Per our conversation regarding [Name of Resident #159]. We are currently investigating his alleged incident in dialysis on Monday 06/17/2024. The resident was adamant that the incident happened there, and he stated that the nurse knows (knew) about it because the resident screamed when it happened. With that being said, we will need a statement from your staff to add to our investigation . A follow up report from [Facility's Name] submitted to the State Agecy on 06/21/24 at 4:12 PM documented: He was transferred to the ER [Emergency Room] yesterday 6/20/2024 due to X-ray result of 'Angulated fracture of distal femur with displacement.' The resident returned to the facility from [Name of Local Hospital] on 06/21/2024 around 9:30 AM. Recommendation was given to follow up with orthopedic doctor or physical therapy, and follow the RICE (rest, ice, compression, elevation) method as well. Resident is currently stable and continues pain management. Of note, there was no documented evidence of statements from the Dialysis Nurse, witness statements or the facility's final findings of their investigation into the incident. An email from [Dialysis Center Administrator's name] in response to Employee #26's email on 06/21/24 at 7:44 PM documented: .I will speak with [Name of Dialysis Nurse] about this matter. In addition to our Risk Manager. I will follow up with you on Monday. During a face-to-face interview on 06/25/24 at 8:51 AM, Resident #159 was observed in his room sitting in his wheelchair eating breakfast. When asked about the incident the resident stated that I was finished with dialysis and was about to come back upstairs to my room. The Dialysis Nurse was pushing [me] in my wheelchair to the door where the CNA (Certified Nurse Aide) who was going to take me back upstairs was waiting. The Dialysis Nurse forgot to put my leg on the leg rest and when he pushed me, my leg got caught on the floor. I felt a sharp pain in my knee, and I yelled, 'Ouch!' The Dialysis Nurse said, 'What are you hollering for?' and I said, 'My [expletive] leg hurts.' He then put my leg on the footrest and kept on going (continued to push me to the CNA) who was waiting for me at the door. When I noticed swelling in my leg and continued to have pain the next day, I told the Nurse on my unit what happened, and they sent me out to the ER. During a face-to-face interview conducted on 07/06/24 at 1:34 PM with Employee # 3, Assistant Director of Nursing, she stated that the facility's investigation for the incident was complete, and the report was sent to the State agency on 06/21/24. She commented that when the facility found out about the incident, they sent Resident #159 out for x-ray, and when the resident came back they (ER staff) said it was an old injury. She added further that, The facility did their part by asking the dialysis center for a statement from the Dialysis Nurse who provided care for Resident #159 on 06/17/24. The Dialysis Center said they would provide it, but never did. Cross Reference F610-22B DCMR Sec 3232.2 (b) (c) Based on record reviews and staff interviews for three (3) of 59 sampled residents, facility staff failed to show documented evidence that thorough investigations were conducted for: 1) two incidents in which Resident #128 was found unresponsive on 11/14/23 and 3/5/24, and 2) one incident in which Resident #159 sustained an injury of unknown origin. The findings included: 1.A review of the facility's policy titled Incident and Accident dated revised on 01/03/24 documented the following: When actual incident occurs: Complete head to toe nursing assessment must be completed by the licensed nurse for both witnessed and unwitnessed incidents. Perform neurological assessments for all if appropriate Incident will be reviewed by the clinical team. Notification of physician and responsible party. Incident report must be sent to Department of Health (DOH) for all incidences. Investigation using the incident and accident form. Witness statement if appropriate. A review of the facility's policy titled Prohibition of Abuse that was undated directed, Staff will complete an incident/accident form for any unusual occurrences and submit it to the director of nursing or designee. All alleged violations, substantiated incidents; corrective actions depending on the results of the investigation are reported verbally within 8-72 hours and in writing within 5 working days to the State Agency. A review of the facility's policy titled Use of Naloxone/Narcan with a revised date of 01/24 documented the following: All nurses responsible for the care and management of residents at (Facility name Abbreviation) can administer Narcan and monitor for potential complications associated with the medication use. Narcan will be available for use for residents with past or current history of drug use. Resident #128 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Diabetes Mellitus Type 2, Opioid Dependence, and Acquired Absence of Right Leg above the Knee. A review of a Facility Reported Incident (FRI) DC# 00012281, submitted to the State Agency on 09/08/23 documented the following: Around 9:25 PM today 9/7/2023, nursing supervisors were called to the 2 Blue unit by the charge nurse, informing them that the resident had called 911. Upon arrival, 911 had already left the unit. According to the charge nurse, the resident reported that he had a bump on his forehead and a scratch on his chest. Resident also verbalized that he had an encounter with the staff earlier today. 911 offered to take him to the hospital, but he declined. Upon assessment, the resident was noted with a small bump on his mid forehead and a scratch on his chest. The resident was offered pain medication, but he refused. When asked for further information about the encounter, the resident became agitated and loud. Nursing supervisors calmed the resident down and left the room. A review of a Facility Reported Incident (FRI) DC# 00012448, submitted to the State Agency on 11/14/23, documented the following: At about 5:00 PM the charge nurse called the writer to resident's room. On arrival the resident was observed in bed unresponsive to name call or tactile stimuli. Resident has a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing have a palpable pulse but unresponsive. Blood sugar was checked it was 231mg/dl(milligram deciliter), T (tempreature) 98.5 P (pulse) 98 R (respirations) 22 B/P (Blood Pressure) 132/76. Assessment findings communicated to PA-C (Physician Assistant Certified) ordered was given to transfer the resident to the nearest ER (Emergency Room) via 911 for further evaluation of unresponsiveness. EMS was immediately activated. Resident continue to breathe and have a palpable pulse until the arrival of 911 at about 5:15PM that takes over the care the resident. Additional Narcan was given by 911 and the resident regained consciousness though he was very drowsy. Resident initially refused to be transferred but later he agreed to go with the emergency crew. A review of a Facility Reported Incident (FRI) DC#00012735 submitted to the State Agency on 03/05/24, documented the following: At about 8:00PM the charge nurse called the writer to the resident's room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. His diabetic blood sugar was checked and it was 370 mg/dl (milligram per deciliter). T (Tempreature) 98.5 P (pulse) 97 R (Respirations) 02 B/P (Blood Pressure) 136/76. Assessment findings communicated to MD (medical doctor) ordered to transfer the resident to the nearest ER via 911 for further evaluation of unresponsiveness. EMS (emergency medical services) was immediately activated at about 8:10 PM. A review of a Facility Reported Incident (FRI) DC# 00012736, submitted to the State Agency on 04/10/24, that documented the following: Resident propels himself in and out of his unit on his wheelchair independently. He was closely monitored during the day shift for signs of drug overdose. No signs of drug overdose were noted during the day shift. At about 8:00 PM the charge nurse called the writer to the resident's room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. His diabetic blood sugar was checked and it was 370mg/dl (milligram per deciliter). T (tempreature) 98.5 P (pulse) 97 R (Respirations) 02 B/P (Blood Pressure) 136/76. Assessment findings communicated to MD (medical doctor) ordered to transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. EMS (emergency medical services)was immediately activated at about 8:10 PM. Resident continued to breathe and had a palpable pulse until the arrival of 911 at about 8:20 PM. Review of Resident #128's medical record revealed the following: A physician's order dated 06/06/22 documented, Narcan Nasal Liquid 4mg/0.1ML (milligram per milliliter) (Naloxone HCL(hydrochloride)) 1 spray in each nostril as needed for signs of opioid overdose Administer 1 time. A nursing progress note dated 03/05/24, documented He (Resident #128) was closely monitored during the day shift for signs of drug overdose. No signs of drug overdose were noted during the day shift. At about 8:00 PM the charge nurse called the writer to the resident's room. On arrival the resident was observed unresponsive to his name or tactile stimuli. Resident have a history of unresponsiveness and on Narcan nasal spray as needed for signs of drug overdose. Narcan was given to both nostrils immediately. Resident was breathing and had a palpable pulse but was unresponsive. MD (Medical Doctor) ordered transfer the resident to the nearest ER (emergency room) via 911 for further evaluation of unresponsiveness. A physician's order dated 03/05/24 at 8:15 PM, directed Transfer resident to the nearest ER via 911 for further evaluation of unresponsiveness. A care plan initiated on 03/05/24 documented in part, (Resident #128) has a history of substance abuse hence potential for ineffective Health Maintenance and risk for injury related to substance intoxication or withdrawal as evidenced by opioid/narcotics overdose. Interventions/tasks Monitor resident for safety each shift, Give medication as ordered Narcan (Nasal Naloxone). A review the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility staff coded Resident #128 as having a Brief Interview for Mental Status Summary Score of 15 indicating intact cognition, being independent in eating and using a manual wheel chair 150 ft (Feet) once seated, required supervision for toileting, shower/bath, upper and lower body dressing, personal hygiene, and received antidepressant medication. A review of the facility's investigation packet revealed no documented evidence of the following: statements from Resident #128 or other residents, visitor logs, and physical or neurological assessments of Resident #128. There was no documented evidence of a follow up investigation submitted to the State Agency, or evidenceof a follow up Interdisciplinary team meeting or notes from the social worker. B) The facility staff failed to thoroughly investigate an incident involving Resident #128 being found unresponsive on 11/14/23. A transfer progress note dated 11/14/23 at 6:25 PM, documented in part, On arrival the resident was observed in bed unresponsive . During a face-to-face interview conducted on 07/16/24 at 4:03 PM, Employee #1 (Administrator) acknowledged the findings and asked, Do we need to write an incident report and do an investigation for a resident who is unresponsive and has a history of drug abuse?

2. The facility staff failed to provide written notification for Resident #445 and their representative in a language they could understand, that informed them of the reasons for the resident's discharges to the hospital on [DATE], 12/20/23 and 02/13/24. Resident #445 was admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus (Type 2), Nephropathy, Congestive Heart Failure, Acute Kidney Failure, Lack of Coordination, Neuralgia, Syncope and Collapse, Age-related Osteoporosis and Unspecified Fall Encounter. A review of the resident's medical record revealed: A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #445 had a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognition, used a walker or a wheelchair for mobility and was unsteady for transfers or from a sitting to a standing position. Hospitalization #1 Resident #445 was transferred to the hospital on [DATE], after having an unwitnessed fall with injury. A review of a Nurse Progress Note/Transfer Note dated 11/15/23 at 6:21 documented: Resident was observed on the floor in her room lying on her left side today 11/15/23 at 7:15 AM. Prior to the incident routine rounds were done by the Certified Nurse Assistant (CNA) at 6 AM and the resident was in bed sleeping. Upon questioning, the resident stated that she was trying to go to the bathroom when she slid and fell .Resident later complained of pain in her left lower extremity and left hand. X-rays were ordered and pain medicine was given. Order was given to transfer the resident to the ER (Emergency Room) for further evaluation of pain post-fall . Prior to the departure of the 911 (Emergency Medical Team), [the] X-ray result was received with the impression of fracture of the left sub-capital femur. Resident is self-RP (Representative). A review of DOH (Department of Health) Notice of Discharge Transfer or Relocation Form dated 11/16/2023 at 11:14 AM documented: [Name of Resident #445] was transferred to [Name of Local Hospital] due to a fall and was subsequently admitted .Resident Rep was made aware via phone call on 11/15/2023 and bed hold notice was mailed. A review of a letter to Resident #445 dated 11/16/23 read: Dear [Name of Resident #445] You are receiving this letter because [Resident #445] was transferred to the hospital for further evaluation .Please sign and date the enclosed Acknowledgement of Receipt of Notice and return it immediately . Of note the Acknowledge of Receipt of Notice, was not signed or dated by the resident. There was no documented evidence that the resident received written notification from the facility explaining the reason for the Resident's transfer to the hospital. Hospitalization #2 Resident #445 was transferred to the hospital on [DATE] for hyperglycemia (High blood glucose). A review of a Nurse Progress Note dated 12/20/24 at 06:21 PM, documented: FS (finger stick) found to be at 500 mg/dl (milligrams per deciliter) and resident thirsty. MD (Medical Director) notified, and the resident was transferred to [Name of Local Hospital]. A review of a DOH (Department of Health) Notice of Discharge Transfer or Relocation Form dated 12/21/23 at 10:54 AM documented: [Name of Resident #445] was transferred to [Name of Local Hospital] due to Hyperglycemia and was subsequently admitted .Resident Rep was made aware via phone call on 12/20/2023 and bedhold notice was mailed. A review of a letter to Resident #445 dated 12/21/23 read: Dear [Name of Resident #445] You are receiving this letter because [Resident #445] was transferred to the hospital for further evaluation .Please sign and date the enclosed Acknowledgement of Receipt of Notice and return it immediately . Of note, the Acknowledge of Receipt of Notice, was not signed or dated by the resident. There was no documented evidence that the resident received written notification from the facility explaining the reason for the Resident's transfer to the hospital. A review of a Hospital Discharge summary dated [DATE] documented that Resident #445 was in the hospital from [DATE] to 01/28/24. During the hospitalization, the local hospital petitioned to appoint a temporary guardian for Resident #445. On 01/25/24 a hearing was held, and the resident was appointed a 90 Day Health Care Guardian. Hospitalization #3 A review of a Nurse Progress Note dated 02/12/24 documented, Resident is alert received in bed with no sign of respiratory distress or complaint of pain .was not talking, and not giving response to question asked this morning during wound rounds at about 10:40 AM .did not eat breakfast but accepted juice and water. The abdominal pad on the surgical incision on the resident's left hip was saturated with drainage and when palpated more drainage was oozing out of the 29th -31st staples .Order was given to transfer the resident to the nearest ER via 911 for evaluation of change in Mental Status Poor Appetite and non-resolving wound infection .The POA (Power of Attorney) [Name of Guardian] was notified prior to the transfer . A review of a DOH (Department of Health) Notice of Discharge Transfer or Relocation Form dated 02/13/24 at 1;22 PM documented: [Name of Resident #445] was transferred to [Name of Local Hospital] due to altered mental status and poor appetite and was subsequently admitted .Resident Representative was made aware of transfer via phone call on 02/12/2024 . A review of a letter to Resident #445 dated 02/13/24 read: Dear [Name of Resident #445 Representative] You are receiving this letter because [Resident #445] was transferred to the hospital for further evaluation .Please sign and date the enclosed Acknowledgement of Receipt of Notice and return it immediately . Of note, the Acknowledge of Receipt of Notice, was not signed or dated by the resident's representative. A review of the resident's medical record showed no documented evidence that facility staff provided written notification to the resident or the Resident's representative when the resident was transferred to the hospital on [DATE], 12/20/23, or 01/13/24. During a face-to-face interview on 07/28/24 at approximately 11:50 AM, Employee # 3/Assistant Director of Nursing (ADON), stated that the resident had a high BIMS, represented herself (had no resident representative), and was aware that she needed to be transferred when she was sent out to the hospital in November and December (2023). She added that facility staff contacted the resident's representative by phone when the resident was transferred to the hospital in January 2024. The Employee provided no further explanation for the unsigned and undated Acknowledge of Receipt of Notice(s). Based on record reviews and staff interviews for two (2) of 59 sampled residents the facility staff failed to provide documented evidence of providing notification to the resident or resident guardian of the reason for the residents transfer to the hospital emergency room. Residents' #32 and # 445. The findings included: 1. The facility staff failed to provide documented evidence of providing notification to Resident #32 and thier representative of the reason for the residents transfer to the hospital. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Alzheimer's Disease, Adult Failure to Thrive, Chronic Kidney Disease and Abnormal Weight Loss. A review of Complaint #DC00012878 was submitted to the State Agency on 02/27/24 documented the following: Voicemail received on 2/27/24: My name is (Resident Representative). ( .) I wish to lodge a complaint against . (Facility Name) are located at (Facility Address). I have a I am legal Guardian of award (sp), (Resident Name), and this is the second time she has contracted COVID from that institution and they have taken any measures whatsoever to prevent the spread of COVID. They do not check their visitors and the staff do not do any preparations to such as in masking or any other thing. A review of Resident #32's medical record revealed the following: A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the Resident #32 as having severe cognitive impairment, using a manual wheelchair for mobility and as having no impairment in the upper or lower extremity. A review of a document titled (Hospital Name) Inpatient Discharge summary dated [DATE] at 7:21 AM, showed that it documented that Resident #32 was admitted to the hospital on [DATE] at 1:07 AM and discharged on 02/23/24 at 7:49 AM, and further documented You were seen at (hospital name) for altered mental status and acute hypoxic respiratory failure secondary to Covid. Disposition discharged home stable with instructions to follow up with PCP (primary care provider). A review of a nursing progress note dated 02/23/24 at 7:35 PM documented the following: readmitted back to the facility today 02/23/24 at around 6:00 PM via stretcher from (hospital name) accompanied by 2 male transportation staff. Resident alert-oriented X1 (times one) (to person) with confusion, no distress or discomfort noted; no facial grimacing or guarding noted Discharge dx (diagnosis) AMS (altered mental status), acute respiratory failure secondary to COVID-19 (+); per hospital given report resident was Covid negative before discharged to the facility. It is noted that Resident #32's face sheet documented that the resident has a responsible party/Power of Attorney-Care. There is no documented evidence in Resident #32's medical record that the residents representative (Power of Attorney) was given written notification of Resident #32's reason for transfer to the hospital in February 2024. During a face-to-face interview conducted on 06/28/24 at 11:17 AM, Employee #4 (Unit Manager) stated that she did not know anything about notifying the residents representative in writing of the reason for the residents transfer to the hospital but that the residents representative was called by the nurse.

2.The facility staff failed to provide a baseline care plan or updates to Resident #445's comprehensive care plan within 48 hours that included the instructions needed to provide effective and person-centered care, after the resident was readmitted to the facility on [DATE], and 1/29/24. The findings included: Resident #445 was admitted to the facility on [DATE] with diagnoses that included: Diabetes Mellitus (Type 2), Nephropathy, Congestive Heart Failure, Acute Kidney Failure, Lack of Coordination, Neuralgia, Syncope and Collapse, Age-related Osteoporosis and Unspecified Fall Encounter. A review of the resident's medical record revealed: A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #445 had a Brief Interview for Mental Status (BIMS) summary score of 14, indicating intact cognition, used a walker or a wheelchair for mobility and was unsteady for transfers or from a sitting to a standing position. Hospitalization #1 Resident #445 was transferred to the hospital on [DATE], after having an unwitnessed fall with injury and was readmitted to the facility on [DATE]. A review of a Hospital Discharge Summary on 11/20/23 documented, Discharge Diagnosis:1) Femoral neck fracture s/p (status post) left hip arthroplasty (11/16/2023); Present on admit, Yes; Clinical status, Stable; Details: Patient fell from the bed. Denies syncope, lightheadedness, or dizziness. Hip x-ray showed a left femoral neck fracture. Left hip arthroplasty was done on 11/16 .Procedures: Hospital Procedure Detail Left hip hemiarthroplasty .discharged to Skilled Nursing Facility [Facility's Name] .Health Concern: Falls Risk. A review of the comprehensive care plan documented: Problem Start date: 11/22/2023; Category: Falls .Goal: Minimize the occurrence of falling in the next 90 days; Approach(es): Hourly monitoring for fall prevention (created 11/29/23); Increase staff assistance in bed mobility and transfer. Bed lock, lowest position, and floor mat in place when resident in bed for safety, Keep call light and frequently used items within reach at all times (created 11/22/23) . Hospitalization #2 Resident #445 was transferred to the hospital on [DATE] for hyperglycemia (High blood glucose). The resident was readmitted to the facility on [DATE]. During the resident's hospitalization from 12/20/23 to 01/29/24, the hospital petitioned for and obtained a court-appointed guardian for Resident #445. A review of a Hospital Discharge Summary on 01/29/24 documented, Chief Complaint from nursing home for hyperglycemia, reports recent L (left) hip surgery; BS (blood sugar) reading HI (high) in triage .Presentation and Hospital Course: admitted for one month with a left hip prosthetic joint infection .On 1/27/[24], [Name of Resident #445's representative] was appointed as [Resident's Name] legal guardian on account of [Resident's Name] incapacity (as assessed by the psychiatry team). A review Nurse Progress Note on 01/29/24 documented: Resident returned with a diagnosis of HHS (Hypothenar Hammer Syndrome). No longer self rep.(representative) . A review of the comprehensive care plan documented: Problem Start date: 01/30/2024; Category: .Wound infection: Left hip prosthetic joint infection s/p debridement .Goal: Infection will resolve with the completion of IV therapy with no complication in the next 31 days (edited 02/07/24); Approach(es): .Give medication as ordered Cefepime (an antibiotic) 1 gram every 8 hours via PICC line for wound infection until 03/01/24 (created 01/30/24); Monitor for signs of infection: Increased drainage, redness increase pain, warmth, etc. (created 02/05/24) . A review of Resident #445's medical record, showed no documented evidence that facility staff provided the resident or the resident's representative with a baseline care plan or a review of the new problems, goals, and approaches needed to provide effective and person-centered care of the resident after the Resident #445 was readmitted to the facility on [DATE], and on 1/29/24. During a face-to-face interview on 07/28/24 at approximately 11:50 AM, Employee # 3, (Assistant Director of Nursing /ADON), stated that facility staff only provided baseline care plans to residents or residents' representatives when the resident is a new admission. For residents who are readmitted , the comprehensive care plan is updated. When asked if facility staff shared the updates to the comprehensive care plan with the resident or the Resident Representative, the Employee stated the care plans are for the nurses to follow so we don't give them to the residents or their representatives. Based on record review and staff interviews for two (2) of 59 sampled residents, the facility staff failed to provide documented evidence of forming a baseline care plan upon the residents readmissions to the facility. Residents #32 and #445. The findings included: 1. The facility staff failed to provide documented evidence of forming a baseline care plan upon the Resident #32's readmission to the facility on [DATE] and providing a copy of the baseline care plan summary to the resident and resident representative. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Alzheimer's Disease, Adult Failure to Thrive, Chronic Kidney Disease and Abnormal Weight Loss. A review of Complaint #DC00012878 was submitted to the State Agency on 02/27/24 documented the following: Voicemail received on 2/27/24: My name is (Resident Representative). ( .) I wish to lodge a complaint against started (Facility Name) are located at (Facility Address). I have a I am legal Guardian of award, (Resident Name), and this is the second time she has contracted COVID from that institution and they have taken any measures whatsoever to prevent the spread of COVID. They do not check their visitors and the staff do not do any preparations to AS in masking or any other thing A review of Resident #32's medical record revealed the following: A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the Resident #32 as having severe cognitive impairment, using a manual wheelchair for mobility and as having no impairment in the upper or lower extremity. A review of a document titled (Hospital Name) Inpatient Discharge summary dated [DATE] at 7:21 AM, showed that it documented that Resident #32 was admitted to the hospital on [DATE] at 1:07 AM and discharged on 02/23/24 at 7:49 AM, and further documented You were seen at (hospital name) for altered mental status and acute hypoxic respiratory failure secondary to Covid. Disposition discharged home stable with instructions to follow up with PCP (primary care provider). A review of a nursing progress note dated 02/23/24 at 7:35 PM documented the following: readmitted back to the facility today 02/23/24 at around 6:00 PM via stretcher from (hospital name) accompanied by 2 male transportation staff. Resident alert-oriented X1 (times one) (to person) with confusion, no distress or discomfort noted; no facial grimacing or guarding noted Discharge dx (diagnosis) AMS (altered mental status), acute respiratory failure secondary to COVID-19 (+); per hospital given report resident was Covid negative before discharged to the facility. The medical record lacked any documented evidence of a baseline care plan after the resident was readmitted to the facility on [DATE] and there was no documented evidence that a baseline care plan summary was given to the resident's representative (power of Attorney). During a face-to-face interview was conducted on 06/28/24 at 11:20 AM, Employee #4 (Unit Manager) stated We do not do a baseline care plan when residents are gone for less than 48 hours.

Based on record review and staff interview, for one (1) of 59 sampled residents, the facility staff failed to update the comprehensive care plan with goals and approaches that address the resident's post-dialysis care for a right upper arm AVF [Arteriovenous fistula] access site and respiratory care /treatment. (Resident #249). The findings included: Resident #249 was admitted to the facility on [DATE] with multiple diagnoses including Diabetes Mellitus, End-stage Renal Disease with dependence on Renal dialysis, Anemia, Hypertension, Hyperlipidemia, and Congestive Heart Failure. A. Facility staff failed to update the comprehensive care plan with goals and approaches that address Resident #249's post-dialysis care for a right upper arm AVF access site. Review of Resident #249 physician order date 04/13/2024 18:00 [6:00 pm] directed Remove pressure dressing from left AVG [AVF] 24 hours after dialysis observe for bleeding and document result in nursing notes once a day on Tuesday, Thursday, and Saturday in the evening every Tuesday, Thursday, and Saturday. A review of Resident #249's comprehensive care plan showed a focus area, Resident needs dialysis type hemo [hemodialysis] r/t [related to] renal failure was initiated on 04/15/2024 with goals and interventions. Goal: The resident will have no s/sx [signs and symptoms] of complications from dialysis, Interventions: Assess for fluid excess, Assess right AVF for complications such as bleeding, swelling, pain, and redness q [every] shift, Assure medications are administered before and after dialysis as ordered by the physician to ensure maximum effectiveness and to avoid adverse effects of the medications, check and change dressing daily at access site. Document. Do not draw blood or take B/P [blood pressure]in arm with graft. Encourage resident to go for the scheduled dialysis appointments. Resident receive dialysis (specify frequency). Have pressure dressing kit at bedside for emergency use if bleeding occur at dialysis site. Monitor each shift. Monitor AVF for Bruit and Thrills q [every] shift, monitor intake and output. A continued review of the care plan showed that facility staff failed to update the focus area with goals and interventions to address Resident #249's post-dialysis care for the right upper arm AVF access site to include the physician's direct order mentioned above. B. Facility staff failed to update the comprehensive care plan with goals and approaches that address Resident #249's respiratory care/treatment. A review of Resident #249's physician order directed the following: 4/12/2024 23:30 [11:30 pm] Oxygen: Obtain SPO2 every shift. 4/12/2024 23:30 [11:30 pm] Oxygen: Change Ear Wraps every week on Sunday night every night shift every Sun [Sunday]. 4/12/2024 23:30 [11:30 pm] Change and date Tubing and Humidifier every Sunday night shift and as needed. every night shift every Sun. 6/21/2024 15:30 [3:30 pm] Suction PRN For Increased Secretions every shift. 6/21/2024 15:30 [3:30 pm] Continuous Oxygen at 2L/min via nasal cannula for SOB every shift for SOB. 6/23/2024 23:30 [11:30 pm] Wash Oxygen Concentration filter with warm water and mild soap and replace once a week on Sunday's night. every night shift every Sun for Device cleaning. 6/23/2024 23:30 [11:30 pm] Change and Date nasal cannula every week on Sunday Night shift and as needed every night shift every Sun. 6/23/2024 23:30 [11:30 pm] Change and date Tubing and Humidifier every Sunday night shift and as needed. every night shift every Sun. A review of Resident #249's comprehensive care plan showed a focus area, the resident has oxygen therapy r/t Respiratory illness which was initiated on 04/15/2024 with goals and interventions. Goal: will have no s/sx [signs and symptoms] of poor oxygen absorption. Interventions: Change resident position every 2 hours to facilitate lung secretion movement and drainage, Encourage or assist with ambulation as indicated, For resident who should ambulate, provide extension tubing or portable oxygen apparatus, Give medication as ordered by physician, monitor document side effects and effectiveness, Monitor sign/symptoms of respiratory distress and report to MD [medical doctor] PRN [as needed], Oxygen settings O2 [oxygen] via nasal prongs/mask@ [at] 2L/min [minutes]. Humidified. Continued review revealed that facility staff failed to update this focus area with goals and interventions to address the plan of care for Resident #249's oxygen therapy care to include the physician's order mentioned above. During a face-to-face interview conducted on 06/25/2024, at approximately 3:47 PM, Employee #2 (DON) acknowledged the findings.

Based on record review and staff interview, the facility's staff failed to protect a vulnerable resident from Resident #90. This was evidenced by Resident #90 being observed by staff kissing Resident #16 who did not have the capacity to consent. As a result of these failures, an immediate jeopardy (IJ) was identified on August 31, 2023, at 2:33 PM. The facility provided a plan of action to address the immediate concerns on August 31, 2023, at 11:41 PM and it was accepted. On September 6, 2023, at 1:20 PM, while the survey team was onsite the plan was verified and immediacy was lifted. After removal of the immediacy, the deficient practice remained for the potential for more than minimal harm at a scope and severity of D. The findings include: Resident #90 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Alcohol Use. A review of Resident #90's quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMs) summary score of 12, indicating moderate cognitive impairment. Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with multiple diagnoses including Dementia and Bipolar. Additionally, the medical record showed the resident had a court-appointed guardian. A review of a quarterly Minimum Data Set assessment dated [DATE] documented Resident #16 had a Brief Interview for Mental Status summary score of 13, noting intact cognition. The resident was coded for requiring extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of a facility policy titled, Prohibition of Resident Abuse/ Abuse Prevention (Policy NO: 99-12) with a revision date of 09/24/22 instructed the following but not limited to: Report the incident to the Nursing Supervisor or Department Head immediately, but not less than 2 hours, if the alleged violation involves abuse or results in serious bodily injury. The Nursing Supervisor/Department Head will immediately initiate an investigation and give an oral report to the Administrator, If suspected abuse/inappropriate behavior between two residents, residents will be immediately separated from each from each other and monitored until appropriate interventions are implemented, and Notify DC Regulatory Agency and Ombudsman. A nursing note dated 09/03/22 12:31 AM [Recorded as Late Entry on 09/06/22 12:49 AM] documented, At around 2:35 AM call light was on in [Room #] when caregiver [Employee #12, Certified Nursing Assistant] went there. The caregiver called the nurse [Employee #13, Licensed Practical Nurse] and reported that he saw [Resident #90] kissing [Resident #16]. By the time the nurse went there [Resident #90] was leaving the room. The nurse explained to [Resident #90] that it was very late to be in a female room. [Resident #90] verbalized understanding and promised not to go there anymore. A social worker's note dated 09/05/22 10:59 AM [Recorded as Late Entry on 09/15/2022 4:11 PM] documented, While conducting business with residents on 2 Green Unit [Employee #14, Social Worker] was approached by [Resident #90] who asked if he could leave the facility on a date with another resident [Resident #16]. At that time, he explained his interest in [Resident #16] living across from him stating that they were seeing each other [Resident #90] was advised not to go into her room and that they could talk with each other from the hallway, in part because there are two other female residents in the room. [Resident #90] acknowledged and understood what was said to him. It should be noted according to this social worker's note the conversation with Employee #14 and Resident #90 occurred on 09/05/22 which was two days after the incident where Resident #90 was found kissing Resident #16 on 09/03/22. The note was entered into Resident #90's electronic health record on 09/15/22 which was 12 days after the incident (09/03/22). A unit manager's [Employee #18] progress note dated 09/06/22 at 3:20 PM documented, [Resident #90] was transferred from Unit 2 Greenroom to Unit 3 Orange room. He was transferred off the unit because he was caught several times in the room inappropriately touching [Resident #16] on the bed. [Resident #90] is alert and oriented x3 (name, time, and place), he was advised not to go into the room the first time he was caught in the room in a compromised position with the resident [Resident #16] in question. [Resident #90] verbalized understanding and promised to stay away from [Resident #16], but [Resident #90] continued to sneak into the room during the odd hours of the night. [Resident #90] was caught on 9/6/22 at 2:25 AM in the room inappropriately feeling on [Resident #16]. All related disciplines were notified. [Resident 90's responsible party] was called and a message was left for him to call the unit. NP (nurse practitioner) was also informed. A review of Resident #90's progress notes including nursing, physician, and social work notes dated from 09/03/22 to 09/15/22 revealed Resident #90 was moved to a different unit on 09/06/22, three days after the incident. Additionally, the previously mentioned progress notes lacked documented evidence that the facility's staff made the State Agency or the Ombudsman Office aware of Resident #90's kissing and inappropriately touching Resident #16 which was observed by staff on 09/03/22 or that the staff on Unit 3 Orange where Resident #90 was transferred to was made aware of his previous behaviors. During a face-to-face interview on 08/29/23 at 4:16 PM, Employee #18 (Unit Manager/LPN) stated that Resident #90 and Resident #16 would talk and laugh with each other in the hallway but at night Resident #90 would sneak into Resident #16's room. The employee said that Employee #12 (CNA) and Employee #13 (LPN) informed her that Resident #90 was observed in Resident #16's room in a compromising position during the night shift on 03/06/23, Later that day Resident #90 was moved to 3 Orange. In addition, the employee said that she did not develop a care plan to address protecting the resident from Resident #90. However, she did develop a care plan to address Resident #16's behavior of being attracted to the opposite sex on 09/01/23. During a face-to-face interview on 08/30/23 starting at approximately 8:00 AM, Employee #13 (LPN) and Employee #12 (CNA) stated that around 2:00 AM Resident #90 was observed in Resident #16's room trying to kiss her. When asked what date this happened, they stated that they believed it was the day Resident #90 was moved to 3 Orange (3/6/22 Employee #12 (CNA) said when he walked into Resident #16's room Resident #90 was standing beside the resident's bed. Resident #16's covers were pulled down and the resident's gown was pulled up. Employee #13 stated that she instructed Resident #90 not to be in the resident's room this late. During a telephone interview on 08/30/23 starting at 9:46 AM, Employee #23 (Social Worker) stated that staff did not inform her of the incident that happened between Residents #90 and #16 on 3/3/22 Employee #23 said she learned about the incident when she looked at the electronic record and saw the nursing progress notes. The employee also stated that Resident #90 made her aware that he wanted to take Resident #16 out on a date, but she informed him that he could not do that, and he verbalized understanding. Employee #23 stated that she did inform Employee #18 (Unit Manager) of Resident #90's interest in Resident #16. During a face-to-face interview on 08/31/23 at 11:06 AM, Resident #90 stated that Resident #16 was his girlfriend and everybody [staff] knew it. Additionally, Resident #90 admitted to kissing Resident #16. A review of Resident #16's current and discontinued care plans revealed that the facility's staff did not develop a care plan to protect the resident from Resident #90's sneaking into her room at odd hours at night and Resident #90's inappropriate physical behavior toward her. However, Employee #18 (Unit Manager) developed the following care plan dated 09/01/23 (after the State Agency's intervention) that documented the following but not limited to: Problem: [Resident #16] has a behavior of being attracted to the opposite sex. Goal: Resident will interact with others using socially and culturally acceptable behavior. Approach: maintain resident's safety by monitoring her whereabouts on the units, redirect inappropriate sexual behavior, and staff to ensure that resident is not in any scheduled [secluded] area with males. During a face-to-face interview on 09/01/23 starting at 11:08 AM, Employee #1 (Administrator), Employee #2 (DON), and Employee #3 (ADON) stated that the incident of sexual inappropriateness occurred during the night shift on 03/03/22. The nurse (Employee #13, LPN) failed to inform the nursing supervisor or administration about the incident. Instead, she informed Employee #18 (Unit Manager) during the morning report on 03/06/22. After learning about the incident, Employee #18 had Resident #90 transferred to Unit 3 Orange. During a telephone interview on 09/07/23 starting at 11:26 AM, Resident #16's legal guardian stated that she found it weird that the facility recently made her aware of an incident that happened a year ago between Resident #16 and a male resident. The legal guardian stated, I asked them how are you going to treat something that happened a year ago? A review of Resident #90's current and discontinued care plans revealed the facility's staff failed to develop care plans to address the incident when Resident #90 was found in a compromised position with Resident #16 and the incident when Resident 90 was found sneaking in Resident #16's room at odd hours at night as documented in the unit manager's note dated 09/06/22. Based on these findings, on August 31, 2023, at 2:33 PM, an Immediate Jeopardy (IJ) situation was identified. On August 31, 2023, at 11:41 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: 1. Immediate Action Taken - Resident was moved to another unit in March - no additional issues since he was moved. I. Resident #90 identified in the survey was transferred to a different unit, from 2 Green to unit 3 Orange, after the first incident on 9/6/2022. II. The residents on unit 2 green were interviewed and it was determined that no other resident was found to have a similar situation on 9/6/2022. III. Hourly monitoring program for Resident #90 continued 9/6/2022. A meeting was conducted on 3/29/2023 with the Administrator, DON, ADON, Social work staff, and nurse managers. All components of the abuse investigation form (tool) were addressed including resident-to-resident abuse. VIII. A meeting with Resident #90 was held on 3/29/23. Revised hourly rounding documentation was implemented on 3/29/2023 to include a signage sheet located in the nursing station. This is in addition to the TAR. This is to ensure the safety of other female residents. As a result, it is believed that it would be unlikely that this behavior would occur again. IX. The staff on unit 2 blue, on 8/30/2023, were re-educated regarding the Resident's #90 prior history. During this training, the staff acknowledged that [pronoun] had not exhibited any of that behavior since being moved to Unit 2 Blue. 2. Immediate Action Taken - Monitoring of the Resident I. The unit managers and charge nurses will monitor residents who exhibit abuse toward another resident, including sexual abuse every shift. The residents identified as exhibiting abusive behavior will be corrected immediately and provide safety for the victim. The affected residents will be monitored every 30 minutes to ensure the safety of other residents. This information will be provided to DON who will provide the information to the QAPI committee quarterly and more frequently as indicated. II. A review of the care plan of Resident #90 was developed and updated to reflect the potential issues as it pertains to sexual inappropriateness. III. All Staff were informed on 8/30/2023 of Resident #90 sexual inappropriateness, and they indicated willingness to monitor resident #90 sexual inappropriateness. IV. The assigned caregiver would ensure Resident #90's location, and whereabouts is known at all times. 3. INVESTIGATION - Decision Making S Facility Administration - identification of Abuse and actions taken during/following an investigation I. Meeting held with Administrator, DON and ADON regarding Resident #90's sexual inappropriateness. II. The DON and ADON reviewed all incidences of unusual occurrences from January 2023 through March 2023. No other allegations of sexual abuse were noted. III. Each month the Investigation Committee will review any allegations of abuse. This committee ensures that all aspects of the Investigation form/tool is complete. This is reported to the QAA Committee Quarterly and/or more often as needed. 4. SUPPORTING DOCUMENTS 1. Hourly monitoring from March 29th, 2023, to present. 2. Updated care plan March 30th, 2023, to present. 3. Re-education on Abuse prevention for staff 3/31/23 4. The need for every thirty-minutes monitoring of resident #90 behavior of sexual inappropriateness (previously hourly) 5. Evidence of Abuse Training 3/31/23 6. Updated Care Plan 7. Investigation Tool 8. [NAME] between resident #90 and SBGC regarding consequences for sexual inappropriateness The plan was verified by the State Agency on 09/06/23 at 1:20 PM.

Based on observation, record review, and staff interviews, for three (3) of 11 sampled residents, the facility's staff failed to ensure that residents received adequate supervision to prevent falls. Subsequently, three (3) residents had unwitnessed falls and sustained injuries. (Residents' #3, #4, and #7) Actual harm was determined for residents' #3, #4, and #7. The findings included: 1. Facility staff failed to provide adequate supervision to Resident #3 who had two unwitnessed falls. Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Cerebral Vascular Accident, Type 2 Diabetes Mellitus, Dizziness and Giddiness (feeling of being unbalanced and lightheaded) and Wandering. Review of Resident #3's medical record revealed: 04/15/21 [Care Plan]: Resident is at risk for falls due to wandering behavior .Goal: Minimize falls incidence. No injury . Approach Start Date: 04/15/2021 Approach: . Increased staff supervision with intensity based on Resident need .If Resident looks for family/significant other, re-assure the Resident that family/significant other knows where to find Resident .Place resident in a secure environment .Prevent Resident from going to other Resident's rooms and avoid unsafe situations. A Quarterly Minimum Data Set (MDS) dated [DATE] showed that facility staff documented the Resident in the following manner: Brief Interview for Mental Status Summary Score, was 07, indicating the Resident had severe cognitive impairment; required limited assistance for bed mobility, transfers, and locomotion in her room and on the unit, and extensive assistance for toilet use and personal hygiene, and had a fall within the last month prior to admission and within the past 2 to 6 months. A nursing progress note dated 07/09/21 at 6:03 PM showed, .Today around 4:40 PM charge nurse reported that Resident was noted with blood on her chin .laceration on her chin measuring 2 x 1 cm with profuse bleeding, left ear noted with blood and her right hand wrist extending to thumb with hematoma measuring 7 x 5 cm. Pressure dressing applied to chin area and bleeding was controlled; cold compress was applied to the right hand wrist hematoma .New order was given to transfer Resident to ER [emergency room ] via 911 for AMS (altered mental status) and fall with head involvement . A nursing progress note from Employee #9 (Charge Nurse) dated 07/09/21 at 10:11 documented: This writer was call(ed) to assess Resident noted with blood in her hands at about 4:40 PM in the Solarium, with her two hand(s) holding face mask against her chin bleeding and right thumb slightly swollen and Resident unable to explain what happen, went to Resident('s) room and observed blood on the floor possible unwithers (sp).(unwitnessed) fall . Further review of Resident #3's care plan revealed the following dated 7/9/21: Resident had an actual fall with injury sustained mandible fracture and thumb dislocation on 07/09/21 .Goal: Resident will remain free from fall and injury .Approach Start Date: 04/21/2022 .Approach .1:1 close monitoring for 24 hrs (hours) s/p (status post) fall hospital return .Give verbal reminders not to ambulate/transfer without assistance .Observe frequently and place in supervised area when out of bed .Provide toileting assistance every as needed .Resident remains on 1:1 close monitoring for fall prevention. Of note, there were no approaches recorded after the Resident's first fall on 07/09/21. Review of a facility reported incident (DC10141) revealed the following, On 07/09/2021 around 4:15 PM during round, resident was noted in her room, then by 4:40 PM, charge nurse reported that resident was coming to the Solarium from her room, when staff noticed that she was bleeding from her chin area. Resident was immediately assisted back to her room, and on assessment, she was noted with small laceration on her chin measuring 2 cm x 1 cm x. 07/13/21 Physician's Orders documented -Fall precaution, monitor each shift, every shift night, day, evening. ---Fall risk assessment on admission/readmission, then quarterly every shift; night, day, and evening. On 07/20/21 at 3:28 PM the Nurse Practitioner documented in a progress note: .She had a brief hospitalization ,d+[DATE] (secondary to) unwitnessed fall, found to have bilateral mandibular fracture condyle and anterior wall of the external auditory canal. She is less anxious today, calm, and clinically stable .Remains at risk for falls, nursing staff monitoring her closely. Plan of care discussed at bedside w/ (with) nursing team . A 07/21/21 at 1:49 PM Nursing Progress Note documented, . today, around 8:00 AM, Resident was assisted with ADL (activities of daily living) care, then kept by the nursing station for close monitoring. Charge nurse reported that Resident shortly (there)after got up, walked to her room. The charge nurse immediately ran to the room to bring Resident back, and upon going to the room, she met the Resident coming to the hallway around 8:20 AM with a small amount of blood in her hands. Resident was immediately assessed., she was noted with small laceration on back of her head to stop bleeding .Upon questioning Resident was unable to explain what happened. NP [Nurse Practitioner] was informed, order was received to transfer Resident to ER [emergency room ] via 911 for evaluation and treatment . A nursing progress note dated 07/21/21 at 3:28 PM stated, .On around 7:40 AM. This writer received Resident sitting in the chair by the nursing station with other (another) resident. At about 8:30 AM; writer was call(ed) to the nursing station by charge nurse and observed blood on Resident's hands. Upon assessment, I noted blood with a small laceration on back of Resident's head, ask what happen(ed) but [the Resident was] unable to explained (explain) A 07/21/21[Physician's Order requested Transfer Resident to 911 due sustaining laceration on the back of the head for possible fall. Review of a facility reported incident (DC10158) revealed, Today, around 8:00 AM, resident was assisted with ADL care, then kept by the nursing station for close monitoring, Charge nurse reported that resident shortly after got up, walked to her room. The charge nurse immediately ran to the room to bring the resident back, and upon going to the room, she met with the resident coming to the hallway around 8:20 AM with small amount of blood in her hands. Resident was immediately assessed, she was noted with small laceration on the back of her head. Pressure dressing was applied to the back of the head to stop bleeding. Vital signs were BP 118/75, HR 70, RR 20, Temp 97.6, spo2 99 % RA. Neuro check initiated with no neurological deficit, AROM present to lower extremity. The floor in the room was free of clutter and spill. Upon questioning, resident was unable to explain what happened. NP was informed order was received to transfer resident to ER via 911 for evaluation and treatment. RP was made aware. The 07/21/21 Care Plan showed: Resident had an actual fall on 07/21/2021 and sustained scalp laceration.Goal: Resident will remain free from injury .Approach Start Date: 04/21/2022 .Approach .Assure the floor is free of glare, liquids, foreign objects . Encourage to use environmental devices such as hand grips, handrails, etc.Psych follow-up Use of non-skid socks when ambulating for safety, etc. Of note, the approach start date was nine (9) months after the Resident's unwitnessed fall with sustained injury on 07/21/21. Nursing documented on 07/22/21 at 4:32 AM, Resident returned to the facility from [Local Hospital] ER [emergency room ] .Resident was sent to [Local Hospital]ER on [DATE] for further care due to fall with laceration on the head .Occipital scalp laceration noted with about four (4) staples, site noted dry and no edema . It should be noted that this incident occurred twelve days after the resident's first fall on 7/9/21. There was no evidence that facility staff provided assistance or supervision to Resident #3 when the Resident got up to walk to her room on 07/21/21. Subsequently, per the Nurse Progress Notes the Resident was sent to the emergency room and returned to the facility with a laceration to the back of her head after an unwitnessed fall. The Treatment Administration Record for July 2021 showed the facility staff documented that from 07/13/21 to 07/31/21, they monitored the Resident every shift and performed fall risk assessments. However, review of Resident # 3' medical record, showed no evidence that facility staff conducted falls risks assessments for the Resident. The facility staff provided no documented evidence of falls assessments before or after the falls on 07/09/21 or 07/21/21. Facility staff failed to update the care plan approaches after the Resident's falls in July 2021. The approaches were not updated until nine (9) months post-falls on 04/21/22. During a face-to-face interview on 12/09/22 at 02:22 PM, Employee #9, Nursing Assistant Manager, reported that 07/09/21 when Resident #3 had her first fall, he was called by the CNA who was monitoring the Solarium to come and assess Resident #3. When the Employee went to assess Resident #3, he observed the Resident had blood on both hands and was holding a bloody face mask up to her chin which was bleeding. The Employee said he then took Resident #3 back to her room to assess her and noticed blood in the bathroom. He asked the Resident what happened, but she was unable to explain. On 07/21/21, the day of Resident #3's second fall in July 2021, he was called to the unit by the Charge Nurse. When he got there he observed blood on Resident #3's hands and saw a laceration on the back of the Resident's head. He asked the Resident to explain what happened, but the Resident was unable to explain. The Charge Nurse stated that the Resident had been sitting at the nursing station and the Charge Nurse had just taken the Resident's vital signs when the Resident got up and walked to her room. The Charge Nurse ran toward the Resident's room to bring the Resident back, but when the Employee got to the Resident, the Resident was coming down the hallway with blood on her hands and to the back of her head. The CNA who was monitoring the Solarium on 07/09/21 and the Charge Nurse caring for Resident #3 on 07/21/21 were not available for interview at the time of the survey. During a face-to-face interview on 12/09/22 at 4:00 PM, Employee #2, Director of Nursing, stated that facility staff reported Resident #3's fall on 07/09/21 and 07/21/21 to the State Agency as required and documented the falls in the progress notes, but were no statements taken from staff who worked on 07/09/21 or 07/21/21. The Employee provided no further explanation. Although requested throughout the course of the survey, the facility Administration failed to provide documentation of investigations of Resident #3's falls occurring on 7/9/21 and 7/21/21 2. Facility staff failed to provide adequate supervision to Resident #7 who sustained a fall with injury on 08/28/22. Resident #7 was admitted to the facility on [DATE] with diagnoses including Unspecified Fall, Initial Encounter, Generalized Muscle Weakness, Dementia, Anxiety, Psychotic Disorder, Deep Vein Thrombosis, and Anorexia. A review of Resident #7's medical record revealed: Care Plan Focus Area, Problem Start Date 07/27/2022 Category: Falls, Resident #7 had a fall with injury on 7/25/2022 resulting in laceration on her left forehead. Goal: Long Term Goal Target Date: 09/27/2022, Decrease the incidence of injury if falls occurs. Approach Start Date: 07/27/2022, Initiate Hourly Round Monitoring Sheet .Observe frequently and place in supervised area when out of bed .Psych evaluation for restlessness and increased confusion .Rehab screen PT/OT .Staff education on consistency in monitoring residents .Start physical therapy for Gait training with front wheel walker and Seat and Stand training . On 08/29/22 at 1:05 PM, the facility submitted an incident report (DC00010968) that documented the following: .On 08/28/2022, the day nurse reported .Resident was received at the nursing station, and report was given that she was restless and had been up all night. Resident had breakfast and Lunch at the Nurse's Station with good appetite while being closely monitored by nursing staff per charge nurse. Assigned CNA (Certified Nurse Assistant) reported that around 1:30 PM resident asked her for water to drink. CNA stated that she quickly went to get her the water and, on her way back with the cup, she found the Resident lying on the floor. Charge nurse and nursing supervisor were immediately informed. On assessment, Resident was noted with a small Laceration on her right Eyebrow. Pressure dressing was applied to stop the bleeding, then Tylenol given for complain(t) of pain to the right side. NP (Nurse Practitioner) made aware ordered to transfer Resident to the nearest ER for evaluation . On 08/29/22 at 3:54 PM, a follow-up incident report was received from the facility noting, . Resident was transferred to the hospital for evaluation on 08/28/2022 following up a fall with right eyebrow laceration. She was readmitted to the facility from [Local Hospital] on 09/01/2022 after being treated for Left Hip Fracture and right above the eye laceration . 08/28/22 at 3:09 PM [Nurse Progress Note]: .writer was called to the unit, received report that Resident was on the floor on the right side of her face. Resident was assisted off the floor to the wheelchair by supervisor. This occurred at 1:30 PM. Writer observed Resident on wheelchair with a small laceration on right eyebrow, measuring 1 cm (centimeter) x 0.5 cm x unknown .NO (Nurse Practitioner) informed, order (to) transfer to nearest ER (emergency room ) for evaluation because Resident is on Eliquis (anticoagulant/blood-thinner) . 08/28/22 at 4:30 PM [Nurse Progress Note]: .At 1:00 PM while writer still passing meds, assigned CNA called the writer to the Nurses Station at 1:30 PM and the Supervisor too. Both of us noted the Resident on the floor with small laceration on her right eyebrow side. Caregiver said resident request for water and she just went to get it, back and find (found) Resident on the floor NP made aware and order to transfer Resident to ER (emergency room ) for evaluation and treatment . An 08/28/22 written statement from Employee #7, Certified Nurse Assistant/CNA caring for Resident #7, documented, I came in during a change of shift [The] night shift said [Resident #7] didn't sleep all night I was monitoring her, so she ask[ed] for water to drink. On my way back, I found her on the floor . An 08/28/22 written statement from Employee #8, Registered Nurse assigned to Resident #7]: documented, Resident .received at the Nurse's station, per report been agitated Resident [was being] monitor[ed] within [by] the CNA(s) .During med pass, after 1:00 PM, caregiver call[ed] writer to Nurse's station and [the] Resident note on the floor lying on her right side . 08/29/22 [Care Plan Evaluation Notes]: Category: Falls .Problem Start Date: 07/27/22 .Resident had a fall with injury on 8/28/22 and was transferred to the hospital for further evaluation. New fall care plan will be initiated upon readmission. Current plan of care discontinued. Care Plan Focus Area, Problem Start Date 09/01/2022 [Resident #7] has a right obit laceration Post fall on 08/28/2022 .Long Term Goal Target Date: 12/01/2022, Area will heal without complication .Approach Start Date 09/02/2022, Laceration with sterile strips: Leave open to air .Avoid rubbing right side of face during ADL (activities of daily living) care .Encourage PO meal intake .Monitor area every shift for changes and report to MD/NP (Medical Doctor/Nurse Practitioner) .Monitor for pain, administer pain medication as [ordered] .monitor for sign of infection such as purulent. 09/01/22 [Care Plan]: [Resident #7] has right femoral neck fracture post fall on 8/28/22. Post right hip arthroplasty on 08/29/22 . A Significant Change in Status Minimum Data Set (MDS) dated [DATE] showed that facility staff documented the Resident in the following manner: Brief Interview for Mental Status Summary Score, was 05, indicating the Resident had severe cognitive impairment; rejected evaluation or for 1-3 days, required extensive assistance for bed mobility, dressing, eating, and personal hygiene, required extensive assistance for transfers, locomotion on the unit, and toilet use, and had major orthopedic surgery to repair fractures of the pelvis, hip, leg, knee or ankle. A review of the Falls Assessments for Resident #7 from 03/15/22 to 08/28/22, documented the following: Evaluation-Calculate points and record total Score of 10 or higher represents a high falls risk: 03/15/22 - 17 06/14/22 - 18 08/28/22 - 19 09/01/22 [Hospital Discharge Summary]: Discharge Diagnosis: 1) Fracture of neck of femur, accidental fall .Hospital Course .presents to ED [Emergency Department] with right hip pain falling out of a wheelchair while in her nursing home. She reportedly doesn't remember how she fell ; however, upon hitting her head and sustained a 2 cm laceration over her right orbit (eye). 8/29-8/30: patient s/p (status post) Right Hip arthroplasty . 09/13/2022 at 11:38AM - [Resident Progress Notes] Annual IDT meeting (significant change) was held with all disciplines involved including her RP (Responsible Party). Resident plan of care was discussed. She remains full code and on long term basis. Resident had a fall on 7/25/22 with left upper eye laceration which has resolved. Resident had a fall with injury (fracture on the right femoral neck) on 8/28/22 and was transferred to [hospital name] where she underwent right hip surgery on 8/29/22. She has been seen and followed by the in house wound NP (nurse practitioner). Surgical site wound has greatly improved with order to leave open to air, so is her right obit laceration. A follow up orthopedic appointment is scheduled for 9/16/22. Resident continues on close monitoring to decrease falls. She continues with PT (physical therapy) OT (occupational therapy) sessions as of now. Plan of care continues. During the survey, Employee #7 (CNA caring for the Resident) was out of the country and was unavailable for an interview. Employee #8 (Registered Nurse) could not be reached by phone and was also unavailable for an interview during the survey. Below are the employee's written statements submitted to the facility at the time of the investigation: During a face-to-face interview on 12/09/22 at 4:00 PM, Employee #2, Director of Nursing, stated that the CNA caring for the resident, per the CNA's statement, that she was monitoring Resident #7 when the Resident asked for water. The CNA turned to get the water and found the Resident on the floor. The Employee provided no further explanation or comment. It should be noted that when the surveyor requested the facility's investigation of Resident #7's fall from 8/28/22, the facility only provided a copy of the incident report that was submitted to the State Agency and two written staff statements. Prior to the survey exit, no additional documentation was provided related to the facility's investigation of this fall. 27513 3. Facility staff failed to provide adequate supervision to Resident #4 who sustained a fall with injury (an acute comminuted displaced fracture of the right proximal femur). Resident #4 was admitted on [DATE] with multiple diagnoses including Age-related Physical Disability, Osteoarthritis, Arthritis, Hypertension, Epilepsy, and Anxiety. Review of Resident #4's medical record revealed the following: 01/16/20 at [Physician order] directed, Fall Precaution, monitor each shift every shift night, day, and evening. A Quarterly Minimum Data Set (MDS), with an Assessment Reference dated 07/28/21 documented the following: -In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 13, indicates cognitive intact. Section E (Behavior), no indicators of psychosis, rejection of care, or wandering. -Section G (Functional Status) - documented the resident was totally dependent on the physical assistance of one person for toilet use (how the resident uses the toilet room, commode, bedpan, . transfers on/off the toilet; cleanses self after elimination; changes pad; manages ostomy or catheter and adjust clothes). -Section J (Health Conditions)- documented the resident sustained a fall with no injury since admission/entry/reentry on 01/16/2020. Section K showed the resident's height of 65 inches and weight of 167. Review of the Facility Reported Incident (DC00010203) received on 08/23/2021 documented, According to the assigned CNA [Certified Nursing Assistant], on 8/9/2021 around 7:35 pm, he was providing ADL [activity of daily living] care in the bathroom located in the resident's room. Upon completion of the care as the CNA turn his back to drop some toiletries, the resident slid down on the floor from the toilet seat. Upon questioning the resident stated, I try to get up and slid down on the floor. Head-to-toe assessment [showed] . limited movement to right leg. Resident complaint of pain to the right leg on scale of 5/10 . X-ray of right knee/femur/pelvis was ordered. X-ray result revealed an acute, comminuted displaced fracture of the right proximal femur. Resident was transferred to ER [hospital name] for further treatment and evaluation. 08/09/21 at 9:36 PM [Progress Note] showed, Today around 7:39 PM, charge nurse reported resident slid on the floor inside her bathroom while assigned CNA was doing adls [activities of daily living] care. Upon head-to-toe assessment, no apparent injury was noted, no bleeding, no swelling, no discolorations noted. Resident able to move all extremity, limited movement to right leg. Resident verbalized pain to touch with right Femur, . Upon questioning, resident stated I was taken to bathroom by staff while standing I slid on the floor . 08/09/21 at 11:23 PM [Progress Note] showed, At 7:35pm Writer was called . upon entering the room resident was observed in a sitting position on the floor in the bathroom, resident slid and sat on the floor. Resident assisted on to bed by three staff. Supervisor made aware came and assess resident. Upon assessment .when resident was asked what happen, resident stated that the nurse was given her care in the bathroom while standing up she now slid and sat on the floor, Nurse Practitioner [name] made aware, New order given for . X-ray of Right knee, femur and pelvis to R/O [rule out] Fracture . Review of the resident's care plan section of the electronic medical record showed: Facility staff failed to provide adequate supervision to Resident #4 who had a history of falls and was at risk for falls. Subsequently, the resident had a fall and sustained a Right Femoral Fracture . ORIF right leg and hip on 8/9/2021 while receiving supervised activity of daily living care (PM care) by facility staff. 08/10/21 at 10:27AM [X-ray lab report] showed The distal femur is not visualized. There is an acute, displaced fracture of the proximal femur noted. There is no dislocation or abnormal bone lesion. The soft tissues are normal. Impression: There is an acute, comminuted, displaced fracture of the right proximal femur seen. 08/10/21 at 12:30 pm [Progress note] showed Resident is a wheelchair bound and requires total assistance. According to the assigned CNA, on 08/09/21, around 7:35pm, he was providing care ADL care in the bathroom located in the resident's room. Upon completion of the care as the CNA turn his back to drop some toiletries, the resident slid down on the floor from the toilet seat. Upon questioning the resident stated, I try to get up and slid down on the floor. Head to toe assessment [showed] . limited movement to right leg. Resident complaint of pain to the right leg on a scale of 5/10 . X-ray of right knee/femur/pelvis was ordered .X-ray result revealed an acute, comminuted displaced fracture of the right proximal femur Resident was transferred to ER [hospital name], for further treatment and evaluation. 08/10/21 at 3:32 pm [Progress note] showed . MD [medical doctor] in unit and assess resident and address x-ray result order to send resident to ER to evaluate and treat due to fracture. MD ordered. OT/PT [occupational/physical therapist] to apply splint to right hip/thigh before moving resident. 911 was called and at 12:20pm resident was taken to the ER . Resident was taken to [hospital name], RP made aware . 08/20/21 at 10:51 pm [progress note] showed . readmitted from [hospital name] arrived at 4:00 pm with the discharged diagnosis of Right Femoral Fracture . ORIF [Open reduction and internal fixation] right leg and hip S/P fall, . Right upper hip incision site with 6 sutures measuring 9.5cmx0.5, Right middle incision site with 3 sutures measuring 4.5cm x 0.5 and right lower incision site with 2 staples measuring 3.5cm x 0.5cm area paint all the incision site with betadine and leave open to air . bed to lowest position fall precaution maintained. A further review of the resident's previous falls revealed a history of falls without injury: 1/25/2020 at 8:00 PM, .CNA went to check on the resident, she was observed sitting on the floor in an upright position on her buttocks by her bed. Head-to-toe skin assessment done with no visible injury noted.resident denied hitting her head on the floor.When asked how she got on the floor, resident stated she got up to close her window curtain and slid to the floor. 7/30/2020 at 2:30 PM, Resident observed wheeling herself to the bathroom, she suddenly gets up from the wheelchair before the CNA reach out to help her, she slid to the floor. Head-to-toe assessment was done no apparent injury. 9/6/2020 at 1:15 PM, The assigned nurse . observed the resident at 1:15 pm lying on the floor in a supine position by her bedside, . resident could not explain the fall she denies pain at present. She also denies hitting her head on the floor or surrounding furniture . 5/11/2021 at 6:00 PM . assigned CNA was making rounds when she saw resident on the floor by her bedside in a supine position. Upon questioning, the resident stated, I was trying to get out of bed. Bed at its lowest position. Head-to-toe assessment was done with no apparent injury. Resident denies pain nor hitting her head. Category (Falls start date 10/04/21 - [Resident name] had an actual for fall R/T [related to] decreased mobility [on] 01/25/2020: Resident observed sitting on the floor in an upright position on her buttocks by her bed with no visible injury, . Resident had a fall with no apparent injury on 07/30/2020 . had a fall with no apparent injury on 09/06/2020 .Resident had a fall with no apparent injury on 05/11/2021 .Approaches-hourly rounding to meet the residents need. Keep bed in lowest position .give verbal reminders not to ambulate or transfer without assistance, call light and personal items within reach, observe frequently and place in supervised area when out of bed .provide toilet assistance .as needed, education resident to always call and wait for assistance . Category falls-start date 10/04/2021- Resident had a fall on 08/09/2021, and sustained right femoral fracture, had an ORIF done on 08/11/2021. Approach [Intervention]-observe frequently and place in supervised area when out of bed, do not leave resident unattended anytime during care . Please note that the start date of this care plan was 55 days after Resident #4's fall on 08/09/21. Through observation of the residents' room, it should be noted that when the CNA left the resident in the bathroom to put toiletries in a bedside drawer next located in the resident's bedroom, Resident #4 was no longer in direct eyesight of the staff member as he was in a different area of the room. On 12/8/2022 at 4:20 PM, an observation of the resident's room and bathroom was conducted with Employee #1 [Administrator]. Employee#1 showed the location where the CNA drop some toiletries it was the bedside drawer next to the resident's bed. Further observation showed that the CNA had to turn his back to the resident, who was sitting on the toilet that was greater than 10 steps from where he placed the toiletries in the bedside drawer. During a face-to-face interview on 12/08/2022 at approximately 4:35 PM, Employee #2 (DON) was asked how could the CNA supervise the resident when his back was turned to her while he put toiletries in the bedside drawer. She stated, [Resident #4 name] was being supervised by the CNA. Cross reference DCMR 3211.1

Based on record review and staff interview, the facility failed to: thoroughly investigate an incident of abuse and/or neglect for Resident #164, implement measures to prevent potential abuse and/or neglect to other residents within the facility; and take appropriate corrective actions to keep other residents safe from possible abuse and/or neglect in one (1) of 56 sampled residents. The census on the first day of survey was 243. Findings included . On (MONTH) 23, 2019, at 11:09 AM an Immediate Jeopardy (IJ)-L was identified at 42 CFR§ 483.12 (c)(2)-(4), F610. On (MONTH) 25, 2019 at 3:13 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, as follows: The CNA identified in the complaint survey is no longer employed as of 7/16/2019. All residents were checked and three residents who are combative and/or exhibit combative behaviors were identified. Additional training was provided on the spot for those staff members on 7/22/2019. A meeting was conducted with the Administrator and the DON (Director of Nursing) on 7/23/2019 and 7/24/2019. Root cause analysis and investigation principles as it pertains to Abuse were addressed. All components of abuse were discussed including the interpretation of willful and its relationship to abuse. Abuse training and care of combative resident (training) was started on 7/21/2019 for all staff and is currently in progress. The managers will monitor the care of residents who are combative using the behavioral monitoring tool (see audit tools). The nurse managers and supervisors will continue to monitor the staff that provide care to residents who exhibit combative behaviors. Interventions will be implemented as indicated. The information will be provided to the DON who will provide this information to the QAPI committee quarterly and/or more frequently as indicated. Family request female: The Unit Manager received individual counseling and training on 7/23/2019. Unable to retrospectively correct the occurrence. All Unit Managers received training on 7/23/2019 and 7/24/2019 as it pertains to resident's rights, specifically their wish as it pertains to the caregiver. All Units were checked on 7/23/2019, via the nursing management team to determine if other residents had preference as it pertains to the sexuality of the caregiver. One resident was identified on 7/23/2019 and the Unit manager ensured that it was incorporated in the care plan on 7/23/2019. The Interdisciplinary team was re-educated on care planning and updating the care plan as the resident's conditions changes following detailed assessment of the resident on 7/23/2019. Upon admission and care plan meeting/conferences, the managers will determine the needs of the residents, specifically if a resident request a female and/or male care giver. The resident who expresses the female/male will be checked to ensure that this request was honored. This will be done via the assignment sheet every shift and reported to the QAPI (Quality Assurance and Performance Improvement) committee quarterly and/or more frequently as indicated. The nursing management audits the care plan monthly (see audit tool). When a care plan has not been updated the appropriate discipline is notified. This information is provided to the DON who presents this information to the QAPI committee quarterly and/or more frequently as necessary. In-service/Training: Training of the Administrator and DON regarding Root Cause Analysis and Investigation Principles as it pertains to Abuse (training completed on (MONTH) 24, 2019) Training of the Clinical Leadership Team (Training completed (MONTH) 19, 2019) Evidence of Abuse Training (Training for leadership, managers, and staff on abuse, residents with combative behaviors done on (MONTH) 19 2019- (MONTH) 24, 2019) Training on assignment of male/female CNA per resident's wishes (Training completed (MONTH) 24, 2019) The IJ was abated after the team verified that the plan of correction was in place on (MONTH) 25, 2019, at 4:07 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an F. Policy Title: Prohibition of Abuse; ADM01-003; Revised (MONTH) 2019 stipulates, [NAME] Stoddard Baptist Global Care, Inc. promotes the residents rights to be free from abuse, neglect, misappropriation of resident property and exploitation .No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection . Prevention: 4. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. Identification: .Because some cases of abuse are not directly observed, understanding resident outcomes of abuse could assist in identifying whether abuse is occurring or has occurred. Possible indicators include, but are not limited to: 1) an injury that is suspicious because the source of the injury is not observed or the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time. Investigation: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation. Protection: 1. In the interim of the investigation process, the alleged abuser may be suspended from work until an official notice is issued for clearance to return to work or otherwise by Human Resources. 6. Protection from retaliation. Reporting: .The results of all investigations are reported to the administrator or his or designated representative .and if the alleged violation is verified appropriate correction action must be taken. .2. Resident abuse is a ground for immediate termination refer to Employee Handbook. Employee Handbook revised (MONTH) (YEAR), page 5, stipulates, Abuse Prohibition policy: Actions of such may result in immediate termination . Record Review Review of Resident #164's medial record showed she was admitted to the facility on (MONTH) 29, (YEAR). The Quarterly Minimum Data Set (MDS) dated (MONTH) 3, 2019, under Section A1000 (Race/Ethnicity) the resident was coded as Asian, Native Hawaiian or other Pacific Islander. Under Section A1100 (Language) the resident was coded as needing and wanting an interpreter to communicate with a doctor or health care staff and preferred language Chinese. She was assessed with [REDACTED]. She was assessed as requiring extensive assistance of two (2) persons for bed mobility, transfers, dressing, toileting, personal hygiene and totally dependent for bathing under Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Further review of the record showed a nurse's note dated (MONTH) 16, 2019, at 12:30 PM: Writer was called by CNA (Certified Nursing Assistant/Employee #4) to come to resident room, when asked CNA said, He was trying to give care to resident when she became combative and in the process of turning, resident hit her head on the side rail of the bed. Happened at 11:35 am. Writer went and assessed resident and noted a swelling on her left face. Supervisors were informed. (Nurse Practitioner- Name) was called, who gave orders for resident to be transported via EMR (emergency response)/911. To the nearest ER (emergency room ). (Resident #164) is alert and unable to explain what happened. Her [DIAGNOSES REDACTED]. On assessment resident noted with swelling of the left fore head near the left eye with a cut on the left upper lip with minimal bleeding which was cleansed with normal saline. Ice pack applied to the left forehead swelling. V/S (vital signs) laying 138/69, P (pulse) 74, T (temperature) 97.7, Sp02 (peripheral capillary oxygen saturation) 98% on room air. V/S (vital signs) sitting B/P (blood pressure) 157/80, P 77, T (temperature) 98.2, R (respirations) 18. Pulse ox (oximetry) room air 97% FS (finger stick) 142 mg/dl (milligrams per deciliter). Tylenol 2 tabs 325 mg (milligrams) was administered for pain 4/10 and was very effective. Neuro (neurological) check initiated. RP (Responsible Party) made aware. Continued review of the record showed the (Hospital Name), computed tomography report dated (MONTH) 16, 2019, showed Resident #164 sustained trauma, Left periorbital soft tissue swelling. Associated displaced fracture lamina papyracea (orbital fracture). Minimal blood in the left ethmoid sinuses. Resident #164 was discharged from the facility on (MONTH) 26, 2019. Review of Employee #4's Personnel Record Review of Employee #4's statement dated (MONTH) 20, 2019 showed, Incident report on the 16th of June. I went into (Resident #164) room to clean her up, in the process of cleaning her, she became combative and hit her face on the bedrail which caused swelling on her face. So I decided to report the situation to the charge nurse immediately. I was not contacted on this during the week. Review of Employee #4's time card showed he arrived at work on (MONTH) 16, 2019 at 9:29 AM, punched out at 1:30 PM punched back in at 2:00 PM and punched out for the shift at 3:48 PM. The Personnel Report of Change dated (MONTH) 21, 2019 showed, the Employee #4 was suspended for three (3) days (6/21/19, 6/22/19, and 6/23/19). In-service records showed Employee #4 attended in-services on Prohibition of Resident Abuse and Neglect, Managing Resident with Dementia and Aggressive Behavior, Cultural Competency, and Resident Safety during ADL (activities of daily living) care on (MONTH) 25, 2019, (five days after the incident). The Personnel Report of Change dated (MONTH) 16, 2019 showed, the Employee #4 was terminated from the facility on (MONTH) 16, 2019. There was no evidence facility staff failed to immediately remove Employee #4 from the facility after the incident to ensure the safety of all residents, as evidence below: The incident occurred at approximately 11:35 AM on (MONTH) 16, 2019. According to the Employee's time card, he worked the duration of the shift (until 3:48 PM). There was no documentation of Employee #4's suspension until (MONTH) 21, 2019 (five days after the incident occurred. (The Employee did not work during this period.) On (MONTH) 27, 2019, Employee #4 was allowed to return to work, and assume his duties as a CN[NAME] Interviews: During a face-to-face interview with the Unit Manager (assigned to the unit of Resident #164) on (MONTH) 19, 2019, at 2:13 PM, she stated, I was the manager at the time of the incident with the CNA, it was a weekend on Sunday the supervisor called me there was an incident that occurred on your floor and we called 911. The CNA take took care of her an abrasion during care, the face is swollen and we put on ice packs we have to send her out 911. I do not know why Employee #4 was taking care of her because the family requested that they did not have a male they told this to me. The family requested to have another (Employee Name) and that weekend she was off. Employee # 4 knew he was not supposed to take care of the resident. Employee #4 came in late and the other CNA switched (the resident assignment) .the charge nurse did not know that he switched the resident (assignment). She (the resident) is always is agitated . The surveyor asked, What do you do when a family make a request regarding patient care? Most of the time we have an in-service to let them know what the family is requesting. I care plan it so everyone will know /they are well-informed so that the message is passed on . Resident #1 is an unusual incident I don't tolerate abuse, why should I want to be abused, this is something I will regret. During a face-to-face interview with Employees' #1 and #2 on (MONTH) 19, 2019 they stated, We conducted the investigation of (Resident #1). He (Employee # 4) was the only person involved in the incident. There were no witnesses. The Employee was suspended immediately. He was sent for education/in-services and returned to work on (MONTH) 27, 2019 at 7:28 AM. We believe what he (Employee #4) said about what happened. He probably could have called for additional help. We maintain the actions of Employee #1 (CNA) were not abusive (willful) but a care issue. We still believe it's a care issue. The writer asked, is it my understanding that the Resident only wanted female CNAs? Employees' #1 and #2 stated, The unit manager got the note (from the family), the note was received before this incident requesting that the resident (Resident #164) not have a male CN[NAME] The writer asked, what was the outcome of the investigation? Employees' #1 and #2 stated, The Employee needed further education on combative residents and dignity and monitoring during care. The writer asked, how were they monitoring Employee #4? Employees' #1 and #2 stated, They were asking the charge nurses how the employee was doing. The monitoring started immediately (upon his return to work on (MONTH) 27, 2019). There was no monitoring tool. They would touch basis on the days he worked to ensure he was fine. The writer asked, why was the Employee terminated on (MONTH) 16, 2019? Employee #1, stated, he was terminated on (MONTH) 16, 2019, as a result of the DC Department of Health Complaint Investigation Report (C-19-057, DC-4819, harm level deficiency cited), gross negligence, carelessness, failure to follow the policy and procedure in the care of a resident. We could have done better. Summary of Findings: The facility failed to provide an interpreter to communicate with the resident while providing health care services (ADL care) Per the MDS dated (MONTH) 3, 2019. The facility failed to provide two (2) person physical assistant when performing adl care for Resident #4 on (MONTH) 16, 2019, Per the MDS dated (MONTH) 3, 2019. The facility staff failed to ask why Resident #164's family did not want male CNAs caring for the resident. The facility staff failed to have written documentation that staff were in-serviced on the family's wishes not to have male CNAs care for Resident #164. The facility CNA staff failed to follow their resident care assignments given by the Charge Nurse on (MONTH) 16, 2019. Employee #4 (CNA) failed to stop caring for Resident #164 who became combative during ADL care on (MONTH) 16, 2019. Employee #4 failed to call for assistance when Resident #164 became combative on (MONTH) 16, 2019. The facility's investigation lacked evidence such as, the supervisor's written account of what occurred and how Employee #4 was supervised/managed after the incident, and a written statement from Employee #4 at the time of the incident stating what occurred during care of the resident. There was no formal written summary/conclusion of the facility's investigation. The facility administrative staff failed to thoroughly investigate and recognize the incident on (MONTH) 16, 2019 as a likelihood of abuse or neglect. The administrative staff, however, identified the incident on (MONTH) 16, 2019 as a care issue. The facility's administration received the survey findings from the (DC Department of Health) complaint report, and as a result of the findings Employee #4 was terminated on (MONTH) 16, 2019 for gross negligence, carelessness, and failure to follow the policy and procedure in the care of a resident. Employee #4 worked 33 hours providing care to other residents from (MONTH) 27, 2019 to (MONTH) 16, 2019, prior to being terminated. During the face-to-face interview on (MONTH) 23, 2019 approximately at 2:15 PM, Employees' #1 and #2 acknowledged the findings.

Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to ensure one (1) resident who was identified as a fall risk received adequate supervision. The resident was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 Findings included . A review of the Resident's Clinical record showed that on (MONTH) 7, 2019, at 11: 00 AM Resident #182 was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A review of Resident #182's admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 11 which indicates the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance with one (1) person physical assist for bed mobility, transfer, locomotion on the unit and locomotion off the unit. Section G 0400 Functional Limitation in Range of motion code 0 indicates No impairment. Section J I700 Fall History on Admission/entry was coded as1 to indicate that the resident had a fall 2 - 6 months prior to his admission to the facility. A review of the care plan initiated on 5/17/19 showed resident at risk for falling r/t (related) cognitive impairment, unsteady gait and [DIAGNOSES REDACTED]. resident was observe on the floor with no injury. There was no mention that Resident #182 had a fall on 7/7/19. A review of the Resident's progress note showed the following: 7/7/19/ 1:41 PM Writer (RN Supervisor) was called to unit 3 green and noted resident in a sitting position in front of his wheel chair in the solarium. Upon assessment resident denied pain or discomfort, no injury noted, denied hitting his head able to move his upper arm and lower extremities without difficulty to his baseline. Resident was asked how he got to the floor he said that he did not know 7/9/19 1:51 PM NP's (Nurse Practitioner's) Progress note showed Pt c/o pain today at left leg . x-ray ordered . pain with ROM at left leg at knee part, had pain earlier at left hip, slight swelling left leg and lower thigh, x-ray left leg. 7/10/19 9:52 AM (RN) late entry for 7/9/19 Resident is status [REDACTED]. Seen by the NP .due to complaint of pain on the left hip that radiates to the lower extremity. As result, x-ray of the left hip, left femur and left knee was ordered. X-ray was done at 3 pm, preliminary x-ray result showed resident has [MEDICAL CONDITION] femur NP was notified An order to transfer resident to the emergency room . A review of the result of the stat x-ray of left femur, left knee, left hip and pelvis on 7/9/19 ordered by NP showed Impression: Acute [MEDICAL CONDITION] Left Femur. A face to face interview was conducted on 7/26/19 at 1:55 PM with Employee #19 (CNA) who stated, I was in the solarium watching and monitoring residents when my coworker in the room next to the solarium asked me for help to put a resident in chair. I left the solarium to the room right outside the solarium to help with another resident. While in the room I heard someone say resident on the floor in solarium and ran back in there he was sitting on the floor in front of wheel chair. On Tuesday I was giving AM care when I went to move him he says ouch, ouch. I asked what was wrong he pointed to left side of hip. I called charge nurse and she came to see him. Another face to face interview was conducted on 7/26/19 at 1:59 PM with Employee #20 (CNA) who stated, I was in (resident,s name) room getting her ready to get out of bed, (CNA name) in solarium covering residents in solarium. I had went to her to ask her to help me put (resident's name) in chair. She did and while in room another resident called out patient on floor. We both ran out to solarium he was sitting up on the floor beside his wheel chair. He did not complain staff came and assessed him. The evidence showed that facility staff failed to ensure one (1) resident who sustained a fall with an injury received adequate supervision to prevent an accident as evidenced by the staff assigned to watch and monitor the residents in the solarium left him unattended. During a face-to-face interview with Employee #13 (unit manager) on 7/26/19, at 1:44 PM, he acknowledged the findings and stated, The staff assigned to the solarium left to help a coworker although we educate them not to leave residents in the solarium alone.

Based on policy review, medical record review, and staff interviews for one (1) of 56 sampled residents, the facility staff failed to provide appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. Findings included . Wound, Ostomy and Continence Nurses Society. (2016). Care and management of patients with urinary catheters: A clinical resource guide. MT. Laurel: N[NAME] Author Securement Devices: .Indwelling catheters should be secured to avoid traction on the catheter, which causes irritation and trauma to the urethra(e.g., urethritis, necrosis, erosion, stricture) .monitor the urethra daily for irritation, erosion, or urine leakage and assess the skin integrity under the securement device. Resident #58 was readmitted to facility on 12/21/18, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Comprehensive MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of the care plan for Foley Catheter due to [MEDICAL CONDITION] showed it was initiated on 1/23/2019. Goal: resident will have catheter care managed appropriately .not exhibiting signs of urinary tract infection or urethral trauma. Approach: .report signs of UTI .manipulate tubing as little as possible during care .provide catheter care .use catheter strap .use leg bag as needed . A review of Medical Record Revealed: A physician's orders [REDACTED]. Urology consult for UR 12/10/2018. Urology Consult-1/3/2019, Diagnosis; [MEDICAL CONDITION] with chronic indwelling Foley catheter and urethral erosion. A review of NP (Nurse Practitioner) progress note dated 5/31/2019, revealed, .10:36 PM Pt with UR, observed during day, unable to pee, Foley reinserted able to drain urine. Penis lacerated from previous Foley catheter with ulcer at glans Pt states pain burning at penis. Purulent drainage from penis . Foley inserted attached to right leg to avoid further laceration at left side avoid diaper when patient has Foley (to lacerate penis). 5/31/2019 - Interim Order, Please avoid diaper when pt. has a Foley (cause Laceration of penis) Foley inserted routine Foley care q shift. A review of NP Progress note dated 6/4/2019, .Pt with Foley catheter with ulcer of glans purulent drainage from penis . 6/5/2019- Interim Order, D/C order to avoid diaper when pt. has a Foley Use diaper to make it loose to prevent laceration. Urology Consult for possible Suprapubic catheter (6/20/2019) .Progress note [MEDICAL CONDITION] UTI (Urinary .Penile erosion .plan for SP (Suprapubic) tube placement under local . Urology consultation for [MEDICAL CONDITION] at (Hospital Name) at 1:30 PM with (Physician name) (07/03/19). Change Foley catheter q 6 weeks obtain medical records or other history to determine if there are reasonable alternative to indwelling Foley catheter . 7/5/2019- Urology Consult findings: S/P tube inserted under u/s (ultrasound) guidance New Diagnosis: [REDACTED].urethral erosion. 7/9/ 2019- Interim Order urology F/U (follow up) for Suprapubic Cath . Upon review of the nursing progress notes dated (MONTH) 1, 2019 through (MONTH) 30, 2019 showed no evidence the facility staff assessed the resident's [MEDICAL CONDITION] status for complications (irritation and trauma to the penis or urethra) regarding indwelling Foley catheter prior to or after the penile laceration and erosion occurred and was documented by Nurse Practitioner resulting in the surgical insertion of the suprapubic catheter directly in to the Residents bladder for further care. Through record review, it was noted the resident was diagnosed with [REDACTED]. There was no evidence that facility staff conducted an initial and ongoing [MEDICAL CONDITION] assessment (size, discoloration of skin, odor, swelling, pain, drainage) and treatment plan to promote healing. On 5/31/19, the resident was noted with a laceration to his penis from previous Foley catheter with ulcer at glans, with pain burning and purulent drainage from penis. On 7/5/19, the resident had a suprapubic catheter inserted due to [MEDICAL CONDITION] and urethral erosion. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee # 3 who stated she did not know what erosion was and would look it up on the internet.

Based on staff interview and record review for one (1) of seven (7) residents reviewed, it was determined that facility staff failed to stop giving morning care to a combative resident who was attempting to scratch the employee. Subsequently, the resident sustained [REDACTED]. Resident #1 The findings include: Resident #1 was admitted to the facility on (MONTH) 29, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 3, 2019, he/she was assessed with [REDACTED]. He/she was assessed as requiring extensive assistance of one (1) for bed mobility, transfers, dressing, personal hygiene and totally dependent for bathing and toilet use with the assistance of two (2) in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse's note dated (MONTH) 16, 2019 at 12:30 PM: Writer was called by CNA to come to resident room, when asked CNA said He/she was trying to give care to resident when he/she became combative and in the process of turning, resident hit his/her head on the side rail of the bed. Happened at 11:35 am. Writer went and assessed resident and noted a swelling on his/her left face. Supervisors were informed. NP was called , who gave orders for resident to be transported via EMR/911. To the nearest ER. Resident #1 is alert and unable to explain what happened. His/her [DIAGNOSES REDACTED]. On assessment resident noted with swelling of the left fore head near the left eye with a cut on the left upper lip with minimal bleeding which was cleansed with normal saline. Ice pack applied to the left forehead swelling. V/S laying 138/69, P74, T 97.7, Spo2 98% on room air. V/S sitting B/P 157/80, P77, T98.2, R 18. Pulse ox room air 97% . Finger stick 142 mg/dl. Tylenol 2 tabs 325 mg was administered for pain 4/10 and was very effective. Neuro check initiated. RP made aware. According to a progress note written by the dentist on (MONTH) 21, 2019: Received a call on 6/19 regarding patient injury. Informed charge nurse that [MEDICATION NAME] would be added prior to procedure. He/she told me he/she would call me once it was received (after NP left orders and X-ray results). S/P hit face on bed railing. Patient has black eye (periorbital) swollen lip (upper/inner) and slightly bruised periocular area. Patient is .lying in bed/sleep. Comprehensive exam of oral soft/hard tissues completed to rule out fractured teeth. Patient has fractured [MEDICATION NAME] teeth unrelated to this incident. There is no associated mobility or intra-oral trauma. Patient does have swelling of face and lips which are clearly trauma related. Patient's teeth which are broken also have excessive decay which is unrelated to incident. Recommend that area of trauma be resolved prior to any future clinical treatment unless patient's teeth become symptomatic due to patient's altered mental status. Dr. contacted (RP) to inform him/her of findings. A telephone interview was conducted with Employee #1 on (MONTH) 8, 2019 at 9:40 AM. He/she was giving care to Resident #1 when the incident occurred. Employee #1 stated, I was cleaning him/her up and I had his/her diaper and pants to pull up. Then I was done with the job. He/she started to wave around his/her arms and tried to scratch me. I turned him/her to pull up his/her pants and his/her arms went under him/her. Then he/she hit her face on the side rail. It's metal. I called the charge nurse who called the supervisor and then they did an assessment and we sent him/her out 911. Employee #1was asked if he/she stopped caring for Resident #1 when he/she became combative. Employee ##1 stated, I left him/her alone. I went to the bathroom and cleaned up the items I used. I went back to the resident. He/she was still combative . I know that I was supposed to wait a few minutes to let him/her calm down, but I had to get the job done. I had to finish pulling up his/her pants because I had to finish the job. Facility staff continued to complete morning care despite the resident being combative and attempting to scratch Employee #1. Subsequently, the resident sustained [REDACTED]. A face-to-face interview was conducted with Employee #2 on (MONTH) 1, 2019 at 10:45 AM, who acknowledged the above findings. The record was reviewed (MONTH) 1, 2019.

Based on observation, record review, and interview for three (3) of 43 Stage 2 sampled residents, it was determined that facility staff failed to ensure that a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming, personal and oral hygiene as evidenced by failure to: consistently provide personal care and grooming for one (1) resident who was observed with unkempt hair and eyelids stuck together with drainage; one (1) resident in need of oral hygiene and one (1) resident observed with excessive facial hair. Residents #80, 9, and 126. The findings include: 1. Facility staff failed to ensure that Resident #80, who was unable to carry out activities of daily living, received the necessary services to maintain grooming and personal hygiene as evidenced by an observation wherein it was determined the resident ' s eyelids were stuck together with excessive eye drainage and his/her hair was unkempt. According to Resident #80 ' s annual and quarterly Minimum Data Sets (MDS) dated [DATE] and May 18, 2016 respectively, revealed: Resident #80 was totally dependent on one (1) staff for hygiene and bathing according to Section G, Functional Status. The resident was coded as severely impaired for daily decision making under Section C, Cognition and under Section B, Hearing Speech and Vision, Resident #80 was coded as rarely/never understands and no speech (absence of spoken words). According to the history and physical examination [REDACTED]. A. On July 13, 2016 at approximately 10:00 AM, following the completion of AM care (confirmed by the assigned certified nurse assistant), Resident #80 was observed in his/her room lying in bed. The resident's eyes were closed and his/her eyelids were observed to be soiled with drainage. Immediately following the observation, a query was made to Employee #35 (physician) who was present on the unit. Employee #35attempted to examine the resident's eyes, however, he/she was unable to open the resident ' s eyes due to buildup of a yellow crusted substance. Employee #35 stated (he/she) would prescribe an antibiotic treatment for [REDACTED]. A review of physician's order [REDACTED]. A review of the resident's care plan revealed: ADL Functional /Rehabilitation (Activities of Daily Living): care plan, initiated on February 24, 2016, last updated May 25, 2016 revealed that the resident was identified with a potential for decline in functional (status) and mobility ADLs due to Dementia, Approaches: Assist resident with ADL's .Evaluation: Resident depends on staff for all aspect of ADLs . A review of the Medication Administration Record [REDACTED]. Facility staff failed to provide eye care and personal hygiene consistent with the resident's needs. The resident's eyelids were stuck together with drainage. Facility staff completed AM care and medications were administered; however, there was no evidence that clinical staff assessed the buildup of drainage and/or crusting around the resident ' s eyes prior to the surveyor ' s observation. Subsequently, the resident was diagnosed with [REDACTED]. A face-to-face interview was conducted with Employee #33 on July 13, 2016 at approximately 1:30 PM. He/she acknowledged that Resident #80 ' s eyes were stuck together with drainage and that licensed staff acted on the physician's order [REDACTED]. A face-to-face interview was conducted with Employees # 1, 2, and 3 on July 13, 2016 at approximately 4:00 PM regarding the aforementioned observation. The clinical record was reviewed on July 13, 2016. B. Facility staff failed to maintain grooming for Resident #80 who was observed with his/her hair unkempt (untidy/disheveled). A resident observation was conducted on July 13, 2016 at approximately 12:00 PM with Employee #33. The employee repositioned the resident on his/her left side. At this time, Resident #80's hair (towards the back of the head) was observed uncombed, matted and unclean. The clinical record lacked evidence of documentation related to the resident ' s most recent shampoo and/or hair styling. The resident was unable to communicate his/her needs and the staff was required to anticipate the resident ' s needs. According to the care plan ADL Functional /Rehabilitation (Activities of Daily Living) dated May 25, 2016, Resident depends on staff for all aspect of ADLs . On July 14, 2016, subsequent to the surveyor ' s observation, Resident #80 was observed in the beauty shop having a shampoo. A face-to-face interview was conducted with Employees' #1, #2, #3, #4, #33, and #36 at the time of the observations. After review of the aforementioned, all acknowledged the findings. 2. Facility staff failed to consistently provide routine oral care for Resident #9 who was totally dependent and was observed with large amounts of food particles around his/her gums and between the teeth. A family interview was conducted on July 8, 2016 at approximately 12:40 PM. In response to the question; Does the resident receive the help he/she needs in cleaning his/her teeth, the family member responded, No. (His/her) teeth always have food particles. The family member then said to the resident, Show me your teeth. The resident responded by opening his/her mouth and revealed large amounts of food particles around the gums and between the teeth. Subsequent observations prior to breakfast on July 11 and 12, 2016 also revealed the food particles caked between the resident ' s teeth and on the gums. A review of the quarterly MDS with an ARD (Assessment Reference Date) of June 10, 2016 revealed, the resident was coded as totally dependent for dressing, toilet use and personal hygiene. According to Section I (Diagnoses) the resident was admitted to the facility with [DIAGNOSES REDACTED]. and Depression. A face-to-face interview was conducted with Employee #47 at approximately 2:30PM on July 14, 2016. The employee was queried whether he/she usually brushed the resident ' s teeth when providing daily oral care. He/she responded, No. When I tried to brush (his/her) teeth they bled and I was told not to brush them. I wipe them but ( he/she) does not always open his/her mouth. A face-to-face interview was also conducted with Employee #9 at approximately 3:00PM on July14, 2016. The employee was informed of the family member ' s statement, the surveyor ' s observations and the staff ' s interview. In response the employee stated, it is true that (he/she) does not always open (his/her) mouth and allow the teeth to be cleaned. That ' s why we use the sponges. Employee #9 acknowledged the finding. 3. Facility staff failed to provide necessary services to maintain grooming for Resident #126 who requires extensive assistance to maintain his/her grooming was observed with excessive facial hair. On July 8, 2016 at approximately 12:16 PM and July 13, 2016 at approximately 10:00 AM, Resident #126 was observed with gray colored hair covering (his/her) upper lip and chin. According to the Certified Nursing Aide charting, the resident received AM and PM care (personal hygiene/grooming) on July1-13, 2016, however there was no evidence that facility staff shaved the resident while providing AM care. A face-to-face interview was conducted with Resident #126 on July 13, 2016 at approximately 3:30 PM. He/she stated, Someone use to shave me, I don't know who. I tried to find someone who is regular to remove it (the hair on his/her chin). I asked someone but they never came back. I would like it (the hair on his/her chin) removed. This interview was conducted in the presence of Employee # 38 who acknowledged the findings.

Based on observation, record review and staff interview for two (2) of 43 Stage 2 sampled residents, it was determined that facility staff failed to ensure that the resident environment was as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents as evidenced by: failure to utilize appropriate safety measures while providing AM (morning) care to one (1) resident who subsequently sustained a fall and required transport to a local emergency department for treatment of [REDACTED]. Residents' #126, #154 and #279. Additionally, facility staff failed to maintain resident's environment free of accident hazards as evidenced by: frayed call bells in three (3) of 44 resident's rooms, an accessible container of cleaning chemical in one (1) of eight (8) resident units surveyed, and an unsecured surge protector in one (1) of 44 resident's rooms surveyed. Facility staff failed to ensure that Safety Data Sheets were (includes information such as the properties of each chemical; the physical, health, and environmental health hazards; protective measures; and safety precautions for handling, storing, and transporting the chemical) readily available in the Safety Data Sheet Book on each nursing unit. The findings include: 1. Facility staff failed to utilize appropriate safety measures while providing AM/ADL (morning activities of daily living) care to Resident # 126 who sustained a fall during care in the company of a CNA (certified nurse assistant), complained of chest pain at the time of the fall and subsequently required transport to the local emergency department for treatment post fall. According to the Minimum Data Set completed June 15, 2016, Resident #126 was coded as requiring two-person physical assistance for transfers, toilet use, and bathing. The resident was coded as not steady, only able to stabilize with staff assistance and impairment to lower extremities on both sides, under Section G Functional Status. Under section H (Bladder and Bowel) the resident was coded as always incontinent of urine and bowel. Review of the nursing progress notes revealed: July 10, 2016 at 9:28 AM, At 8:30 AM writer received a report from the assigned CNA that resident slid from standing position to the floor while receiving AM care. On assessment resident alert and oriented x2, verbalized chest pain, r (right) 2nd toe skin tear 0.8 x 0.4 x 0.0 cm with minimal active bleeding, pressure dressing applied to R 2nd toe, bleeding stopped, NP (nurse practitioner) called and new order received to send (the resident to the) ER (emergency room ) via 911 for chest pain . July 10, 2016 at 9:28 PM, Resident return from the (Hospital Name) at 6:19 PM alert and stable . Falls risk Assessment completed June 22, 2016 revealed, Evaluation Score = 21 (Score of 10 or higher represents a high risk for falls) According to the Point of Care History Activities of Daily Living data competed by the respective Certified Nurse Assistant from July 1-10, 2016, revealed that Resident #126 was coded as having one (1) person physical assistance during transferring and toileting. A face-to-face interview was conducted with the Employee # 39 (staff assigned to care for Resident #126 on July 10, 2016, day of the fall) on July 14, 2016 at approximately 1:30 PM Employee #39 was asked to explain how the incident occurred with the resident ending up on the floor during AM care. He/she stated, I washed (his/her) face. The (resident) likes to stand up on the side of the bed and stand. (He/she) holds the rails. On this morning (he/she) was standing facing the window. (He/she) was at the bottom part of the bed. I raised the rail so (he/she) could grab it. (He/she) urinated and (he/she) wanted to step out of it (urine) and (his/her) foot slipped. (His/her) right foot hit the foot pedal on the wheel chair. The wheel chair was behind the resident. (He/she) stepped to the left to get out of the urine, I was standing to the right of the (him/her). I lowered (him/her) to the floor. I never use a Hoyer lift with (him/her) before because (he/she) can stand. Now, since the incident we use a Hoyer lift . A follow up interview was conducted on July 14, 2016 at approximately 3:10 PM with Employee #39. He/she stated, Foot rest were not removed from the wheelchair. If (he/she) had fallen backward (he/she) would have fallen into the chair. No gait belt was used. I wasn't expecting (him/her) to move. (He/she) moved (his/her) leg without me knowing. I was washing (him/her) up. (He/she) can stand. When (he/she) says I want to sit down we let (him/her) sit down. (The resident) doesn't like (his/her) head to be lying flat, (he/she) would rather stand. The old manager knew, I never discussed it with the new manager. Review of the Care plan section of the resident ' s clinical record revealed that there was no approach or intervention to address the resident ' s choice to have AM care provided while standing at the bed side. In addition, there was no evidence of a Physical or Occupational therapy screening or evaluation to ensure that it was safe for the resident to stand and for how long to have am care provided. Through interview with Employee #39, he/she stated that the resident stepped to the left, there was no evidence that the employee applied the resident ' s shoes and used a gate belt while transferring the resident from a lying position in the bed to then have the resident stand and hold on to the side rail of the bed to have AM care performed. In addition, the employee stated that the resident ' s wheel chair was directly behind the resident, however he/she failed to remove the footrest/legs of the wheelchair prior to transferring the resident. A telephone interview was conducted on July 27, 2016 at approximately 4:05 PM with Employee #27. He/she stated, I knew (that the resident likes to stand to have AM care provided), that ' s how he/she is, that was his/her request. In addition, Employee #27 acknowledged the findings. There was no evidence that appropriate safety measures were taken when Employee #39 provided AM care to Resident #126. The resident was transferred with the assistance of one (1) staff from lying in the bed to a standing position at the bottom part of the bed. However, the MDS was coded that the resident required the assistance of two (2) persons for transfer. Subsequently, the resident sustained [REDACTED]. During the assessment of the resident at the time of the fall, the resident verbalized chest pain and required transport to a local emergency department via emergency medical services (911). The record was reviewed on July 15, 2016. 2. Facility staff failed to provide adequate supervision for Resident #154 who had a history of [REDACTED].#154 was placed at the nurse ' s station without supervision, he/she then wandered into Resident #279 ' s room, encountered an altercation with the resident and subsequently Resident #279 sustained an abrasion to the right eyelid. A review of Resident #154 ' s quarterly Minimum Data Set (MDS) dated [DATE] under Section I, Active [DIAGNOSES REDACTED]. Section C, Cognitive Skills for daily decision making revealed the resident was coded as moderately impaired, decisions poor, cues/supervision required. Section E, Behavior was coded as having physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others .) occurred 1 to 3 days. Section E, wandering (Presence & Frequency)- resident was coded as having behavior of this type daily. A review of the comprehensive care plan for Resident #154 revealed the interdisciplinary team (IDT) identified wanderer, as a problem with a goal that the resident ' s safety be maintained, no injury occurs . The plan was initiated December 30, 2015 and updated June 25, 2016. The wanderer care plan included (but was not limited to) the following: Problem Start Date: 12/30/2015- Identified wanderer, Potential for Injury r/t (related to) Dementia, Alzheimer ' s manifested by: walking back and forth toward exit. Wanders near exits. Long Term Goal Target Date: March 30, 2016- Safety maintained, no injury occurs, Resident will not leave the unit during the review period. Approach Start Date: December 30, 2015- Provide calm environment. Have photo taken for identification, Check ID (Identification) bracelet. Picture on chart, ensure resident wander guard bracelet is working properly. Staff to walk resident to the front exit door every Wednesday to ensure wander guard is working. If not to notify security for a new bracelet. Monitor resident for elopement every shift. Offer activities. A review of Resident #154 ' s clinical record revealed the following nurses' notes: June 19, 2016- 3:59 PM- resident wandering on the unit. Resident takes objects found on the unit (Christmas decorations, cleaning wipes, food from breakfast and lunch trays). Resident behavior unimproved. June 21, 2016- 8:27 AM- Resident noted several times pulling lamp and radio from wall outlet and dropping it on the floor. Also took it off again and took it to roommate ' s bed. June 21, 2016- 3:54 PM- Resident continue wandering on the unit, touching everything (he/she) can lay (his/her) hand on. Staff continue to be redirect. June 23, 2016- 9:43 PM- Resident alert and responsive. Continues to wander in the unit. Dropped keyboard in the nursing station on the floor, keyboard broken. Resident redirected by staff. Refused to be redirected. June 25, 2016- 10:49 PM- resident continues to wander in the unit touching and pulling everything (he/she) sees. Attempted pulling the assignment board by the nursing station. Redirected by staff. Refused to be redirected. Ate 100% of dinner. Safety precaution maintained. June 27, 2016- 4:16PM- Resident is alert and verbal with intermittent confusion, resident wandered into another resident room and (tried) to take the other resident (Bible) and they started dragging the (Bible) and both residents fell , resident (#154) thoroughly assessed with [REDACTED]. Resident remain stable at this time. RP (Responsible Party) and MD (Medical Doctor) made aware of resident's fall. V/S (Vital Signs)- 130/70 (blood pressure), 60 (pulse), 18 (respirations) . A review of the facility ' s incident report titled, Incident Report , documented by nursing staff, dated June 27, 2016, (time of incident: 8:30 AM). Read as follows: (Exact Location of Incident: (location recorded), Patient ' s Condition Before Incident: Alert and confused; Was Resident Attended: No; . Describe Exactly What Happened (What you Saw-Who Reported the Incident-What The Resident Said)- (Resident # 154) went into another resident (room) and was trying to pick up the resident ' s Bible and the resident try to stop (his/her) and they both ended up on the floor. Resident has no apparent injury . Supervisor Comments and Recommendations: Indicate what contributes to the incident: Resident will be closely monitored for wandering. What action is recommended to prevent similar incidents: When the CNA ' s (Certified Nursing Assistants) are busy doing AM (morning) care, the charge nurse will make sure (Resident # 154) is in sight at all times . According to the 24 Hour Nursing Report, Unit dated June 26, 2016 revealed the following: Name: (Resident #154), Room - (Diagnosis): Dementia. Day Remarks: Resident found on the floor in Room 106. No visible bruising or hematomas/lacerations. Name: (Resident #279), , (Diagnosis): Dementia. Day Remarks: Resident has a hematoma to the right side of (his/her) head as a result of fall as a result of fall as stated by resident. Resident transported to hospital (hospital named) at 12 noon The Day Shift Assignment Sheet dated June 26, 2016 for unit (7:30 AM-4:00 PM) revealed: the on the morning of the incident there was one License Practical Nurse (LPN) and two Certified Nurse Assistants (CNA). The assessments were as follows: Charge Nurse: (assigned LPN), Resident Group I- (assignment split between CNA assigned to Group II and Group III), Group II (assigned CNA), Group III (assigned CNA), Solarium Monitoring: 8:00- I (split); 8:30- II (assigned CNA) A face-to-face interview was conducted with the night CNA assigned to Resident #154 on July26, 2016 at approximately 10:00 AM. He/she stated after Resident #154 was given him/her AM care, he/she escorted the resident to sit at the nurse ' s station. Also, stated, he/she was sitting beside the resident. When her tour of duty ended; he/she left; however, it was a charge nurse at the nurse ' s station. Employee #32 was asked about the staffing for the day shift, and what was the unit ' s process for monitoring residents in the solarium. He/she stated, that he/she was re-assigned to another unit to assist with medication administration when the incident happened. There was one charge nurse for days after he/she was re-assigned. Further stated; there is usually three CNA's assigned on day shift. A follow up face-to-face interview was conducted with Employee #9 on July 12, 2016 at approximately 3:00 PM. He/she stated there were only two (2) CNA ' s assigned to the unit. Group I residents had to be split between the two CNA ' s. At the time of the incident, the CNA were doing am in care to other residents. The day charge nurse was at the nurse ' s station and was doing drug reconciliation with the off going night charge nurse. Further stated, there was no one in the solarium monitoring residents. Through record review and staff interview it was determined that facility staff assessed and identified Resident #154 as a wanderer. On June 27, 2016 at approximately 8:30 AM, Resident #154 was placed at the nurse ' s station without supervision. He/she then wandered into the room of Resident #279, and tried to take his/her Bible. This initiated a resident-to-resident altercation that caused Resident #279 to fall and sustain a hematoma to the right side of his/her head. Resident #279 was sent to the emergency room for treatment. There is no evidence that facility staff took reasonable precautions to maintain adequate supervision for Resident #154 who wandered into Resident #279 ' s room encountered a resident-to-resident altercation and subsequently Resident #279 sustained an abrasion to the right eyelid. The record was reviewed on July 12, 2016. 3. Facility staff failed to maintain resident's environment free of accident hazards as evidenced by frayed call bells in three (3) of 44 resident's rooms, an accessible container of cleaning chemical in one (1) of eight (8) resident units surveyed, and an unsecured surge protector in one (1) of 44 resident's rooms surveyed. Observations of the facility made on July 12, 2016 between 9:50 AM and 12:30 PM, were as follows: Call bell cords were frayed in three (3) of 44 resident's rooms surveyed including rooms #200, #240A and #337C. A container of General Purpose (GP) cleaning chemical was observed in an unsecured, easily accessible biohazard room on resident unit 3 Blue, one (1) of eight (8) resident units surveyed. A surge protector was observed unsecured, on the floor of resident room #215, one (1) of 44 resident's rooms surveyed. These observations were made in the presence of Employee #5 and Employee #6 who acknowledged the findings. 4. Facility staff failed to ensure that Safety Data Sheets were (includes information such as the properties of each chemical; the physical, health, and environmental health hazards; protective measures; and safety precautions for handling, storing, and transporting the chemical) readily available in the Safety Data Sheet Book on each unit. The Occupational Safety & Health Administration <https://www.osha.gov/>, Hazard Communication Standard: Safety Data Sheets (SDS); The Hazard Communication Standard (HCS) (29 CFR 1910.1200(g)), revised in 2012 stipulates, Employer Responsibilities- Employers must ensure that the SDSs are readily accessible to employees for all hazardous chemicals in their workplace. This may be done in many ways. For example, employers may keep the SDSs in a binder or on computers as long as the employees have immediate access to the information without leaving their work area when needed and a back-up is available for rapid access to the SDS in the case of a power outage or other emergency . https://www.osha.gov/Publications/OSHA3514.html During tour of the facility on July 14, 2016 at 12:15 PM it was observed that a container of Micro-Kill One (germicidal alcohol wipes) was placed atop the desk of the nursing station on 3 Orange; and in the day/dining room there were several containers of Epi-clensz instant hand sanitizing wipes. Review of the facility ' s Safe Data Sheets books located on nursing units 1 Blue and 3 Blue was conducted. There was no evidence that safety data sheets for Micro-Kill One and Epi-clensz were available for review and guidance to employees in the event of an emergency. A face-to-face interview was conducted on July 15, 2016 at approximately 10:26 AM with Employee #49. He/she acknowledged the findings.

Based on record review and staff interviews for one (1) of 39 sampled residents, it was determined that facility staff failed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care; as evidenced by: failure to consistently assess and monitor one (1) resident's orthostatic blood pressure(s) according to the physician 's orders. Residents #262. The findings include: Facility staff failed to consistently assess and monitor Resident #262's orthostatic blood pressure(s) in accordance with the physician's orders [REDACTED]. According to the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, " Measuring Orthostatic Blood Pressure: 1. Have the patient lie down for 5 minutes. 2. Measure blood pressure and pulse rate. 3. Have the patient stand. 4. Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes. A drop in BP (blood pressure) of (greater than or equal to 20 mmHg) (millimeters of mercury), or in diastolic BP of (greater than or equal to) 10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal." <http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi/measuring_orthostatic_bp.pdf> The facility's policy entitled, "Orthostatic Blood Pressure," last updated (no date indicated), stipulated, " Count the pulses (P) and take the blood pressure in baseline position (supine or sitting). Move resident to next most upright position that can be maintained. Ask resident is he or she experiencing symptoms. Wait one minute if possible, recheck the pulse and blood pressure, restore resident to prior position...Orthostatic changes are reflected when: Pulse is increased by ten beats per minute or more, with or without blood pressure change, Systolic blood pressure is decreased by 15mm Hg or more, without change in diastolic blood pressure, diastolic blood pressure is decreased by 5mm Hg or more with or without change in systolic blood pressure or pulse..." According to Web MD.com " [MEDICATION NAME] (Common brand name: [MEDICATION NAME]) ...Warning: [MEDICATION NAME] should be used in carefully selected patients. When you are lying on your back, this medication causes a significant increase in blood pressure. Your blood pressure will be monitored carefully during treatment. This medication is used for certain patients who have symptoms of low blood pressure. " Side Effects "...this medication can cause your blood pressure to increase, especially when you are lying down (supine hypertension. Stop taking [MEDICATION NAME] and contact your doctor immediately if you experience the following signs of supine hypertension: pounding heartbeat, pounding in the ears, headache ...Notes ...Blood pressure checks (lying, sitting, and standing) should be routinely taken. Share the results with your doctor. " <http://webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details> A review of (rehabilitation hospital) discharge summary dated [DATE] revealed the following: "Functional Status at the time of Discharge: With physical therapy, the patient required minimal assistance for bed mobility and stand-pivot transfers with and without the use of a rolling walker (He/she) was able to ambulate up to 25 feet with a rolling walker with minimal assistance. (He/she) was able to propel a wheelchair 20 feet with minimal assistance over tiled surfaces using (his/her) bilateral upper extremities ... (He/she) is limited by fatigue and orthostasis, and requires slow transitions from supine-to-sit and sit-to-stand. (He/she) is limited by fatigue and orthostatic [MEDICAL CONDITION]." Hospital course while at (rehabilitation hospital)... Cardiovascular- (Resident name) has a history of [DIAGNOSES REDACTED] with significant orthostatic [MEDICAL CONDITION] related to (his/her) Parkinsonism. (He/she) had been started on [MEDICATION NAME] in (Therapeutic Class: Anti hypotensive Vasopressor) the acute hospital on the day of transfer... [MEDICATION NAME] was titrated to a stepped dose of 7.5mg at 6 am, 10mg at 10 am, and 5mg at 2 pm ... The patient's blood pressure should be monitored to avoid supine hypertension. On (his/her) current regimen (his/her) blood pressure on routine vital signs ranged from 120s to 145. (His/her) dose of [MEDICATION NAME] should be decreased if (his/her) systolic blood pressure is routinely going above 150 or if (he/she) is symptomatic with headaches or chest pain. (He/she) will need continued monitoring and adjustment of these medications after discharge. " The history and physical dated [DATE] revealed that Resident #262's [DIAGNOSES REDACTED]. Resident was admitted to the skilled nursing facility on [DATE] for skilled speech, occupational and physical therapy. According to the admission MDS (Minimum Data Set) dated [DATE], the resident was coded under Section G0300 - (Functional Status) Balance during Transitions and Walking as "Not steady, only able to stabilize with human assistance when moving from seated to (a) standing position. The physician's admission orders [REDACTED]. Please reduce dosing if patient is experiencing supine hypertension. [MEDICATION NAME] (Tylenol- [MEDICATION NAME]/antipyretic) 325mg- 2 (two) tabs po (every) 6 hours as needed for pain. " An interim physician's orders [REDACTED]. " There was no evidence that the physician included parameters for monitoring the blood pressure and pulse rate for orthostatic [MEDICAL CONDITION]. A review of the electronic nursing notes revealed the following: "[DATE] at 2:50 AM- ,[DATE] (blood pressure), 78 (apical pulse), 20 (respirations), 97.6 (temperature) [DATE] at 11:06 PM - Temp (temperature) 98.2, 72(Pulse), ,[DATE] (Blood Pressure), Resident had c/o (complaint of) headache and Tylenol PRN medication was offered but resident refused to take. No other distress noted at this time. [DATE]- Night shift - No vital signs recorded. [DATE]- Day shift -No vital signs documented. [DATE]- Evening- No vital signs documented. [DATE]- Night shift- 12:03 AM, Temp 98.3- Pulse-88, Blood Pressure-,[DATE], Respiratory Rate-20 [DATE]- Night shift-2:53 AM -,[DATE] (Blood Pressure), 70 (apical pulse), 98.3 (temp), 20 (respiratory rate). [DATE]- Evening shift at 5:13 PM - 98.2 Temp, 84- Pulse, Respiration Rate-20, Blood Pressuere-,[DATE]. Resident is sitting in wheelchair with bedside table near and call light within reach. [DATE]- Day shift- No vital signs documented. [DATE]- Night shift-at 3:14 AM-,[DATE] (Blood Pressure), 77 (Pulse), 20-(Respiratory Rate), Temp- 97.8. [DATE]- No vital signs documented. [DATE]- Evening shift at 9:54 PM- ,[DATE] (Blood Pressure), 78 (Pulse), 97.6 (Temperature) [DATE]- Night shift - no vital signs documented. [DATE]-Night shift at 02: 04 AM- ,[DATE] (Blood Pressure), 78 (Apical Pulse), 97.3 (Temperature), 18 (Respiratory Rate) [DATE]- Evening shift at 3:26 PM- ,[DATE](Blood Pressure), 74 (Pulse), 18 (Respiratory Rate), 97.0 (Temperature) [DATE]- Evening shift at 11:25 PM- ,[DATE] (Blood Pressure), 84 (Pulse), 20 (Respiratory Rate), 98.3 (Temperature) [DATE] - Night shift at 2:37 AM- ,[DATE](Blood Pressure), 80 (apical pulse), 97.9 (Temperature), 20 (Respirations) [DATE]- Night shift- No vital signs documented. [DATE]- Day shift- No vital signs documented. [DATE]- Evening shift- No vital signs documented. [DATE] at 4:26 PM- Writer was called to room because resident (was) unresponsive. V/S (Vital Signs): Temperature 97.4, Heart Rate-114, Respiratory Rate- 12, Oxygen Saturation- 64%. CPR (Cardiopulmonary Resuscitation) started, 911, and MD (Medical Doctor) called and gave order to transfer resident to hospital for unresponsiveness. Resident left unit via EMT (Emergency Medical Team) at 1:15 PM." There was no evidence that the resident's blood pressure was obtained at the time of the transfer to the hospital. A review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) revealed the following vital signs/medication: " [DATE]- Tylenol administered (no time indicated) - Reason- c/o (complaint of) headache- pain assessed as " ,[DATE]. " Result- effective - " ,[DATE]. " No blood pressure or pulse documented. [DATE]- No vital signs recorded on night shift [DATE] - Day shift -vital signs documented- not legible to read. [DATE]- Evening shift -,[DATE] (Blood Pressure) [DATE]- Evening shift - writing not legible to read [DATE]- Day shift- ,[DATE] (Blood Pressure) - Pulse- writing not legible to read [DATE]- Evening shift- ,[DATE] (Blood Pressure)- Pulse- writing not legible to read [DATE]- Night shift -writing not legible to read [DATE]- Night shift- Blood Pressure - ,[DATE] [DATE]- Day shift- Blood Pressure: ,[DATE]- Pulse-60 [DATE] - Evening shift- Blood Pressure - ,[DATE]. [DATE]- Day shift according to MAR- ,[DATE] (Blood Pressure "0," No pulse documented." There was no evidence in the clinical record that the attending physician or nurse practitioner was informed of Resident #262's complaint of a headache on [DATE]. In addition, the resident's blood pressure(s) was not taken every shift as prescribed. When the blood pressures were taken, there was no evidence that the staff obtained orthostatic blood pressures as ordered by the physician. A review of the Doctors Progress notes revealed: [DATE]- Nurse Practitioner's note - "... admitted to NH (nursing home) after hospital ... (Treatment) of [MEDICAL CONDITION] with significant [DIAGNOSES REDACTED], Dementia,[MEDICAL CONDITION](Gastro [MEDICAL CONDITION] Reflux Disease) ... Orthostatic [MEDICAL CONDITION], UTI (Urinary Tract infection) with ESBL (Extended Spectrum Beta-Lactamase) E. coli (Escherichia Coli). Alert- Weak." [DATE] - "... Transferred to NH (nursing home) for further OT (Occupational Therapy), PT (Physical Therapy) and SLP (Speech Language Pathology)." Problem List: "Old (and) Chronic Problems ... Orthostatic [MEDICAL CONDITION]. Physical Examination: Temp (Temperature)- 97.6, Pulse-74, (Respiratory Rate) - 16, (Blood Pressure) - ,[DATE]." [DATE]- Nurse Practitioner's note- "(Patient) with recent UTI (with) ESBL- (status [REDACTED]. Plan... Calcium with Vitamin D ,[DATE]- one QD (everyday). " There was no evidence in the clinical record that the attending physician or nurse practitioner addressed the status of the Resident #262 ' s Orthostatic [MEDICAL CONDITION] in the total plan of care. Facility staff inconsistently and/or failed to assess the resident's orthostatic blood pressure as prescribed and there was no evidence that the medical team questioned clinical staff regarding the lack of orthostatic blood pressure assessments. A face-to-face interview was conducted with Employee #2 on [DATE] at approximately 3:46 PM. After reviewing the clinical record. He/she acknowledged the aforementioned findings. A follow-up telephone interview was conducted with Employee # 32 on [DATE] at approximately 2:18 PM in the presence of Employees #1 and 2. Employee #32 acknowledged that parameters may have been indicated for the orthostatic blood pressure reading(s). It was further stated that orthostatic blood pressure(s) are generally initially taken in the supine position before assuming a standing position. " In conclusion, there was no evidence that the facility consistently assessed and monitored Resident #262's orthostatic blood pressure and pulse (who had a [DIAGNOSES REDACTED]. In addition, there was no evidence that the facility staff indicated the position of the resident when the orthostatic blood pressure and pulse were reportedly obtained or notified the physician regarding the resident's complaint of a headache. On [DATE], the resident was found unresponsive and was transferred to the nearest emergency room via 911. The clinical record was reviewed on [DATE].

Based on staff interview and record review for one (1) of seven (7) residents, it was determined that facility staff failed to consistently assess and document worsening venous stasis ulcer. Resident #3 The findings include: Resident #3 was [AGE] years old and admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of December 12, 2013, Resident #3 achieved a score of 9/15 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 " mild cognitive impairment. " Resident #3 was assessed as requiring extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and totally dependent for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. A left anterior leg venous stasis ulcer was identified on April 12, 2013. Venus stasis ulcer measurements were consistently documented weekly. The following wound measurements were reviewed: December 4, 2013 7.7 cm x 4.3 cm x 0.1 cm December 11, 2013 8.9 cm x 6.9 cm x 0.1 cm December 18, 2013 9.1 cm x 6.7 cm x 0.1 cm The above cited weekly venous stasis ulcer measurements were completed by the wound team. According to the December 2013 Treatment Administration Record revealed that the unit nurses completed the venous stasis ulcer treatment twice per week. There was no evidence that the unit nurse assessed and documented the status of the venous stasis ulcer when the treatments were completed. The venous stasis ulcer had subsequently increased in size from December 4, 2013 through December 18, 2013. Venous stasis ulcer measurements on February 24, 2014 were 4 cm x 6.5 cm x 0.2 cm with 100% granulation of the tissue. According to a physician's order [REDACTED]. " According to a physician's order [REDACTED]. " The resident ' s care plan was reviewed and found to include appropriate interventions after the weekly wound team assessment. The nutritionist reviewed Resident #3 ' s status and recommended changes as appropriate for nutritional support to promote wound healing. There was no evidence that facility staff performing bi-weekly venous stasis ulcer treatment assessed and documented the status of a worsening venous stasis ulcer from . The record was reviewed February 27, 2014.

Based on staff interview and record review for two (2) of seven (7) residents, it was determined that facility staff failed to consistently assess and document worsening pressure sores. Residents #1 and 2 The findings include: A face-to-face interview was conducted with Employee #1 was conducted on February 27, 2014 at 11:30 AM. He/she stated, " The wound team sees every wound weekly. The wound nurse does the treatments daily to the stage three and four wounds. The unit nurses do the daily treatments on all the stage two wounds. We have nothing in place to direct the unit nurses to document their assessments when there is a change in the status of the wound. If there is a change that the wound team finds on their weekly rounds, there should be some assessment by the unit nurses about the status of the wound during the week and that should be documented. " 1. Facility staff failed to consistently assess and document Resident #1 ' s worsening sacral pressure sore. Resident #1 was [AGE] years old and was admitted to the facility on [DATE]. According to the admission Minimum Data Set assessment dated [DATE], Resident #1 was identified with long and short term memory problems with severely impaired cognitive skills for daily decision making in Section C (Cognitive Patterns). Resident #1 was assessed as requiring supervision for eating and limited assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility with a Stage II sacral pressure sore that progressed as follows: September 26, 2013 1.9 cm x 1.2 cm x 0.1 cm October 2, 2013 4.2 cm x 8.7 cm x 0.1 cm October 8, 2013 10.7 cm x 13.4 cm x 0.1 cm physician's order [REDACTED]. admission orders [REDACTED]. " Physician ' s telephone orders dated October 2, 2013 at 11:30 AM and signed by the physician on October 8, 2013 directed: " Cleanse sacral ulcer with normal saline, pat dry, apply skin prep to peri wound and collagen to wound base daily x 14 days. Cover with foam dressing. Secure with tape. " Telephone orders dated October 8, 2013 at 4:30 AM signed by the physician on October 8, 2013: " 1. D/C all previous treatments to sacral ulcer. 2. Cleanse sacral ulcer with wound cleanser, pat dry, apply skin prep to peri wound and Santyl ointment and [MEDICATION NAME] powder to wound base daily x 14 days. Cover with foam dressing. " According to the September and October 2013 Treatment Administration Record the above cited treatment was administered daily. The resident ' s care plan was reviewed and found to include appropriate interventions. The nutritionist reviewed Resident #1 ' s status and recommended changes as appropriate for nutritional support to promote pressure sore healing. There was no evidence that facility staff performing the pressure sore treatments assessed and documented the status of a worsening Stage II sacral pressure sore between the wound team's assessments from September 26, 2013 and October 9, 2013. The record was reviewed February 27, 2014. 2. Facility staff failed to consistently assess and document when Resident #2 ' s sacral pressure sore increased in size. Resident #2 was [AGE] years old and was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of January 1, 2014, Resident #2 was assessed with [REDACTED]. Resident #2 was assessed as requiring extensive assistance with dressing and eating and totally dependent for bed mobility, transfers, toilet use, personal hygiene and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to the nurses ' notes, a sacral pressure sore was identified on January 21, 2014 and measured " 2.3 centimeters (cm) x 1 cm " . On January 27, 2014 the pressure sore measured " 4 cm x 2.5 cm x unable to determine with 95% slough and tunneling. " According to the physician's order [REDACTED]. " A physician's order [REDACTED]. " According to the January 2014 Treatment Medication Record, the pressure sore treatment was completed on January 24, 2014. There was no evidence that the nurse assessed and documented the status of the sacral pressure sore when the wound treatment was done on January 24, 2014. Subsequently the pressure sore had increased in size as cited above. Pressure sore measurements for February 24, 2014 were 3 cm x 2 cm x 0 cm with tunneling and 100% granulation of the tissue. The resident ' s care plan was reviewed and found to include appropriate interventions. The nutritionist reviewed Resident #2 ' s status and recommended changes as appropriate for nutritional support to promote pressure sore healing. There was no evidence that facility staff performing the pressure sore treatments assessed and documented the status of a worsening Stage II sacral pressure sore between the wound team's assessment from January 21, 2014 through January 27, 2014. The record was reviewed February 27, 2014.

Based on staff interviews and record review for Resident #1, it was determined that facility staff failed to adequately supervise the resident ' s transfer which subsequently resulted in the resident sustaining a bilateral mallelor right ankle fracture. The findings include: Resident #1 was born on December 20, 1917 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment completed September 16, 2011. Resident #1 was assessed with [REDACTED]. He/she was assessed as being totally dependent for all activities of daily living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. " Late entry for November 15, 2011 " dated November 16, 2011 at 6:31 PM: " Writer was notified by charge nurse with care giver explanation - care giver was putting resident to bed with Hoyer lift, resident was sitting in the wheelchair. While lifting and moving resident to bed, his/her right leg got twisted. Upon assessment resident ' s right leg swollen and painful to touch. No open area noted. Circulation good with pedal pulse palpable. Resident started on pain management Tylenol for pain and ice pack applied to reduce swelling. (Physician) and RP notified. MD ordered right leg X-ray. " An x-ray was taken of the right ankle on November 16, 2011 at 1:28 PM and reported the following: " Bimalleolar fractures with swelling present. " A review of the facility ' s policy, " Lifting and Transferring Resident, " policy number NSD04-091, page one (1) of three (3), under " Policy - Mechanical lift procedures are used on any resident who is obese or deemed unsafe for a two person manual transfer. Residents that require assistance with transfers from bed to wheelchair or back into bed will be assisted by two nursing staff members. " A telephone interview was conducted with Employee #1, on November 23, 2011 at 9:13 AM who stated, " I transferred (Resident #1) myself with the Hoyer lift. I knew I shouldn ' t have done that by myself. I thought I could get (the resident) to bed and settled and then do my other residents. It wasn ' t busy that night, nothing special was happening. I was working evening shift, I usually work night shift. I transferred (Resident #1) from the wheelchair to the bed and his/her foot caught in the foot pedal and twisted and he/she hollered. I have never had any incident happen with a resident. I am really sorry. I should never have tried to transfer (the resident) by myself. " A review of Employee #1 ' s personnel file revealed that he/she was hired on March 14, 2011. A criminal background check was completed February 2, 2011 with no findings. Employee #1 demonstrated competency in using the mechanical lifts on March 14, 2011 and November 22, 2011. Employee #1 had no negative personnel actions in his/her file. Facility staff failed to adequately supervise the resident ' s transfer which subsequently resulted in the resident sustaining a bilateral mallelor right ankle fracture. The record was reviewed November 19, 2011.

Based on record review and staff interview for Resident #1, it was determined that facility staff failed to monitor and document assessments for bruising and/or bleed for a resident receiving [MEDICATION NAME]. The findings include: Resident #1 was born on May 18, 1939 and was admitted to the facility on [DATE]. According to the admission Minimum Data Set assessment completed September 21, 2010, he/she was assessed with [REDACTED]. He/she was assessed as being totally dependent for bed mobility, transfers, dressing, toilet use, requiring extensive assistance for personal hygiene and bathing and independent for eating in Section G (Physical Functioning and Structural Problems). Disease [DIAGNOSES REDACTED]. According to the physician ' s admission orders [MEDICATION NAME] ([MEDICATION NAME]) 5 mg po q HS (orally at bedtime). " A PT/INR ([MEDICATION NAME] Time/ International Normalized Ratio) laboratory result dated September 10, 2010 was 58.7 (normal range 12 - 15 seconds). The physician ordered " [MEDICATION NAME] 5 mg po q HS. Hold x 2 days Resume when INR therapeutic " on September 10, 2010. Therapeutic range was defined as between 2 and 3 seconds as per the standards printed on the laboratory report. The therapeutic range for INR remained above 2 to 3 seconds from September 10 through 21, 2010. On September 21, 2010, the INR was 2.38. According to the September and October 2010 Medication Administration Record, [REDACTED]. Entries in the " [MEDICATION NAME] Management and Monitoring Record " for September 13, 14 and 16, 2010 noted the resident had no signs or symptoms of bruising or bleeding. There was no evidence in the " [MEDICATION NAME] Management and Monitoring Record " or the nurses ' noted from September 22 through October 4, 2010 that facility staff assessed Resident #1 for bruising or bleeding while he/she was receiving [MEDICATION NAME]. Upon admission, the physician's order [REDACTED].e. bruises, scratches, skin breakdown or discoloration). Record abnormalities in nurses ' notes every Monday. " The order was not transcribed onto the September 2010 Treatment Administration Record. According to the October 2010 Treatment Administration Record a " Head to toe skin assessment for any abnormalities (i.e. bruises, scratches, skin breakdown or discoloration). Record abnormalities in nurses ' notes every Monday " was conducted on October 4, 2010. There was no entry in the nurses ' notes regarding the resident ' s skin condition. A nurse ' s note dated October 5, 2010 at 3:00 PM documented: " Resident was noted with bruises on the stomach, left side 5 x 5 cm and right side 9 x 6 cm. PMD informed. He ordered to repeat PT/INR stat, CBC for perfusion, and monitor resident for any signs of bleeding. If any noted send resident out to ER via 911. Presently no bleeding noted. " A nurse ' s note dated October 5, 2010 at 8:00 PM documented: " PT INR stat, CBC done, lab results received. PT >10 and (physician) made aware and gave an order to send resident out secondary to huge subcutaneous bleeding ... " According to the " 2009 Lippincott ' s Nursing Drug Guide " page 1221, " Black box Warning: Evaluate patient regularly for signs of blood loss (petechiae, bleeding gums, bruises, dark stool, and dark urine) ... " A face-to-face interview was conducted with Employee #1 on October 28, 2010 at 3:00 PM. He/she acknowledged that the admission order to assess the resident ' s skin weekly was not transcribed and that there was no documentation that the nurses ' assessed the resident for bruising and/or bleeding during the time Resident #1 was receiving [MEDICATION NAME]. The record was reviewed October 28, 2010.

Based on record review and staff interview for Resident #1, it was determined that the physician failed to adequately monitor the PT/INR values for a resident receiving [MEDICATION NAME]. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the physician ' s admission orders [MEDICATION NAME] ([MEDICATION NAME]) 5 mg po q HS (orally at bedtime). " A PT/INR ([MEDICATION NAME] Time/ International Normalized Ratio) laboratory result dated September 10, 2010 was 58.7 (normal range 12 - 15 seconds). The physician ordered " [MEDICATION NAME] 5 mg po q HS. Hold x 2 days Resume when INR therapeutic " on September 10, 2010. Therapeutic range was defined as between 2 and 3 seconds as per the standards printed on the laboratory report. The therapeutic range for INR remained above 2 to 3 seconds from September 10 through 21, 2010. On September 21, 2010, the INR was 2.38. On September 21, 2010, the physician ordered, " [MEDICATION NAME] 4.5 mg po at 6 PM. PT/INR in two weeks. " According to the September and October 2010 Medication Administration Record, [REDACTED]. According to the pack insert for [MEDICATION NAME]: " Laboratory Control: The PT should be determined daily after the administration of the initial dose until PT/INR results stabilize in the therapeutic range ...To ensure adequate control, it is recommended that additional PT tests be done ...whenever other medications are initiated, discontinued or taken irregularly ... " (http://packageinserts.bms.com) " The resident had not received [MEDICATION NAME] from September 9 through September 21, 2010, a total of 12 days. There was no evidence that the physician ordered daily PT/INR laboratory tests after the medication was initiated on September 21, 2010 as per the manufacturer ' s recommendations. The resident was hospitalized on [DATE] for [MEDICAL CONDITION]. He/she returned to the facility on the same day. A urinalysis was completed while the resident was in the hospital and showed a moderate amount of blood in the urine. (Normal range is no blood in the urine.) When the resident returned from this hospitalization , the physician ordered a Basic Metabolic Panel (blood test) but did not order a PT/INR. The record was reviewed October 28, 2010.