Capitol City Rehab and Healthcare Center

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and staff interviews for two (2) of 65 sampled residents, it was determined that the facility's staff failed to ensure residents were provided with adequate monitoring and supervision as evidenced by one resident who sustained a fall with injury when she was left unattended in her room, in a bed that was positioned in the highest raised position and another resident who sustained a fall with injury during an assisted shower. Residents' #95 and #258.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on an observation and a staff interview the facility failed to ensure survey results were placed in a readily accessible area where individuals wishing to examine the results do not have to ask to see them for 65 of 65 sampled residents/resident's family.

Inspectors wroteBased on record reviews, and staff interviews for one (1) of 65 sampled residents, the facility staff failed to develop and implement a comprehensive person-centered care plan with measurable objectives and individualized interventions to address the resident's allergy to eggs and preference for double portions at each meal. Residents #316 and #89. Resident #89 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis, Type 2 Diabetes with Hyperglycemia, Discitis, End Stage Renal Disease, and Weakness. A review of Resident #89's medical record revealed the following: A physician's order dated 02/21/25 that stated: LCS/NAS (low concentrated sweets/no added salt) diet, regular texture, thin liquids consistency. A History and Physical assessment dated [DATE] at 12:00 AM that documented: .C . 2. Meds .Allergies: aspirin, codeine, and eggs. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, the facility's staff failed to ensure a resident's packages were not open by staff before delivery for one (1) of 65 sampled residents. (Resident #10)

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interviews, the facility staff failed to provide a safe, clean, and sanitary environment for residents.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interviews for two (2) of 65 sampled residents, it was determined that the facility's staff failed to provide written notice of a resident's discharge from the facility, including bed hold policy with number of bed hold days, notification to the Long Term Care Ombudsman and State Agency to the resident or their representative upon transfer to the emergency room. Residents' #95 and #301.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) in the Minimum Data Set (MDS) within 14 days after the facility determined or should have determined that a significant change had occurred for Resident #313. The resident experienced a non-self-limiting weight loss of 5.8% in 30 days (117.4 lbs on [DATE] to 110.6 lbs on [DATE]) and was not on a physician-prescribed weight-loss regimen. This deficient practice affected 1 of 65 sampled residents. Resident #313 was admitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's disease without dyskinesia and without fluctuations, adjustment disorder with anxiety, adult failure to thrive, dysphagia (oropharyngeal phase), anorexia, and cognitive communication deficit. [...]

Inspectors wroteBased on record review and staff interview for two (2) of 65 sampled residents, facility failed to update one resident's care plan to include ophthalmology visits and update another resident's care plan with new goals and interventions status post unwitnessed fall with injury. (Residents #11 and #309)Findings Include . Resident #11 was admitted to facility on 08/25/2017 with diagnosis anemia, Polyneuropathy, Atherosclerotic Heart Disease, Peripheral Vascular Disease, HIV Presbyopia and Dry eye Syndrome of Bilateral Lacrimal Gland. The resident#11 during interview reported to the surveyor I want to see the ophthalmologist. Review of the resident medical record on 2/6/2026 showed the resident was last seen by the Ophthalmologist on 12/31/2021. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interviews, the facility failed to ensure the necessary services of activities of daily living such as personal hygiene, mobility, toileting and hydration were provided for one (1) of sixty-five (65) sampled residents (Resident #302), who was dependent on staff for activities of daily living.

Inspectors wroteBased on observations, record review and staff interviews for two (2) of 65 sampled residents, it was determined that facility staff failed to follow physician orders for the use of floor mats while in bed to minimize fall related injuries for one (1) resident; and failed to follow physician orders when providing wound care for one (1) of three (3) sampled residents receiving wound care. Residents' #95 and #285. Resident #95 was admitted to the facility on [DATE] with multiple diagnoses that included: Difficulty Walking, Muscle Weakness, Severe Anemia and Fibromyalgia. A care plan dated 02/04/25 documented, in part: Focus: [Resident #95's name] had a fall in her room sustaining a swelling with open area on her right forehead . Interventions: Floor mats to both sides of bed when resident is in bed to minimize fall related injuries . [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: 685Based on record review and staff interview facility staff failed to ensure residents received treatment and care in accordance with professional standard of practice for services to maintain his eye vision as evidence by Follow up visit with the Ophthalmologist in one year was not completed. Resident #11Finding includes .Resident #11 was admitted to facility on 08/25/2017with diagnosis anemia, Polyneuropathy, Atherosclerotic Heart Disease, Peripheral Vascular Disease, HIV, Presbyopia and Dry eye Syndrome of Bilateral Lacrimal Gland. Resident #11 requested by the surveyor I want to see the Ophthalmologist. A review of Ophthalmologist report dated 12/31/2021 showed residents. to follow up visit in one year. [...]

Inspectors wroteBased on observations, record review and staff interviews for one (1) of 65 sampled residents, it was determined that facility staff failed to ensure that extra tracheostomy supplies were available at the bedside for a resident who is tracheostomy dependent. Resident #17.

Inspectors wroteBased on record review and staff interviews, for one (1) of 65 sampled residents the facility staff failed to ensure nursing staff functioned with the appropriate competencies and skills to provide nursing and related services to assure resident safety as evidenced by the nurse's administration of a significant medication error.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review, and staff interviews, the facility staff failed to establish a consistent location for the pharmacist's monthly medication review recommendations for each resident, thereby ensuring that the pharmacist's

Inspectors wroteBased on observations, record reviews, and staff interviews for two (2) of 65 sampled residents, the facility staff failed to ensure that food services accommodated one (1) resident's allergy to eggs and personal preferences for two (2) residents. Residents #89 and #67). Resident #89 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis, Type 2 Diabetes with Hyperglycemia, Discitis, End Stage Renal Disease, and Weakness. A review of Resident #89's medical record revealed the following: A physician's order dated 02/21/25 that stated: LCS/NAS (low concentrated sweets/no added salt) diet, regular texture, thin liquids consistency. A History and Physical assessment dated [DATE] at 12:00 AM that documented: .C . 2. Meds .Allergies: aspirin, codeine, and eggs. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on residents' interviews, observation, and staff interviews, the facility staff failed to ensure residents received pm snacks.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and staff interviews, facility staff failed to prepare and distribute foods under sanitary condition, as evidenced by the following observations.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 65 sampled residents, it was determined that facility staff failed to show documented evidence that the facility's visitor logbook was retained with accuracy and documentation of gastrostomy management was lacking for one resident. (Residents #55 and #220).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record review, and staff interviews for one (1) of 65 sampled residents, the facility staff failed ensure no breaks in infection control by failing to wear proper personal protective equipment while providing incontinent care for a resident on Enhanced Barrier Precautions (EBP).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and staff interviews, the facility staff failed to maintain essential kitchen equipment in good working condition as evidenced by the following:

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interviews, the facility staff failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet facilities.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interviews, the facility staff failed to equip corridors with firmly secured handrails.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interview, the facility staff failed to maintain an efficient pest control system as evidenced dead cockroaches were seen on floor at the cookline area in the kitchen.

Inspectors wroteBased on record reviews and staff interviews, facility staff failed to follow a physician order with timeliness, as evidenced by the transfer of a resident to the emergency room for a higher level of care approximately three (3) hours after receiving the order for one of three sampled residents.

Inspectors wroteBased on record review and staff interviews for one (1) of 12 sampled residents, the facility staff failed to show accurate documentation for a resident who was dependent on staff for Activities of Daily Living care and ensured he was offered and provided a shower or bath on scheduled days as prescribed by the physician. Resident #1. Based on record review and staff interviews for one (1) of 12 sampled residents, the facility staff failed to show accurate documentation for a resident who was dependent on staff for Activities of Daily Living care and ensured he was offered and provided a shower or bath on scheduled days as prescribed by the physician. (Resident #1)

Inspectors wroteBased on record reviews and staff interviews, for one (1) of eleven (11) sampled residents, facility staff failed to ensure that a care plan meeting was held or that a comprehensive care plan review was done at least quarterly (every 90 days) for one resident. Resident #11.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of eleven (11) sampled residents, facility staff failed to ensure that the residents received medications as ordered by the physician. Residents #1 and #2.

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of eleven sampled residents, facility staff failed to minimize risks to a resident receiving intravenous (IV) therapy as evidenced by failing to label and date, as appropriate, the IV infusion tubing. Resident #1.

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of eleven (11) sampled residents, facility staff failed to demonstrate competent nursing competencies and skills sets to provide safe nursing services as evidenced by a licensed nurse crushing resident medications that were labeled, Do not crush and without a physician's order. Resident #11.

Inspectors wroteBased on observation and staff interviews, facility staff failed to ensure that the medication error rate was less than 5%.

Inspectors wroteBased on observations, record reviews and staff interviews, facility staff failed to implement infection control policies and procedures as evidenced by multiple staff observed not following posted personal protective equipment (PPE) requirements throughout the facility.

Inspectors wroteBased on record review and staff interviews, for one (1) of 11 sampled residents, facility staff failed to administer the COVID-19 immunization as ordered for Resident #7.

Inspectors wroteBased on record reviews and staff interviews for one (1) of three (3) sampled residents, the facility staff failed to notify the State Agency of an allegation of abuse/neglect or injury of unknown origin within 24 hours of an incident involving Resident #1 who was found by staff with bloodied bed linens and with cuts to his right wrist from a disposable razor on [DATE].

Inspectors wroteBased on record reviews and staff interviews for one (1) of three (3) sampled residents, the facility staff failed to develop a comprehensive, person-centered care plan that documented the residents' use of a communication aid which the resident needed in order to communicate with others.

Inspectors wroteBased on observations, record reviews, staff interviews and a resident's interview, for three (3) of nine (9) sampled residents, the facility failed to ensure residents were free from physical abuse as evidenced by: (1) The Administrative staff making the decision to place Resident #2 (new admission), who was known for physical aggressive behaviors toward other residents, in a room with Resident #1, who was also known for physical aggression against other residents and staff and sexual misconduct. Subsequently, on 06/08/24, Resident #1 and Resident #2 were involved in a physical altercation which resulted in Resident #2 sustaining a stab wound to his left leg; and (2) An altercation on 06/15/24 between Employee #9 and Resident #4 led to the employee throwing lemonade and ice in the resident's face. Residents' #1, #2, and #4. [...]

Inspectors wroteBased on record reviews and staff interviews, for one (1) of nine (9) sampled residents, facility staff failed to ensure that reasonable accommodations for a room assignment was provided for a resident that did not endanger his health or safety as evidenced by placing Resident #2 (new admission), with a known history of physically aggressive behaviors toward other residents, in a room with Resident #1, also with a known history of physical aggression towards other residents and staff.

Inspectors wroteBased on record review and staff interview, for one (1) of nine (9) sampled residents, the facility's staff failed to provide a resident with written notice that a new roommate had been assigned to his room on 06/06/24. (Resident #1).

Inspectors wroteBased on record review and staff interviews, for one (1) of nine (9) sampled residents, the facility failed to ensure that Resident #8 received appropriate treatment, services, care and management related to complications (clog) of his enteral feeding tube.

Inspectors wroteBased on record review and staff interviews, for one (1) of nine (9) sampled residents, the licensed nursing staff failed to demonstrate the appropriate competencies and skill sets to provide nursing services to assure resident safety and well-being of each resident. Resident #8.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, for five (5) of 16 sampled residents, the facility's staff failed to: (1) implement safety measures to prevent Resident #1 from having access to a lighter. As a result, Resident #1 lit Resident #2's bedsheets and mattress on fire with the lighter at approximately 11:25 PM on 04/20/24. (2) Ensure Resident #8's safety by providing adequate supervision to prevent her from wandering into other residents' rooms, resulting in Resident #8 sustaining a head laceration when Resident #6 hit her in the head with a cane for wandering into his room on 02/08/24. (3) Ensure Resident #6 was adequately supervised while possessing a cane following an incident where he used it as a weapon on 02/08/24. [...]

Inspectors wroteBased on record review and staff interview, the facility staff failed to have documented evidence that residents care plans (with goals and approaches to address resident needs) were reviewed for effectiveness and revised following each MDS assessment for 10 of 16 sampled residents. Residents' #1, #2, #4, #5, #6, #7, #8, #9, #11 and #12

Inspectors wroteBased on record review and staff interview, the facility's staff failed to have documented evidence that a physician was notified of a safety concern with an order for hourly monitoring for one (1) of 16 sampled residents. (Resident # 8)

Inspectors wroteBased on record review and staff interviews for one (1) of 16 sampled residents, facility staff failed to respect Resident #1's right to personal privacy when they searched her room and personal belongings without getting her permission to do so.

Inspectors wroteBased on the record review and staff interview, for one (2) of 16 sampled residents, the facility's staff failed to follow the Abuse policy by not: (1) reporting an incident of resident-to-resident abuse (fire incident) immediately but not later than 2 hours to the Administrator or the State Survey Agency. This is evidenced by the Administrator stating that he received notification of a residents mattress being lit by another resident on the following Monday 04/22/24 at 9:00 AM, 34 hours after the incident. In addition, the State Survey Agency was notified of the incident approximately 46 hours later; And (2) Interviewing all who might have knowledge of the allegation of resident-to-resident abuse. (Resident #1 and Resident #6)

Inspectors wroteBased on the record review and staff interview, for one (2) of 16 sampled residents, the facility's staff failed to follow the Abuse policy by not: (1) reporting an incident of resident-to-resident abuse (fire incident) that had the potential to affect all residents immediately but no later than 2 hours after the allegation to the Administrator and the State Survey Agency. And (2) Interviewing all who might have knowledge of the allegation of resident-to-resident abuse. (Resident #1 and Resident #6)

Inspectors wroteBased on record review and staff interview, for one (1) of 16 sampled residents, the facility staff failed to take appropriate corrective action after Resident #6 used his cane to assault Resident #8 on 02/08/24. As a result, Resident #6 used his cane again to assault Resident #7 on 03/26/24.

Inspectors wroteBased on record review and interview, for three (3) of 16 sampled residents, the facility staff failed to develop a comprehensive care plan that (1) addressed safety measures for Resident #6 who used a cane inappropriately in the past. (2) addressed Resident #8's order for hourly monitoring (3) included Resident 5's physician orders for up in chair as tolerated and out of bed as tolerated in the care plan interventions. (Residents' #5 , #6, and #8)

Inspectors wroteBased on a record review and staff interview, the administration failed to effectively and efficiently maintain a safe environment for all residents. This is evidenced by: (1) The staff to include the DON not reporting a fire incident immediately, but not later than 2 hours to the Survey State Agency or the Administrator. (2)Resident #7 not protected from an altercation with Resident #8 following an investigation of a similar incident involving Resident #8 on 02/08/24. The facility's census on the first day of the survey was 287.

Inspectors wroteBased on a record review and staff interview, the governing body failed to ensure that the Abuse, Neglect, and Exploitation Policy was implemented. This is evidenced by: (1)The staff to include the DON not reporting a fire incident immediately, but not later than 2 hours to the Survey State Agency or the Administrator. (2) Resident 6's two resident-to-resident abuse investigations not including interviews with all who might had knowledge of the incidents. (3) Resident #7 not being protected against abuse from Resident #8 following an investigation of a similar incident involving Resident #8 on 02/08/24. The facility's census on the first day of the survey was 287.

Inspectors wroteBased on a record review and staff interview, the Administration staff failed to ensure that their current Facility assessment dated [DATE] included services to competently care for residents who are smokers. The facility's census on the first day of the survey was 287.

Inspectors wroteBased on record review and staff interview, for two (2) of 16 samples residents, the facility staff failed to ensure: Resident 5's Medication Administration Record showed what the resident received and Resident #8's care plan contained accurate information.

Inspectors wroteBased on record review and staff interview, the facility's staff failed to have an effective Quality Assurance and Performance Improvement Plan (QAPI). This is evident by the plan's failure to address residents with behaviors or outline safety measures for staff to follow to ensure residents did not possess smoking paraphernalia outside of the designated smoking area. The facility's census on the first day of the survey was 287.

Inspectors wroteBased on observation, staff interview and family interview, the facility staff failed to ensure a resident's bed control did not have exposed encased wires for one (1) of 16 sampled residents. (Resident #11)

Inspectors wroteBased on review of a facility reported incident, medical records, facility documentation, and interviews with family members and staff, for four (4) of 101 sampled residents, the facility's staff failed to 1. safely administer medications in accordance with Standard of Practice or Manufactures Specifications as evidenced by (1) Employee #22 (Agency Registered Nurse; RN) administered one unit of Novolog R insulin to Resident #313 without a physician's order on 02/10/23, (2) Employee # 25 (Agency RN) signed that he administered medication to Resident #494 who had no medication in the facility, (3) Employee #11 (RN) administered Resident #5 a deceased resident's (Resident #488) medication (Gabapentin), and (4) storing and administering expired Humalog (Lispro) insulin medication to Resident # 7. [...]

Inspectors wroteBased on review of a facility reported incident, medical records, facility documentation, and family and staff interviews, for six (6) of 104 sampled residents, the facility's staff failed properly store medications in accordance with Standards of Practice or Medication Manufacturer's Specifications as evidenced by: (1) not ensuring Resident #7's individual medication compartment did not contain expired Humalog (Lispro) insulin. Subsequently, the resident was administered expired Humalog (Lispro) insulin, (2) Employee #34 failed to ensure Resident #224's individual medication compartment did not contain a deceased resident's [Resident #488] medication, Subsequently the resident was administered the deceased resident's medication [Gabapentin], (3) Employee #35 stored Resident #147's Novolog insulin in her uniform pocket, (4). [...]

Inspectors wroteBased on review of medical records, administrative records, facility documentation/policies, and family and staff interviews, for three (3) of 3 sampled discharged residents, the facility's staff failed to ensure residents were safely discharged as evidenced by not providing Residents #332, #585, and #586 with written instructions for discharge medications. In addition, Resident #332 was discharged with Resident #27's Lisinopril (hypertensive medication). These failures have the potential to affect any resident who is discharged from the facility. Due to these failures, an Immediate Jeopardy situation was identified on February 17, 2023, at 4:17 PM. The facility submitted a Plan of Action to the survey team that was on onsite at 2:21 AM on February 18, 2023, and the plan was accepted. [...]

Inspectors wroteBased on observations, record reviews, resident, and staff interviews, for one (1) of 98 sampled residents, the facility's staff failed to ensure Resident #255's menu was followed, as evidenced by not providing a pureed diet on 02/17/22. Subsequently, after eating approximately 10% of a biscuit that was provided by facility staff on 02/17/22, the resident complained of feeling the biscuit in his throat. Due to these failures, an Immediate Jeopardy situation was identified on February 17, 2023, at approximately 5:30 PM. The facility submitted a Plan of Action to the survey team that was on onsite at 2:21 AM on February 18, 2023, and the plan was accepted. The survey team verified implementation of the plan on February 21 - 22 2023. The Immediate Jeopardy was lifted on February 22, 2023, at 6:40 PM. [...]

Inspectors wroteBased on observations, record reviews, and staff interviews for six (6) of 105 sampled residents, the facility staff failed to ensure residents were free from abuse. (Residents #146, #163, #254, #70, #131 and #169.) Actual harm was determined to be present for Residents #169, and #131.

Inspectors wroteBased on staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failure to identify areas for improvement and to develop and implement corrective and preventive actions. The resident census during the survey was 343.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, for one (1) of 19 sampled residents whose personal funds are managed by the facility, the facility's staff failed to adhere to generally accepted accounting principles when acting as a manager (representative payee) for the resident's personal funds (social security benefits). (Resident #229).

Inspectors wroteBased on observation, record review, and staff interviews for 8 of 105 sampled residents, facility staff failed to: 1. ensure that residents or their family members were provided information to formulate an Advance Directive and 2. ensure that current copies of the Advance Directives were in the resident's medical record. (Residents' #286, #101, #272, #29, #158, #10, #53, and #247).

Inspectors wroteBased on observations and interviews, it was determined that facility staff failed to provide the housekeeping services necessary to maintain a safe, clean, and comfortable environment, as evidenced by 1. torn privacy curtains in eight (8) of 52 resident's rooms, 2. soiled exhaust vents in 15 of 52 resident's rooms, 3. trash thrown throughout the facility parking lot between February 21 and [DATE], 4. two (2) of two (2) overly packed trash cans in the facility parking lot, and 5. expired dental items in the dental office.

Inspectors wroteBased on observations, record review, resident interview and staff interview, the facility's staff failed to ensure residents were able to file grievances anonymously and receive written decisions regarding their grievances.

Inspectors wroteBased on record review and staff interviews, for (3) of 105 sampled residents, the Inter Disciplinary Team (IDT) failed to conduct quarterly care planning conferences for Residents #29, #150, and #60. 1. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Schizophrenia, Acquired Absence of Right Leg Below Knee, and Acute Kidney Failure. A review of the medical record revealed the face sheet noting Resident #29 was his/her own responsible party. The following care plan meeting notes were noted: -02/10/22 at 11:17 AM, IDT (Interdisciplinary Team) reviewed plan of care, goals and interventions up to date for [Resident #29] Representative ( .) invited but unable to attend. -04/14/22 at 1:19 PM, IDT reviewed plan of care goals and interventions up to date with [Resident #29]. [...]

Inspectors wroteBased on observations, record reviews and staff interviews, for five (5) of 104 sampled residents, the facility's staff failed to follow physician orders or acceptable standards of practice evidenced by failing to 1. provide Resident #56's daily mouth care, resulting in extensive oral thrush (yeast infection), 2. provide Resident #130's two-person assistance with incontinent care, 3. provide Resident #493's left-hand wound treatment, 4. ensure straws were not provided to Resident #51 as ordered, and 5. offload Resident #113's bilateral heals per physician's order. (Residents #56, #51 #130, #493, and #113).

Inspectors wroteBased on observation, record review, resident and staff interview for five (5) of 105 sampled residents, facility staff failed to provide food at appropriate temperatures for consumption, and that met residents preferences (Residents #143, #251, #79, #197, and #231

Inspectors wroteBased on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by foods such as puree Salisbury Steak, puree peas, and from the regular menu, mashed potatoes that tested below 135 degrees Fahrenheit (F).

Inspectors wroteBased on observations, record reviews, resident interview, and staff interviews for six (6) of 104 sampled residents, the facility's staff failed to ensure resident's records contained accurate documentation. (Residents #132, #93, #101, #313, and #492.)

Inspectors wroteBased on record review and staff interview, for four (4) of 105 sampled residents, the facility's staff failed to maintain Infection Control and Prevention Practices during wound care, dressing changes, and medication administration. (Residents #587, #76, #75, and #313. In addition, the facility failed to ensure trash and used personal protective equipment was disposed of properly.

Inspectors wroteBased on record review and staff interview, for six (6) of 98 sampled residents, facility staff failed to ensure that residents were offered influenza and pneumococcal immunizations. Resident #73, #132, #184, #248, #311 and #324

Inspectors wroteBased on record review and staff interview, for ten (10) of 98 sampled residents, facility staff failed to ensure the residents were provided COVID-19 immunization according to the Centers for Disease Control (CDC) recommendation and manufacturer specifications as appropriate (Residents #55, #73, #76, #77, #184, #248, #291, #311, #324 and #327).

Inspectors wroteBased on record review, family interview, and staff interview, for one (1) of 105 sampled residents, the facility's staff failed to notify a resident's family regarding use of medications (Depakote and Exelon). (Resident #74.)

Inspectors wroteBased on record review and staff interview, for one (1) of 105 sampled residents, the facility failed to ensure a resident's family was provided information to schedule zoom calls for virtual visitation from 11/31/22 to 03/09/23 (Resident #60).

Inspectors wroteBased on record reviews, family interviews, and staff interview for one (1) of 104 sampled residents, the facility's staff failed to notify a resident's family of the resident's significant unplanned weight loss of 5.2 percent from 11/12/22 to 12/21/22 [40 Days].

Inspectors wroteBased on record reviews and staff interviews for one (1) of 105 sampled residents, facility staff failed to implement its policies and procedures for investigating allegations of abuse, neglect, and injuries of an unknown source. (Resident #237)

Inspectors wroteBased on record reviews and staff interviews for one (1) of 105 sampled residents, facility staff failed to report an injury of an unknown source timely to the State Agency per its policies and procedures. (Resident #237)

Inspectors wroteBased on record review, family interview, and staff interview, for one (1) of 104 sampled residents, the facility's staff failed to develop a baseline care plan for Resident #74.

Inspectors wroteBased on observations, record reviews, and staff interviews, facility staff failed to develop/implement care plans for (2) of 105 sampled residents. (Residents #131 and #53)

Inspectors wroteBased on observation, record review and staff interview for one (1) of 105 sampled residents (231), facility staff failed to follow physician's orders to provide weekly skin assessments for a resident who is bedridden and totally dependent of care as evidenced by a pressure ulcer to the sacrum that facility staff first discovered and documented at an unstageable level.

Inspectors wroteBased on observations, record reviews, resident and staff interviews for one (1) of 105 sampled residents, the facility's staff failed to ensure that Resident #51's environment was free of accident hazards by 1. not removing drinking straws from the resident's meal tray, 2. having two portable space heaters in the clean linen area of the facility, and several cracks from the concrete driveway and sidewalk, located at the entrance of the facility, that presented a tripping hazard.

Inspectors wroteBased on observation, record reviews, family interview and staff interviews, for one (2) of 104 sampled residents, the facility's staff failed to adequately monitor a resident's nutritional status and obtain after admission and at least monthly thereafter to help identify and document potential weight loss or weight gain. (Residents #313 and #60)

Inspectors wroteBased on review of medical record and staff interview, for one (1) of 102 sampled residents, the facility's staff failed to ensure Resident #313 was seen by a physician or nurse practitioner at least once every 30 days for the first 90 days after admission.

Inspectors wroteBased on record review and staff interview for one (1) of 105 sampled residents, facility staff failed to show documented evidence that a pharmacist performed a monthly medication review for Resident #150, from 01/23/23 through 02/23/23. (Resident #150)

Inspectors wroteBased on observations and interview, it was determined that facility staff failed to maintain resident call system in good working condition as evidenced by the failure of the call bell system to operate correctly in two (2) of 52 resident rooms.

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure: (1) Medication Regimen Reviews were conducted at least once a month by a licensed pharmacist for seven (7) of 82 sampled residents; and (2) failed to ensure a licensed pharmacist included a resident's complete medical record when conducting the drug regimen review for one (1) of 82 sampled residents. Residents' #5, #77, #98, #205, #210, #211, #244, and #283.

Inspectors wroteBased on record review and staff interview, facility staff failed to update the Facility Assessment to reflect the facility's current operations. The resident census on the first day of survey was 315.

Inspectors wroteBased on observation, record review and staff interviews, facility staff failed to maintain infection prevention and control to prevent the transmission of communicable diseases and infections as evidenced by: (1) not preparing and serving foods under sanitary conditions, (2) not wearing personal protective equipment (PPE) properly, (3) to follow clean technique when suctioning one (1) of 82 sampled residents and (4) ensure the medication room on Unit 3 South was kept in sanitary manner and (5) improper hand hygiene during medication administration. Resident #283.

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by six (6) of six (6) resident shower rooms throughout the facility with marred floors.

Inspectors wroteBased on observation, record review and staff interview, for five (5) of 82 sampled residents, facility staff failed to develop care plans with goals and approaches to address: one (1) resident's use of behavioral health services; one (1) resident's use of a perm-a-cath; and one (1) resident who sustained a fall; additionally, facility's staff failed to implement care plan interventions for one (1) resident's use of a scoop mattress and one (1) resident's use of psychoactive medications. Residents' #24, #161 #205, #229 and #290.

Inspectors wroteBased on observation, record review, resident and staff interviews, for three (3) of 82 sampled residents, facility staff failed to: (1) administer Midodrine (used to treat low blood pressure) to a resident in accordance with the physician's order, (2) follow a consult receive/obtain pumps to treat a resident with lymphedema, (3) ensure a resident received reading glasses as prescribed. Residents' #98, #174 and #210.

Inspectors wroteBased on record review and staff interview, for two (2) of 82 sampled residents, facility staff failed to ensure one (1) resident had an physician's order in place to treat a pressure ulcer located on the resident's right buttock and failed to follow physician orders for a Stage 4 (sacral) pressure ulcer for one (1) Resident. Residents' #211 and #229.

Inspectors wroteBased on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure that one (1) resident with limited mobility received restorative nursing services as needed to help promote optimal safety and independence and in accordance with their comprehensive person-centered care plans.

Inspectors wroteBased on observation, record review, and staff interviews, for three (3) of 82 sampled residents, the facility staff failed to: (1) ensure that a resident's environment was free of accidents, (2) implement interventions to reduce hazard and risk to prevent a resident from accidental falls and (3) provide adequate supervision in accordance with the plan of care. Residents' #61, #249 and #402.

Inspectors wroteBased on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to establish parameters to determine when to administer pain medications to Resident #98.

Inspectors wroteBased on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure that a resident did not receive Tylenol (pain reliever) in excessive doses and failed to ensure that a resident did not receive Midodrine (low blood pressure medication) in accordance with the physician's order. Resident #98.

Inspectors wroteBased on record review, resident and staff interview, for one (1) of 82 sampled residents, facility staff failed to provide an outside resource for routine dental services to meet a resident's needs. Resident #205.

Inspectors wroteBased on observations and staff interview, facility staff failed to prepare and serve foods under sanitary conditions as evidenced by dietary staff in the kitchen with no hair net and no beard net, 400 of 400 food serving trays that were soiled and/or damaged, and one (1) of one (1) soiled tilt skillet.

Inspectors wroteBased on record review and staff interview, for four (4) of 82 sampled residents, facility staff failed to maintain medical records on each resident that were complete and accurately documented. Residents' #1, #126, #290 and #298.

Inspectors wroteBased on record review and staff interview, for one (1) of 82 sampled residents and three (3) employees, facility staff failed to provide COVID-19 immunization per regulations and manufactures specifications and failed to maintain compliance requirements for COVID-19 vaccination employees. Resident #GG2.

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of 82 sampled residents, the facility staff failed to provide a resident with dignity by not covering the resident's urinary catheter collection bag. Resident #249.

Inspectors wroteBased on observation, record review and family and staff interview for two (2) of 82 sampled residents, facility staff failed to provide one (1) resident with safe and appropriate transportation for a doctor's visit; and provide a one (1) resident with an operable cell phone that was replaced by the facility. Residents' #24 and #283.

Inspectors wroteBased on record review and staff interviews, for one (1) of 82 sampled residents, the facility's contracted Behavioral Facilitator failed to provide privacy for a resident receiving telehealth psychological (counseling) services. Resident #24.

Inspectors wroteBased on record review and staff interview, for three (3) of 82 sampled residents, facility staff failed to show evidence that residents or their representatives were able to formulate an advance directive. Residents' #1, #249 and #298.

Inspectors wroteBased on record review and interview, for one (1) of 82 sampled residents, the facility's staff failed to ensure a resident was free from physical abuse from an employee. Resident #230.

Inspectors wroteBased on record review and staff interviews, for three (3) of 82 sampled residents, the facility staff failed to implement their written policies and procedures on abuse and neglect of residents by failure to report allegations and actual abuse of residents immediately and to conduct thorough investigations for allegations. Residents' #1, #205 and #230.

Inspectors wroteBased on observation, record review and staff interviews, the facility staff failed to ensure that alleged violations involving abuse and neglect or mistreatment, were reported immediately for two (2) of 82 sampled residents.

Inspectors wroteBased on record review and staff interviews for one (1) of 82 sampled residents, the facility staff failed to ensure a thorough investigation was conducted of an allegation of neglect. Resident #1.

Inspectors wroteBased on record review and interview, for one (1) of 82 sampled residents, the facility's staff failed to provide the hospital with required documentation when transferring a resident. Resident #283.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 82 sampled residents, the facility staff failed to notify a resident and their representative of the transfer/discharge and the reasons for the move in writing. Resident #290.

Inspectors wroteBased on record review, and staff interviews, for three (3) of 82 sampled residents, the facility staff failed to provide information about the facility's bed hold policy. Residents' #1, #117 and #283.

Inspectors wroteBased on record review and staff interview, for one (1) out of 82 sampled residents, facility staff failed to accurate code the Minimum Data Set (MDS) assessment for Resident #161.

Inspectors wroteBased on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to conduct a Pre-admission Screening and Resident Review (PASARR) for Resident #251.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of 82 sampled residents, the facility staff failed to: (1) update the care plan to address a resident calling 911 and (2) update a residents care plan to include goals and approaches to address pressure ulcer/injury. Residents' #205 and #400.

Inspectors wroteBased on record review and staff interview, for one (1) of 82, sampled residents, facility staff failed to record the residents discharge plan in the active clinical record for Resident #194.

Inspectors wroteBased on observations, interviews and record reviews, the facility's staff failed to ensure a resident who is totally dependent on staff received services to maintain good grooming and personal hygiene for one (1) of 82 sampled residents. Resident #283.

Inspectors wroteBased on record review, resident and staff interview, for one (1) of 82 sampled residents, the facility's staff failed to ensure a resident received an optometry assessment and an assistive device to maintain vision. Resident #210.

Inspectors wroteBased on observations, record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure a resident's supra-pubic catheter drainage bag was positioned below the level of the bladder. Resident #211.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure a resident received their prescribed diet of pureed texture. Resident #161.

Inspectors wroteBased on observation, record review and staff interview, two (2) of 82 sampled residents, the facility's staff failed to: ensure an ambu [artificial manual breathing unit] bag (used to deliver positive pressure ventilation to any patient with insufficient or ineffective breaths) was easily accessible for a resident; and to follow physician's orders to show of titrating/monitoring a residents oxygen saturation. Residents' #283 and #298.

Inspectors wroteBased on record review and staff interview, facility staff failed to reconcile narcotics in two (2) of two (2) occurrences.

Inspectors wroteBased on observation and staff interview, facility staff failed to: (1) discard of expired medications and dietary supplements and (2) initial and date medications after opening.

Inspectors wroteBased on observations and staff and resident interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on three (3) of six (6) observations.

Inspectors wroteBased on observation, record review, and staff interviews, for one (1) of 82 sampled residents, the facility staff failed to provide a resident with occupational therapy. Resident #1.

Inspectors wroteBased on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to conduct COVID-19 testing for a resident exposed to COVID-19 who subsequently tested positive for COVID-19 as well. Resident #GG1.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by: kitchen hood baffles that were not securely attached, three (3) of three (3) drainpipes from the three-compartment sink that extended into a floor drain, one (1) of one (1) walk-in refrigerator and walk-in freezer with missing slats, and a plumber's snake that was stuck in a drain located near the three-compartment sink.

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells in three (3) of 58 resident's rooms that did not emit an alarm when tested.

Inspectors wroteBased on record review, resident and staff interview for one (1) of 75 sampled residents, facility staff failed to consistently monitor Resident #274 with sexually aggressive behavior from inappropriately touching female residents.

Inspectors wroteBased on record review and interviews for five (5) of 75 sampled residents, the facility's staff failed to: (1) ensure 1 to 1 monitoring (supervision) was provided for one resident; (2) ensure two (2) residents, who were asssessed as fall risks, recieved adequate supervision; and (3) supervise two (2) residents when placing them in a ride share car (Uber). for two (2) of 75 sampled residents (Residents' #56, #187, #226, #235, and #305).

Inspectors wroteBased on observations and staff interview, facility staff failed to store and prepare foods under sanitary conditions as evidenced by inadequate internal temperatures in one (1) of one (1) walk-in freezer, four (4) of four (4) soiled convection ovens, one (1) of five (5) missing slat in one (1) of one (1) walk-in refrigerator and a broken outer temperature gauge in one (1) of three (3) reach-in refrigerator.

Inspectors wroteBased on observation, record review, and interview for five (5) of 11 sampled residents, whose personal funds are managed by the facility, the facility's staff failed to follow generally accepted accounting principles when depositing a money order made out to one (1) resident and to ensure five (5) residents who have Resident Fund Management System (RFMS) accounts gave the facility staff authorization to manage their funds. Residents' #187, #112, #116, #181 and #238

Inspectors wroteBased on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by stained ceiling tiles in nine (9) of 60 resident's rooms, soiled exhaust vents in six (6) of 60 resident's rooms, broken door closures in three (3) of 180 resident's rooms and a bed bumper board observed on the floor in one (1) of 60 resident rooms.

Inspectors wroteBased on record review and interview, for five (5) of 75 sampled residents, the facility's staff failed to update Care Plans for : (1) one (1) resident, who fell during care; (2) 1 to 1 monitoring for safety for one (1) resident; (3) two (2) residents, who had a resident-to-resident verbal interaction; and (4) one (1) resident's dialysis information (Residents' #81, #235, #246, #297 and #322).

Inspectors wroteBased on record review and interview, the facility staff failed to ensure a resident was free from a significant medication error for one (1) of 75 sampled residents (Resident #23).

Inspectors wroteBased on observation and interview, facility staff failed to provide a safe, sanitary environment to help prevent the expansion and transmission of communicable diseases and infections as evidenced by one (1) of one (1) heater blower in use, that was soiled with dust in the laundry room and the lack of a water management program with a risk assessment to identify where Legionella and other waterborne pathogens could grow in the facility's water system.

Inspectors wroteBased on observations, record review and staff interview, facility staff failed to: (I) maintain essential equipment in a safe condition as evidenced by a high internal temperature in one (1) of one (1) walk-in freezer, a broken temperature gauge in one (1) of five (5) reach-in refrigerators and one (1) of five (5) slats from one (1) of one (1) walk-in refrigerator that was completely torn off; and (II) ensure a New Life Intensity Oxygen Concentrator was operating in a safe condition for one (1) of 75 sampled residents (Resident #215).

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells in two (2) of 60 resident's rooms that failed to alarm when tested, torn protective call bells cord cover in five (5) of 60 observations and a broken reset button from one (1) of 60 resident call bell housing.

Inspectors wroteBased on observation, record review, and interviews for two (2) of 75 sampled residents, the facilty's staff failed to treat residents with respect and dignity, as evidenced by: allowing one (1) resident to lay on soiled linen until the change of shift, and by not providing incontinent care and not removing facial hair for one (1) resident.

Inspectors wroteBased on observation, record review and interview for two (2) of 75 sampled residents the facility's staff failed to ensure that one (1) resident was provided with a Bariatric bed to promote safety with bed mobility, and to ensure one (1) resident was clothed, cleaned and dry. (Residents' #23 and #197).

Inspectors wroteBased on observation, record review and staff interview for one (1) of 75 sampled residents, the facility staff failed to complete an Advance Directive for Resident #222. Findings Include . Review of the resident's clinical record showed that the resident was admitted to the facility on [DATE]. The record lacked documented evidence of a completed Advance Directive on the resident's record. Review of Section I (Active Diagnoses) of the annual Minimum Data Set (MDS) dated [DATE] showed diagnoses which include Hypertension, Renal Insufficiency, Diabetes Mellitus, Hyperlipidemia, Parkinson's Disease and Schizophrenia. Review of Section C (Cognitive Patterns) showed a Summary Score of 10 for C0500 Brief Interview of Mental Status (BIMS). A summary Score of 10 is an indication that the resident's cognition is moderately impaired and therefore he may be unable to make some decisions. [...]

Inspectors wroteBased on review of the facility's Abuse policy and staff interviews, the facility failed to instruct staff to report allegations of abuse immediately but not later than two hours in their abuse policy. The census on the first day of survey was 346.

Inspectors wroteBased on review of the facility's incident report and staff interviews, one (1) of 75 sampled resident, the facility staff failed to thoroughly investigate an allegation of sexual abuse to one (1) female resident. Resident # 99.

Inspectors wroteBased on record review and staff interview, for three (3) of 75 sampled residents, the facility's staff failed to develop patient-centered Care Plans for: (1) the use of oxygen for one (1) resident; (2) the resistant /refusal of ADL [activity of daily living] care for one (1) resident; and (3) the diagnosis of Adjustment Disorder with Anxiety and Depressed Mood for one (1) resident (Residents' #106, #220 and #235).

Inspectors wroteBased on observation, record review, and interviews, for three (3) of 75 sampled residents, the facility's staff failed to: (1) provide care per the person-centered Care Plan for one (1) resident; (2) provide medication per professional standards and as prescribed by the physician for one (1) resident; and (3) failed to obtain a physician's order to release the resident's body to the DC Medical Examiner for one (1) resident. (Residents' #23, #295, and #TF)

Inspectors wroteBased on record review and interview, the facility's staff failed to provide incontinent care in a timely manner for one (1) of 75 sampled residents (Resident #23).

Inspectors wroteBased on observation, record review and staff interview for one (1) of 75 sampled residents, facility staff failed to administer Resident #148's enteral feeding as directed by the physician.

Inspectors wroteBased on observation, record review, and staff interview for one (1) of 75 sampled residents, the facility's staff failed to provide appropriate care to the Percutaneous Endoscopic Gastrostomy tube (PEG-tube) site for one (1) resident. (Resident #233).

Inspectors wroteBased on record review and interview, the facility staff failed to ensure that they followed a physician order for oxygen therapy for one (1) of 75 sampled residents (Resident #215).

Inspectors wroteBased on observation, record review and staff interview for one (1) of 75 sampled residents, facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility and dialysis staff was included in the medical record for Resident #322.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a nursing assistant had the skill to safely provide 1:1 care for one (1) of 75 residents in the sample (Resident #235).

Inspectors wroteBased on observation and staff interview, facility staff failed to post daily nurse staffing information in a readily accessible location. The resident census on the first day of the survey was 346.

Inspectors wroteBased on record review and interview, for two (2) of 75 sampled residents, the facility's pharmacist failed to identify a medication error (Omission of Antihypertensive medications ) during the January 2020's Drug Regimen Review for one (1 resident; and to ensure the pharmacist completed The Pharmacist's Chronological Record of Medication Regimen Review for 2 months (August 2019 and Jaqnuary 2020) for one (1) resident. (Residents #23 and #220).

Inspectors wroteBased on record review and staff interview for one (1) of 75 sampled residents, the facility's staff failed to respond to the pharmacist's recommendation for dosage reduction for one resident who receives Remeron. (Antidepressant).

Inspectors wroteBased on observation resident and staff interview for one (1) of 75 sampled residents, the facility's staff failed to ensure the food prepared for the resident was attractive refers to the appearance of the food when served to residents. (Resident #246).

Inspectors wroteBased on observations, record review, resident and staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems; as evidenced by failing to ensure that they developed plans of action to identify quality deficiencies. The resident census during the survey was 346.