**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, for one (1) of 19 sampled residents, the facility's staff failed to provide care consistent with professional standards of practice to promote healing of Resident #2's Moisture Associated Skin Disorder (MASD). Subsequently, Resident #2's sacrum MASD declined to a Stage III pressure ulcer/injury. These failures resulted in actual harm to Resident #2 when it was determined that the resident's Moisture Associated Skin Disorder to the sacrum, first observed on (04/20/2022) was not treated in accordance with the Nurse Practitioners recommendation. Seven days later, the skin disorder further declined, and the resident was observed with a Stage III pressure ulcer/injury to the sacrum. The findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Cerebral Vascular Accident, Hemiplegia affecting Left Side, Generalized Weakness, and Diabetes Mellitus. Review of District of Columbia Department of Health's Intake Information form dated 07/07/22 documented, [Resident's name] . [had an] infected bedsore . the nurses there neglected to their job, the bedsore was not being treated properly . Review of the resident's medical record showed the following: 12/08/21 {Phuysican order] directed, Cleanse sacrum with soap and water, pat dry, apply A&D ointment TID (three-times-a-day) for protection. 02/15/22 [Significant Change Minimum Data Set] showed the following: Section C (Brief Interview for Mental Status Summary Score) documented the resident had a score of 9 indicating that the resident had moderately impaired cognition. Section E (Behavior) did not code the resident for rejection of care. Section G (Functional Status) coded the resident as requiring extensive assistance from two (2) staff members for bed mobility, being totally dependent on two staff members for toilet use, being totally dependent on staff for bathing, and using a wheelchair as a mobility device. Section GG (Functional Abilities and Goals) coded the resident as always being incontinent of bowel and bladder and not being on a toileting program. And Section M (Skin Conditions) coded the resident for being at risk for developing pressure ulcers and injuries but did not have any at the time of assessment. 04/07/22 [Braden Scale for Predicting Pressure Score Risk] documented the resident had a score of 10 indicating that Resident #2 was at risk for developing pressure ulcers/injuries. 04/07/22 to 04/20/22 [Treatment Administration Record] showed, the nursing staff was providing care per the following order [start date of 12/08/21], Cleanse sacrum with soap and water, pat dry, apply A&D ointment three-times-a-day (6 AM, 2 PM, and 10 PM). 04/20/22 at 12:07 PM [Skin Evaluation] form assessed by Employee #16 (License Practical Nurse/LPN) showed, . sacrum MASD (Moisture Associated Skin Damage) . size - length 2.5 centimeters and width 2.5 centimeters . description - slough not applicable, 100% pink granulating tissue, no drainage, no cellulitis, no foul smell, .Treatment - Z guard cream plus [and] A&D ointment three-times-a-day and as needed . Nurses Notes: Resident was observed with opening on sacrum during ADL (activities of daily living) care by assigned CNA (certified Nurse Aide) .Resident denies pain on assessment. NP (Nurse Practitioner made aware, new order received for Z guard plus [and] A&D ointment tid and prn . (Zguard is indicated to protect minor skin irritation associated with diaper rash and to help seal out wetness. Also protects and helps relieve chapped or cracked skin. https://www.woundsource.com/product/remedy-phytoplex-z-guard-skin-protectant-paste) Review of the physician's orders and the TAR from 04/20/22 to 04/26/22 lacked documented evidence that Z guard cream plus was ordered to treat the resident's MASD. 04/20/22 to 04/26/22 [Treatment Administration Record] showed, the nursing staff was providing care per the following order [start date of 12/08/21], Cleanse sacrum with soap and water, pat dry, apply A&D ointment three-times-a-day (6 AM, 2 PM, and 10 PM). However, there was not documented evidence that nursing staff applied Z-guard. 04/26/22 at 9:00 AM [Physician Progress Note]- eating 25-50 % .no skin breakdown .left sided weakness and contracted . It should be noted, that the physician's note of 04/26/22 at 9:00 AM records that the resident has no skin breakdown, however the resident was noted with MASD to her sacrum on 04/20/22. 04/27/22 at 12:31 PM [Nursing Progress Note] documented - Sacrum Stage 3 measured 4X2 centimeters (length), 4X8 centimeters (width), 40% slough, pink granulating 60%, no cellulitis, mild serous drainage. New order received for [NAME] Na cream plus Santyl ointment two-times-a-day and as needed cover with Allevyn Life (foam dressing), [resident representative name] made aware . 04/27/22 at 20:40 (8:40 PM) [Physician Consult Record] documented, Report- Sacrum Stage 3, 4.2 X 4.8 cm (centimeters), slough 40 %, pink granulation 60 %, mild serious drainage) cellulites. Recommendations - Salna +Santyl bid (two-times-a-day) and prn (as needed), cover with bordered dressing. 04/27/22 at 22:00 (10:00 PM) [Physician Order] directed, Cleanse sacrum wound with normal saline, pat dry, apply [NAME] cream and Santyl ), cover with Allevyn life, twice a day [and] as needed . There was no evidence that facility staff provided the treatment as prescribed by the NP recorded in the Skin Evaluation form dated 04/20/2022. Review of Resident #2's care plan dated 08/30/21 revealed the following: Problem - Pressure Ulcer/Skin Prevention) documented [resident's name] is at risk for pressure injury secondary to her decreased mobility, incont [incontinence] and inability to toilet herself. Goal - [resident's name] will maintain skin integrity without new skin related injures over the next review period. The care plan outlined multiple interventions including observe skin for redness and breakdown during routine care, and [provide] treatment as ordered when needed . During a face-to-face interview on 11/07/22 at approximately 9:00 AM, the resident's physician stated that she was not aware that Resident #2 had MASD wound. However, she was informed by the nursing staff that the resident had a Stage III sacral wound on 04/27/22 at which time she assessed and gave treatment orders. During a face-to-face interview on 11/08/22 at approximately 10:30 AM, Employee #2 (Director of Nursing) stated she did not see where the staff had provided the treatment for Z guard. There was no evidence that facility staff implemented the comprehensive care plan intervention, [provide] treatment as ordered when needed . when they failed to transcribe the physician's order to apply Z guard to Resident #2's sacrum MASD when it was first identified on 04/20/2022. Subsequently, within seven days (04/27/22), Resident #2's sacrum MASD declined to a Stage III pressure ulcer/injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, that record reviews and interviews, for four (4) of 19 sampled residents, the facility's staff failed to ensure that Resident #1 received adequate supervision to prevent a fall with injury (subdural hematoma) on 11/18/21. Subsequently, following the fall, the resident required surgery repair (left decompressive hemi-craniotomy for evaluation of subdural hematoma). Failed to ensure that: Resident #3 received adequate supervision to prevent an elopement on 03/10/22; Resident #4 was secure in mechanical lift during a transfer which led to the resident having an assisted fall with minor injury (pain) on 06/22/22; and Resident #5 was not secured in bed which led to fall without injury on 09/30/22. (Residents' #1, #3, #4 and #5) These failures resulted in actual harm to Resident #1 The findings included: 1. The facility's staff failed to ensure Resident #1 received adequate supervision to prevent a fall with injury (subdural hematoma) on 11/18/21. Subsequently, following the fall, the resident required surgery repair (left decompressive hemi-craniotomy for evaluation of subdural hematoma). Resident #1 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including history of falls, muscle weakness, generalized osteoarthritis, age-related debility, hypertension and epilepsy. Review of Resident #1's medical history prior to admission to the facility revealed a computed tomography scan (CT scan of the resident's head) which showed no cranial abnormalities. A review of the District of Columbia's complaint intake #DC00010417 documented, Did the [resident] suffer any physical injuries? Yes, brain clot surgery [local hospital's name] 11/19/21 . Complaint: 09/18/21- first fall .explanation of injury didn't match what I expected when I saw him [Resident #1] in a video chat. 10/23/21- he [Resident #1] fell again not going to hospital .11/18/21 he fell again doctor wants him to go to the hospital .admitted and had surgery [left decompressive hemi-craniotomy] on 11/19/21 .three falls are two too many should have had a better safety plan for patients [residents]. He came their [there] with a history of fall from 1/2021 .not sure how many other times he fell not witnessed [brain blood] clot is [was] older and during the time he was in the nursing home. Review of the policy tilted, Fall Policy with a last approval date of 01/2022 instructed staff complete the [NAME] II Fall Risk (or similar fall risk evaluation) during admission and quarterly . Review of medical record showed the following: 05/13/21 - The record lacked documented evidence the facility's staff completed a [NAME] II Fall Risk (or similar fall risk evaluation) during the resident's admission. 08/10/21- [Quarterly Minimum Data Set] documented, under Section C (Cognitive Pattern) Resident #1 had a Brief Interview for Mental Status summary score of 9, which suggested that the resident had a moderately impaired cognitive status. Under section E (Behavior)- the resident was not coded for rejection of care. Under section G (Functional Status) the resident was coded for needing extensive physical assistance from one staff person for transfers between surfaces and toilet use, the resident required supervision from one staff member for walking in his room. And used an assistive device (walker) for mobility. Under Section J (Health Condition) the resident was coded for not having any fall since admission. Under Section O, the resident was not coded for receiving physical or occupational therapy services, And Under Section P (Restraints and Alarms) the resident was not coded for using any restraints or alarms. 08/01/21 to 08/31/21- the record lacked documented evidence the facility's staff completed a quarterly [NAME] II Fall Risk (or similar fall risk evaluation). Review of Resident #1's care plans showed the following: Care Plan Problem: [Resident #1's name] requires assistance with related to pain, dementia, and depression with an initial date of 09/02/21. Continue review of the care plan revealed multiple interventions including need extensive assistance with transfers, keep environment clean, clutter free and provide adequate light, keep personal items within reach, complete fall risk quarterly and as indicated. Care Plan Problem -Falls with an initial date of 09/03/21. Interventions included physical and occupational therapy consult as needed 09/18/21 at 4:46 PM [Nursing Progress Note (1st documented fall)] documented, at about 4:30 PM resident was observed on the floor in a supine position in the hallway in front of his room with his walker close by. Resident was observed walking in the hallway towards his room then tripped and fell. Resident stated that he went to get a blanket .tripled [tripped] on his walker and fell. Sustained skin tear to right upper eyelid, swollen measured 3 cm (centimeter) X 0.6 (cm) with minimal bleeding, pressure and ice applied. Resident complained of pain on right eye lid. Dr notified .transfer to ER (emergency room) for further evaluation and treatment . Review of the [NAME] II showed that on 09/18/21 at 5:37 PM the resident had a score of 7 indicating he was a high risk for having falls. 09/19/21 at 10:49 AM [Hospital Discharge Summary] documented, reason for visit- fall and head injury. Diagnoses - multiple closed fractures of facial bone, subdural hematoma, facial hematoma, and facial laceration .you have been seen for a subdural hematoma. On your CT scan it does not look recent and was not caused by today's fall. It was probably from another fall or minor injury at some point in the last few weeks or months . 09/19/21 at 1:55 PM [Nursing Progress Note] documented, resident returned to the facility at 12:00 noon from [local hospital's name] where he was transferred after being observed on the floor .He is alert and verbally responsive .has periods of confusion .steri-strips noted to the lateral area of right brow with no active bleeding, no swelling, no bone protrusion. Discoloration also noted especially around the right eye and right lower eyelid area . 09/19/21 [Hospital After Visit Summary] documented, Reason for visit- fall and head injury. Diagnoses - multiple closed fractures of facial bone, subdural hematoma, facial hematoma, and facial laceration .you have been seen for a subdural hematoma. On your CT scan it does not look recent and was not caused by today's fall. It was probably from another fall or minor injury at some point in the last few weeks or months . 10/23/21 at 10:41 PM [nursing progress note (2nd documented fall)]- at 10:20 PM writer was called by assigned CNA (certified nursing assistant) to report an unwitnessed fall, upon arrival to residents room, resident was found in a sitting position by his chair in his room, when asked what happened stated, I was trying to get up [but] didn't give any other information .head to toe assessment done .no acute distress .initiated neuro-checks .alert but oriented X1 .educated to always call for assistance and verbalized understanding . Care Plan Problem- Falls with an initial date of 10/23/21. Interventions included physical/occupational therapy screen post fall, resident will be queuing to always call for help before any transfer and keep room clutter free, dry floor, and low bed. 11/02/21 [Quarterly Minimum Data Set] documented, under Section C (Cognitive Pattern) Resident #1 had a Brief Interview for Mental Status summary score of 4, which suggested that the resident had a severely impaired cognitive status. Under section E (Behavior)- the resident was coded for rejection of care behavior that occurred 1 to 3 days a week. Under section G (Functional Status) the resident was coded for needing extensive physical assistance from one staff person for transfers between surfaces and toilet use, the resident required supervision from one staff member for walking in his room. And used an assistive device (walker) for mobility. Under Section J (Health Condition) the resident was coded for having one (1) fall with no injury since his admission. Under Section 0 the resident was the resident was coded for receiving occupational therapy services. And, Under Section P (Restraints and Alarms) the resident was not coded for using any restraints or alarms. It should be noted that Section J of the MDS dated [DATE] is inaccurately coded under section J as the resident had two falls within this look back period. 11/17/22 at 11:50 PM [Professional Communication Form (3rd documented fall)] documented, .fall .resident hit his head . temperature 97.1, pulse 56, respirations 20, blood pressure 108/62, pulse ox 98% on room air .resident was more confused, change in behavior, insomnia .transfer to hospital . 11/18/21 at 3:08 AM [Nursing Note] documented, .at 11:50 PM CNA (certified nursing assistant) called to this write's attention and reported resident was observed on the floor .resident was lying on the floor near his bed, [resident's] head was very closed (sp) to the dresser, on assessment noted on the top of his head skin was scrapped, resident was aert [alert] and verbally responsive, [Resident #1] stated [he was] trying to get his socks. 11/18/21 at 5:41 AM [Supervisor Nursing Note] documented, called received for 2nd Floor charge nurse at 11:50 PM that resident was observed lying on the floor close to dresser at the foot of the bed .upon arrival, resident observed in bed resting, with abrasion measured 1 cm (centimeter) X 2 cm not at top of his head .resident stated I was trying to get my socks from the dresser .for work .then I fell , bending down .and hit my head on the dresser .head to toe assessment completed .resident denied pain. Neurological assessment implemented and no changes from resident baseline . Care plan Problem- Fall with an initial date of 11/18/21. Interventions included transfer resident to ED (emergency department) for further evaluation, monitor sleep pattern X 1 week, anti-roll back wheelchair for safety when out of bed, and corner guard applied to edges of furniture in resident's room. 11/20/21 at 1:39 PM [Nursing Progress Note] documented, . the ER (emergency room) nurse informed writer that resident was admitted [to] .medical surgical ICU (intensive care unit) on 11/18/21, and ICU nurse informed writer that there was no discharge plan for resident yet. 12/02/21 at 7:59 PM [Nursing Progress Note] documented, resident .re-admitted to facility at about 2:30 PM from [local hospital's name] after being treated for subdural hematoma evacuation after a fall .he is alert, awake, oriented to self .resident was re-admitted to the unit with diagnoses of subdural hemorrhage .left side of head surgical site sutures intact, dry and healing progresses well . 12/02/21 [Hospital Discharge Summary]-CT head shows bilateral subdural hematomas. Pt taken to the operating room for left decompressive hemi-craniotomy for evacuation of subdural hematoma. 11/19/21- admitted to surgical intensive care unit status-post fall with bilateral SDH (subdural hematoma) L > R with left to right shift. Radiology review details shows .Bilateral subdural hematoma (subacute/chronic with questionable acute superimposed subarachnoid hemorrhage versus artifact .There is a mild rightward midline shift .Discharge Diagnosis - Subdural Hemorrhage present on admission. A review of rehabilitation notes showed an occupational therapist progress and discharge summary note dated 11/23/2021, documented, the resident started care from 09/21/21 to 11/18/22 .Indoor mobility (ambulation) -resident needed partial assistance of another person to complete activities .functional transfer from sit to stand [the resident required] stand by assist (close enough to reach patient if assistance needed) .precautious -falls .patient was unexpectantly discharged to hospital. The complainant stated during a telephone interview on 10/25/22 at approximately 2:30 PM, The staff took insufficient care of my dad (Resident #1). The complaint stated that the resident fell for the first time on 09/18/21. According to the complainant, the staff kept giving her conflicting explanations about the (09/18/21) fall because her dad didn't look like what the nurses described. She said that Resident #1 looked horrible, with a black and blue face, a fractured nose, and an eye fracture. Also, the staff called her an informed that Resident #1 suffered a second fall on 10/23/21, but he did not require a hospital transfer. The complainant also said, Her father had to have an operation to remove a brain blood clot after his third fall on 11/18/22. During a face-to-face interview on 10/28/22 starting at 2:31 PM, Employee #3 (Rehab Director) stated that staff should have provided stand by assist (been no more than an arm length away from resident for safety). When asked, if staff should have been at least an arm length away from Resident #1 with the fall on 10/23/22, Employee #3 stated, yes. Additionally, the employee said that according to the therapy notes Resident #1 was not safe to ambulate independently in his room on 11/18/21. He required the assistance from another person to complete the activity. When asked, how is nursing staff made aware of the recommendation for rehab, Employee #3 stated they are discussed weekly during utilization review meetings. The employee was asked for copies of the utilization review notes at the time of the interview; however, the notes were not provided to the surveyor for review. During a face-to-face interview on 10/29/22 at 5:00 PM, Employee #4 (Occupational Therapist) was asked how was nursing staff made aware that the resident required stand-by-assistance with transfers and assistance from staff with ambulation? The employee said that he made nursing staff aware of the assistance the resident required during a care plan meeting on 09/23/21. Employee #4 also stated that Resident #1 was impulsive. During a telephone interview on 10/31/22 starting at 12:14 PM, the resident's physician stated that Resident #1's daughter brought the resident to the nursing home because he was falling at home. According to the physician, the resident failed to call for help, which led to him falling. The physician stated, How can we control him if doesn't call for help. When we have patients with dementia, they may refuse care (call for assistance from staff). I asked nursing staff for one-to-one care for him [Resident #1], but they told me that they don't have one-to-one services. Additionally, the physician, stated that he could not remember what nurse he talked to about one-to-one services for the resident. During a face-to-face interview on 10/31/22 starting a 12:20 PM, Employee #2 (DON) who was present doing the telephone interview with the previously mentioned telephone interview with the resident physician, said that the physician was right when he said the facility does not offer one-to-one services for residents. The employee was then asked how did you keep Resident #1 safe from falls? The employee said we moved him closer to the nursing station. The employee was then asked how was that an arm length away as recommended by rehab. The employee failed to provide an answer. 2. The facility staff failed ensure Resident #3 received adequate supervision Subsequently, the resident eloped from the facility on 03/10/22. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's Disease and Dementia. Review of a District of Columbia Intake form #DC00010619 documented, .the resident was missing from the unit at 5:15 PM .Another staff from the activity department brought the resident to the unit at 5:30 PM .the resident [was] on 12th [NAME] Street NE (at the entrance of the campus of the facility). Resident was assessed .no skin bruises, discomfort, distress .She thought she could walk outside to get some fresh air on her own . During an observation on 11/03/22 at approximately 10:00AM, Resident #3 was walking around the talking and laughing with other residents. The resident had on a wander/elopement alarm (bracelet) on her ankle. She was oriented to her name only and unable to recall the incident when she wandered away from the facility on 03/09/2022. Further observation showed the unit was secured (locked) with monitors and alarms to capture people entering and exiting the unit. Review of the resident's medical record showed the following: 07/15/21 [Physician Order]- Roam alert for safety monitoring- check placement every shift . 01/31/22 [Quarterly Minimum Data Set] showed Under Section C (Cognitive Pattern) the resident a Brief Interview of Mental Status summary of 3 indicating the resident was severely impaired cognitively. Under Section E (Behavior)- the resident was not coded for refusal behavior. Under Section G (Functional Status)- the resident was coded for activity did not occur for locomotion off the unit, needing supervision of one staff member when walking in the corridor, and needing set-up for walking in her room. Under Section O- the resident was not coded for receiving psychological therapy. Under Section P (Alarms) the resident was coded for using a wander/elopement alarm daily. 03/01/22 to 03/09/22 [Medication Administration Record] showed that nursing staff was checking the placement of the wander/elopement alarm every shift. 03/09/22 at 10:26 PM [Nursing Progress Note] documented, At 4:30 PM this writer noted resident was in her room alert and verbally responsive with her room alert on her right wrist but non-compliant in keeping it on. At 5PM this writer notice resident was not in her room .We searched for the resident .within the unit. While searching .activity personnel show up with resident. She reported that the resident on 12th and [NAME] Street .On assessment [resident] is calm, no distress noted .and without her room alert (wander/elopement device). A new room alert was immediately place on resident and its working properly . 03/09/22 [5 Working Day/Final Report] documented, .Summary of Investigation; Ms. [NAME] left the memory care unit, when a visitor held the door open for her. The following actions are in place to prevent further exits: Notice was sent to RR (resident representative), unit access and exit changed, and staff was re-educated on the elopement prevention process. 03/10/22 at 7:45 AM [Physician Progress Note] documented, Resident was found by staff member outside the building on the street, left outside the unit with some other family member no injuries noted .PT (patient) to keep roam alert (wander/elopement alarm). 03/15/22 at 4:01 PM [Social Work Progress Note] documented, A care plan meeting was held 3/14/22 to address [resident's name] elopement on 03/09/22. In attendance virtually .[two family members names]. How [resident's name] managed to get off the unit was explained: she was unintentionally let out of the unit at 5:13 PM by another resident's family member, she was returned to the unit by staff at 5:27 PM. Family .watched the security footage (video) of the elopement .In order to prevent any future risk of elopement, the security code for the floor has ben changed and will not be disturbed to family or visitors. All visitors to the unit will need to be escorted onto and off the unit by staff .[resident's name] is also wearing a roam alert bracelet. Review of the resident's care plan showed the following: 08/14/21 - Problem- [Resident's name] is at risk for .elopement. Intervention included follow community elopement evaluation and monitoring process . 10/01/21 - Problem - Potential for elopement from the facility secondary to dx (diagnosis of dementia/verbalized intentions to leave the facility. Interventions included apply roam mate bracelet as ordered, access .for potential to wander, replace roam alert if becomes lost, orient to surroundings . 01/07/22 -Problem [Resident's name] has impaired behavior related to exit seeking, hovering around the exit doors (with a start dated on .Interventions included nursing to re-direct resident when standing at the exit door . During a face-to-face interview on 11/03/22 at approximately 3:00 PM, Employee #5 (Activity Assistant) stated that when she was going home for the day, she saw Resident #3 at the back of the hospital (located on the same grounds as the nursing home). She escorted the resident back to the nursing home. During a face-to-face interview on 11/03/22 at approximately 4:30 PM, Employee #1 (Administrator) stated that they looked at the security video and saw that that another resident's family member let Resident #3 out of the unit. When asked, if the alarm went off when resident went through the door, the employee stated no because she did not have her wander/elopement alarm on at the time. She removed the alarm. We put a care plan in place for removing her wander/elopement alarm. 3.The facility's staff failed to ensure Resident #4 was secure in a mechanical lift during transfer which led to the resident having an assisted fall with minor injury (pain). Review of District of Columbia Intake form #DC00010829 dated 06/22/22 documented, .resident was transferred with a full body mechanical left [lift] to the bed to wheelchair with 2 staff .in an attempt to adjust the mechanical pad left underneath her for comfort while in the wheelchair, suddenly resident slide off the wheelchair to the floor in a sitting position in front of her wheelchair .she reported pain to left hip on touch and by nodding her head, no swelling noted, and skin warm and dry to touch. During an observation on 11/10/22 at 8:45 AM showed Resident #4 alert, non-verbal, totally dependent on staff for activities of daily living. When asked about the fall on 06/22/22, the resident hunched her shoulders indicating that she did not know about the fall. Review of the resident's medical record showed the following: Review of Resident #4's care plans showed the following: 08/19/21 - Problem- [Resident's name] needs assistance with daily activities of daily living care. Interventions included .need total assistance with mobility .need one person staff support mobility .use wheelchair device for mobility 08/19/21 - Problem- [Resident's name] has a potential for falls related to hx (history) of seizure activity. Interventions included assist with all transfers and mobility prn (as needed) 05/31/22 [Annual Minimum Data Set] showed the following: Under Section C (Cognitive) Brief Interview for Mental Status summary score of 12 indicating the resident intact cognitively. Under Section G (Functional Status) the resident was coded for extensive assistance from one staff member for transferring between surfaces and uses a wheelchair for mobility. Under Section J (Health Condition) the resident was not coded for fall since her admission to the facility. Under Section O (Special Treatments, Procedures and Programs) the resident was not coded for receiving occupational/physical therapy services. 06/22/22 at 1:09 PM [Nursing Progress Note] documented, Nurse was called to the hallway by resident's assigned CNA (certified nursing assistant) at 11:30 AM .resident was observed sitting on the floor in front of her wheelchair with legs stretched out .about .1:00 PM .resident identified that she is feeling pain now on her left hip. Tylenol 500 mg (milligrams) po (by mouth) was given for pain. Order received for x-ray of left hip . 06/22/22 [Physician Order]- X-ray of left hip for pain post fall. 06/23/22 [Physician Progress Note] documented, Transferred from bed to chair with [name of mechanical lift] but slid and fell to floor . left hip WNL (within normal limits) . Some pain with adduction . Xray of (left) hip negative. Lower back pain on exam. Assessment/plan- status post fall, LT (left) lower back pain, ice TID (three-times-a-day), Naprosyn 500 mg (milligrams) BID (two-times-a-day) for 10 days. X-ray of lower back. 06/23/22- [X-Ray Results of Lumbar Spine] documented, Vertebral bodies are normal .Impressions; mild-to-moderate degenerative changes in lumbar spine . Review of the facility's investigative notes showed the following: 06/22/22 [Incident Witness Statement Form] from assigned certified nursing assistant, documented, We were transferring the incident [resident] in her wheelchair. While we were adjusting the pad to make her comfortable. She started sliding, so we lowered her to the floor in front of her wheelchair . During a face-to-face interview on 11/10/22 at approximately 1:00 PM, Employee #7 (Activity Assistant) stated, Staff was trying to put the resident in her wheelchair. Because the blue sling (used with mechanical lift) was not under the resident properly, she (Resident #4) started to slide forward. When she started sliding forward, I helped the two staff members assist her down to the floor in front of her wheelchair. 4. The facility's staff failed to ensure Resident #5 was safe in bed which led to a fall without injury on 09/30/22. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia, muscle weakness, and need for assistance with personal care. Review of the District of Columbia's Intake Information form #DC00011009 documented, [At 8:00 AM .Resident #5's name was observed lying on the floor beside her bed on her right side with both of her legs stretched out .alert, oriented to name and place .reported she rolled out of the bed to the floor and refused hitting her head .At 9:30 AM resident noted lethargic and difficult to arouse .transferred to [local hospital's name] . An observation was conducted at 10:30 AM on 11/10/22 revealed Resident #5 was lying in bed, on her back and the bed was in high position (from the floor). The head of bed elevated at a 45-degree angle, and quarter side rails in up position. The resident was not eating at the time of the observation. Employee #13 (LPN/Licensed Practical Nurse) was called to the bedside. The employee lowered the bed and stated, She is a fall risk and it's not safe to leave her bed elevated that high. The staff may have left the bed elevated when she was eating. Review of the resident's medical record showed the following: Review of the resident's care plan dated 11/27/21 showed the following: Problem [Resident's name] fell . Further review of the care plan revealed multiple interventions including place bed in lowest position while in bed . 09/20/22 [Quarterly Minimum Data Set] documented, Under Section C (Cognitive) the resident had a Brief Summary Score of 11 indicating the resident was intact cognitively. Under Section E (Behavior) the resident was not coded for rejection of care. Under Section G (Functional Status) the resident was coded for requiring extensive assistance from two or more staff members for bed mobility. Under Section J (Health Condition) the resident was coded for have one fall since admission. Under Section O (Special Treatment, Procedures, and Programs) the resident was coded for receiving occupational therapy services, and Under Section P (Restraints and Alarms) the resident was not coded for using physical restraints or alarms. 09/27/2022 [[NAME] II Fall Risk] documented that the resident has a score of 11 indicating that the resident was a high Risk for falls. 09/30/22 at 11:08 AM [Nursing Progress Note] documented, At 8:00 AM .[Resident #5] was observed lying on the floor beside her bed on her right side with both of her legs stretched out .alert, oriented to name and place reported she rolled out of the bed to the floor and refused hitting her head. Denies pain or discomfort. Resident bed in low position . assisted from the floor by 3 staff to bed via full body mechanical lift . denies dizziness . no apparent injury noted . v/s (vital signs) 117/74 (blood pressure), 78 (pulse), 20 (respirations), 97.5 (temperature) . At 9:30 AM resident noted lethargic and difficult to arouse .transferred to [local hospital's name]. 09/30/22 at 8:08 PM [Nursing Progress Note] documented, writer placed call to [local hospital's name] .nurse stated [Resident #5] was admitted . 09/30/22 [hospital discharge summary] documented, Active problems principal urinary tract infection . ED (emergency department) course: . UA (urinary analysis) consistent with UTI (urinary tract infection), CT of the head no acute intracranial hemorrhage .Hospital course- UTI confirmed . in urine culture . patient will complete course of (oral) antibiotics X 2 days . Other medical issues are stable at this time . During a face-to-face interview on 11/10/22 at 12:10 PM, Employee #13 (LPN), who was the resident's assigned nurse on the day of the fall stated, The resident was trying to reposition herself in the bed, and she rolled onto the floor on the left side of her bed. The bed was in low position. When ask was the resident's side rail up? The employee said, The side rail was not attached to the bed. It was up against the wall. I don't if it was broken. Cross reference DCMR 3211.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, for one (1) of 60 sampled residents, facility staff failed to provide supervision, monitoring and modification of the residents plan of care to decrease the resident ' s risk for falls. Resident #51, who had a history of falls with injury, sustained another subsequent fall with injury. The findings included: Resident #51 was admitted to the facility on [DATE]. The medical record revealed the resident had multiple diagnoses including Dementia, Generalized Muscle Weakness, Wandering, History of Falling, Left Artificial Hip Joint, Fracture of Neck of Left Femur and Age-Related Physical Debility. Review of the medical record revealed the following: 04/15/2021 at 2:37 AM [Nursing Supervisor Note] .I saw the resident sitting on the floor in front of her room .Resident complained of severe pain in her left hip .The resident is alert to herself but confused .We did not move or turn the resident from the floor .MD (medical doctor) said to send resident ot [to] hospital for evaluation and treatment .911 crew arrived . [Resident #51] left facility at 1:14AM . Resident #51 was readmitted to the facility on [DATE] with a diagnoses of Left Hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint). 04/23/2021 [Physician ' s Progress Note] MD (medical doctor) readmission .patient was sent to [hospital name] s/p (status post) fall sustained left hip fracture s/p (status post) left hemiarthroplasty . .Review of Resident #51 ' s Fall Risk Assessments revealed the following: On 04/15/2021 - the resident had a score of 14. On 04/22/2021 - the resident had a score of 24. On 06/04/2021 - the resident had a score of 20. According to the fall risk assessment, A resident whose score is over 9 is at risk for falls. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed the following: In section C (Brief Interview for Mental Status - Summary Score) - the resident was coded as a 3 indicating that the resident was severely impacted cognitively. In Section E (Rejection of Care) -the resident was coded as behavior not exhibited. In Section G (Toileting Use) - the resident was coded as total dependence and requiring one-person physical assist. In section G (Mobility Device) - the resident was coded as using a wheelchair. In Section J (Health Condition - Fall History/ Recent Surgery)- the resident was coded as having fracture related to fall and having major surgery. In Section M (Other Ulcers, Wounds and Skin Problems) - the resident was coded as having a surgical wound. In Section O (Special Treatments, Procedures, and Programs) - the resident was coded as receiving speech, physical and occupational therapy services. In Section V (Care Area Assessment Summary) - indicated that the resident triggered for falls, which were addressed in the resident ' s care plan. Review of the Fall Care Plan with a start date of 10/23/2018 outlined multiple intervention including: Initial interventions: Complete Fall Risk Assessment quarterly. Encourage resident to request assistance, as needed. Encourage resident to rise slowly and sit in upright position before attempting to transfer. Keep frequently used items in easy reach. Revised interventions after fall on 04/15/2021: PT/OT (physical therapy/occupational therapy) Screen. Transferred to ER (emergency room) Left hip hemiarthroplasty It should be noted that the 10/23/2018 interventions were still being implemented. There was no evidence that facility staff revised the plan of care and or facility practice with goals and approaches to reduce the likelihood of another fall for Resident #51 who has a history of a fall with injury and is cognitively impaired. Review of therapy documents revealed the following: Physical Therapy Plan of Care with a start care date of 04/23/2021 and end date of 06/02/2021 revealed, . Treatment diagnosis - aftercare following joint replacement surgery . Frequency/duration of services were four (4) times a week for 60 days Resident #51 required skilled services to focused on . therapeutic exercise, neuromuscular re-education, gait training, manual therapy, physical therapy evaluation moderate complexity, and therapeutic activity. The Physical Therapy Progress & Discharge Summary dated 06/02/2021 documented, Patient has achieved 100% of rehab goal at this time and to be d/c (discharged ) to LTC (long term care) with assistance from nursing staff as needed .Pt (patient) educated in order to improve functional mobility .Pt (patient) educated on safety precautions in order to decrease .falls .Pt. requires *CGA (contact guard assist- the assisting person has one or two hands on your body but provides no other assistance to perform the functional mobility task) -*SBA (stand by assist- the assisting person does not touch you or provide any assistance, but needs to be close by for safety in case you lose your balance or need help to maintain safety during the task being performed.) for safety mobility . The therapy discharge summary indicates that Resident #51 (who was assessed as cognitively impaired) was educated. However, there was no evidence in the discharge summary that the resident verbalized understanding or was able to return demonstration of the material she was taught. On 07/27/2021 at 7:50 AM [Physician Geriatric Progress Note] - Pt (patient) c/o (complained of) severe pain rt (right) hip . she said [that she] fell down while trying to go to bathroom and got back to bed herself . transfer to ER (emergency room) acute severe pain . 07/27/2021 at 8:00 AM [Telephone - physician order] - Transfer resident via 911 to ER (emergency room) for acute severe right hip pain. 07/27/2021 at 9:45 AM [Nursing Note] - Writer ' s attention was called to the resident ' s room secondary to complaining of pain in her right hip during care . that won ' t go away . Resident . remained alert, oriented to her name only and able to verbally make her needs which is her baseline secondary to diagnosis of Dementia .Resident confirmed that she did not tell anyone that she fell . prior to now . 911 called .first responder in house . left with resident via stretcher to [hospital name] . During a face-to-face interview conducted on 07/28/2021, at approximately 10:30 AM, Employee #26 (Director of Rehabilitation) stated that the resident required moderate assistance with transfers. She then said she did not see any evidence that therapy staff provided nursing staff education on safety issues including contact guard assist and stand-by assist to reduce falls and improve functional mobility for Resident #51. During a face-to-face interview conducted on 07/28/2021, at approximately 11:00 AM, Employee #5 (4th floor Unit Manager) acknowledged the findings.