Every finding on record at Autumn Care of Salisbury

Based on observations and staff interviews, the facility failed to store, label and date food in 1 of 1 freezer reviewed for safe food handling. During an observation conducted with the Dietary Manager, multiple food items were observed removed from their original packaging, placed in resealable plastic bags without labeling, and lacked open and/or expiration dates. Additionally, food items in original packaging were observed without opening or expiration dates. These findings had the potential to affect the safety and quality of food served to residents. The findings included:During an initial kitchen tour of the walk-in freezer, conducted with the Dietary Manager on 03/30/2026 at 9:55 AM, the following concerns were identified:- One bag of french fries had been removed from the original packaging and placed in an unlabeled resealable plastic bag exposed to air, with no open date or expiration date.- Three sausages had been removed from the original packaging and placed in an unlabeled resealable plastic bag, with no open date or expiration date, and visible ice crystals present.- One bag of hush puppies was stored in its original packaging with no open date or expiration date.- One bag of 30 baguettes was stored in its original packaging with no open date or expiration date.- Two packages of gluten-free bread were stored in its original packaging labeled with an open date of 12/04/2025, with missing expiration date.- One chocolate cream pie remained in its original packaging with no expiration date.- One package of 25 chicken breasts had been removed from their original packaging and placed in an unlabeled resealable plastic bag and not dated.On 03/30/2026 at 3:00 PM, an interview was conducted with the Dietary Manager. The Dietary Manager stated all food items stored in the freezer should have been labeled and dated when opened, labeled and dated when removed from the original packaging, and discarded once expired. She reported staff had previously been educated on these requirements during an in-service.On 04/01/2026 at 11:39 AM, an interview was conducted with the Cook's Assistant. She reported she completed weekly checks of the freezer, which included entering the freezer, checking for expired food items, and ensuring items were labeled and dated. The Cook's Assistant stated that weekly kitchen audits were not documented and that if concerns arose, they were addressed immediately. She further stated that during the previous week, a freezer audit had been completed by the [NAME] on second shift.On 04/01/2026 at 11:50 AM, an interview was conducted with the Cook. The [NAME] stated she conducted freezer audits with the Cook's Assistant and that they rotated responsibility for completing the audits weekly. The [NAME] stated she was responsible for completing the freezer audit during the previous week. She further reported she checked expired food items but did not check for improperly labeled food items. The [NAME] stated she had received education regarding proper food storage and labeling and reported that all items in the freezer were labeled appropriately after the concerns were identified.On 04/02/2026 at 2:00 PM, an interview was conducted with the Administrator. The Administrator revealed she was not aware of open food items not being labeled with the appropriate date. The Administrator reported she conducted weekly audits with the Dietary Manager, which included overall kitchen cleanliness, as well as review of the freezer, refrigerator, and dry storage areas. The Administrator stated that an audit conducted on 03/18/2026 revealed food items in the freezer that were not labeled or covered. The Administrator reported corrective action was taken at that time and the items were removed. The Administrator stated the expectation was that all food items should be properly labeled, dated, covered, and monitored for compliance.

Based on record review, observations, and staff interviews, the facility failed to secure cords from wall-mounted televisions which could cause a tripping hazard for 7 of 27 rooms (603,604, 605, 606, 607, 608, and 609) on 1 of 4 halls (600 hall).The findings included:The facility grievances were reviewed, and a grievance filed on 4/30/25 indicated that television cords from the wall-mounted televisions poised a tripping hazard.A purchase order form dated 5/5/25 indicated that ten (10) cord securement kits were approved on 5/5/25 by the former Administrator. An education in-service form dated 5/5/25 and presented by the former Administrator to the Maintenance Director indicated that while the television cords were not a safety concern, the cords should be kept close to the wall by cord securement system or by tying up cords.An audit conducted by the Maintenance Director on 5/7/25 indicated that 38 rooms required television cord securement. Included in the audit identified as needing TV cord securement were 27 rooms on the 600-hall including rooms 603,604, 605, 606, 607, 608, and 609.Observations were conducted on 3/30/26 at 9:58 AM to 10:30 AM. The following rooms had television cords hanging loose from the wall-mounted televisions: 603, 604, 605, 606, 607, 608, and 609. The televisions were hung from the walls approximately 6 feet high and two cords hung down from the televisions to hang freely roughly 2 to 3 feet off the ground. One cord was the power cord plugged into the wall at about 2 feet off the ground, and the second cord was an auxiliary cord that dangled freely. These auxiliary cords appeared to be connected to the televisions and a cable box, and several feet of slack wire were noted to hang in the air. While passing through the space between the end of the bed and the hanging cords, the cords needed to be pushed to the side to pass through the area.Observations were conducted on 4/2/26 at 9:46 AM to 10:00 AM with the Maintenance Director. The following rooms had television cords hanging loose from the wall-mounted televisions: 603, 604, 605, 606, 607, 608, and 609. The Maintenance Director reported he could recall that he placed an order for the cord securement kits, but he did not recall installing the cord securement kits and he was not certain if the kits were backordered or if the facility received the kits. The Maintenance Director explained that he did not have a completed work order for the installation of the cord securement kits, and he did not recall why the kits were not installed in the rooms with loose television cords. The Maintenance Director reported he became aware of the television cords when the grievance was filed on 4/30/25, and he completed an audit of all rooms on 5/7/25 and discovered 38 rooms required cord securement. The Maintenance Director explained he did not have the cord securement kits in the facility, and he had to order them but did not recall what happened after the order was placed. The former Administrator was not available for interview.The Administrator was interviewed on 4/2/26 at 11:40 AM. The Administrator reported she started her position in June 2025, and she was informed by the former Administrator that all investigations were completed, and the corrections had been made. The Administrator explained she was not aware the television cords had not been secured. The Administrator reported she expected repairs to be completed and documented to provide a safe environment for residents.

Based on record review and interviews with the Power of Attorney (POA), staff, and the Nurse Practitioner (NP), the facility failed to ensure a resident's advance directive information was accurate and consistent throughout the medical record for 1 of 3 residents reviewed for advance directives (Resident #3). Resident #3 was admitted to the facility on [DATE]. Resident #3's electronic health record (EHR) revealed the resident's code status was listed as full code in the EHR banner. Resident #3's care plan dated 1/9/2026 revealed Resident #3 was a full code. A discharge return anticipated [NAME] Data Set (MDS) dated [DATE] indicated Resident #3 was discharged to the hospital. An entry MDS dated [DATE] indicated Resident #3 was readmitted to the facility. A review of the Advance Directive dated 01/17/2026, initiated by the hospital physician, revealed the resident's code status was Do Not Resuscitate (DNR). An active physician's order initiated on 01/17/2026 indicated Resident #3's code status was Do Not Resuscitate (DNR). A Care Conference Summary dated 01/23/2026, completed by the Social Worker, indicated Resident #3 was a full code. Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. On 03/30/2026 at 2:00 PM, an interview was conducted with Resident #3's POA. The POA stated that a few months ago, the resident became ill and was admitted to the hospital. He reported that he could not recall the exact timeframe of the hospitalization. The POA stated that during that hospitalization, Resident #3 wished for his code status to be DNR. Resident #3's POA further stated that once back at the facility, Resident #3 had expressed a desire to be a full code. The POA stated he notified staff at the facility that Resident #3 would be a full code. He could not recall who specifically was notified or the timeframe of the notification. The POA stated he believed that Resident #3's code status had remained full code while a resident at the facility and that he was unaware the resident's code status was DNR following his readmission from the hospital. Additionally, Resident #3's POA reported that a care plan meeting had occurred within the current year (2026), but he could not recall if Resident #3's code status was reviewed or discussed during the meeting. On 03/30/2026 at 3:00 PM, a phone interview was conducted with the Social Worker regarding Resident #3's code status. The Social Worker stated that upon admission to the facility on [DATE], Resident #3 was a full code. The Social Worker reported that Resident #3 was hospitalized in January 2026 and returned to the facility as a DNR. The Social Worker stated that Resident #3's last care plan meeting was held on 01/23/2026 and included the resident's POA, herself, and the Minimum Data Set (MDS) Nurse. The Social Worker reported that during the meeting, Resident #3's code status was discussed and remained DNR per the POA. When asked about the discrepancy between the physician's order that indicated DNR and the care plan, Care Conference Summary, and the Demographic tab in the EHR that all reflected full code, the Social Worker stated the discrepancy occurred because she did not update the code status at the time of the care plan meeting. She explained that she typically completed updates a few days after the care plan meeting. The Social Worker stated she was also responsible for updating the code status on the Demographic tab of the EHR. The Social Worker further stated she was responsible for conducting code status audits and completed one three months ago, with no concerns identified. On 03/31/2026 at 12:39 PM, an interview was conducted with the MDS Nurse regarding Resident #3's code status. The MDS Nurse reported that during the care plan meeting on 01/23/2026 Resident #3's POA requested that Resident #3's code status remain DNR. The MDS Nurse stated she made the NP aware of this information. The MDS Nurse further stated the Social Worker was responsible for updating the code status on the care plan. On 03/31/2026 at 1:00 PM, a phone interview was conducted with the NP regarding Resident #3's code status. The NP stated he spoke with Resident #3's POA during the resident's most recent hospitalization; however, he could not recall the exact date of the conversation. The NP reported that the POA wished for Resident #3's code status to remain DNR. An interview was conducted on 04/02/2026 at 10:30 AM with the Regional Nurse Consultant, who was serving as the acting Director of Nursing (DON). The Regional Nurse Consultant revealed she was not aware of the discrepancy with Resident #3's code status in the medical record. The Regional Nurse Consultant stated that when a family requested to initiate, change, or maintain an advance directive, the expectation was that the care plan and EHR be updated at that time without delay. She further stated that a resident or family member may change an advance directive at any time and should inform nursing staff or social services of the requested change. The Regional Nurse Consultant acknowledged that the care plan and EHR should have been updated to reflect the resident's current code status. An interview was conducted with the Administrator on 04/02/2026 at 11:00 AM. The Administrator revealed she was not aware of the code status discrepancy with the physician's order for DNR and the care plan/demographic tab information in the EHR that both indicated full code for Resident #3. The Administrator stated that the expectation was that the code status documented in the EHR, physician orders, and care plan be consistent and reflect the same information. The Administrator further stated that Resident #3's care plan and EHR should have been updated immediately upon notification of the change in code status.

Based on observations, record review, manufacturer's instructions, and interviews with staff, Medical Director, and the Nurse Practitioner, the facility failed to dispose of single use feeding tube declogging devices contrary to manufacturer instructions, which increased the risk of contamination and infection (Resident #5) and failed to ensure a resident was administered the tube feeding formula specified in the physician order (Resident #37) for 2 of 2 residents reviewed for tube feeding (Resident #5 and Resident #37).The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnosis of a history of gastrostomy tube (a flexible, hollow tube surgically placed through the abdomen into the stomach) for feeding and medication administration. She was readmitted to the facility on [DATE] with orders to continue the use of her gastrostomy tube for feeding and medication administration. A quarterly Minimum Data Set assessment dated [DATE] indicated severe cognitive impairment, presence of feeding tube, use of a feeding tube for nutrition, received 3-51% or more of her daily total calories from enteral feeding, and received 2-501 milliliters of fluid each day. On 3/30/2026 at 11:55 AM Resident #5 was observed lying in bed with a tube feeding infusing at 40 milliliters per hour. A soiled clear plastic bag containing dried tan feeding residue hung on the wall behind the head of the bed. Inside were two long, thin plastic stylets (declogging devices) with dried residue on them. A manufacturer's package inside the bag displayed the product name Enteral Feeding Tube Declogger and stated under Precautions that the declogger was intended for single use only. During an observation and interview on 3/30/2026 at 11:55 AM, Nurse #8 entered Resident #5's room and offered to answer any questions about the feeding set-up or the resident's care. She reported that night shift staff were responsible for maintaining the declogging devices and stated the decloggers were used for one week. She did not remove used soiled decloggers observed at that time. During an observation of Resident #5's room and interview with Nurse #8 on 3/31/2026 at 9:30 AM, the observation revealed the two used soiled decloggers that had been inside the soiled bag behind the head of the bed were no longer present. Nurse #8 reported she removed the 2 soiled decloggers and discarded the packaging on 3/30/2026. She stated she hung new supplies on the morning of 3/31/2026 and indicated she had not used the decloggers herself. She stated the devices were intended for single use only and should be discarded after each use. On 3/31/2026 and 4/1/2026 attempts to reach Nurse #5 by telephone for an interview were unsuccessful. Nurse #5 was assigned to Resident #5's during night shift on 3/28/2026 and 3/29/2026. On 4/1/2026 at 6:09 AM Nurse #1 reported she was an agency nurse who had worked at the facility for three months and had completed training in feeding tube care. She stated she used a new feeding tube declogger each time and threw it away immediately after use. She confirmed she had not worked night shift on 3/28/2026 or 3/29/2026. On 4/1/2026 at 6:22 AM Nurse #10 reported she completed training in medication administration and feeding tubes. She stated the feeding tube decloggers were not reusable and should be discarded after use. She reported a new declogger could be obtained from the central supply closet. On 4/2/2026 at 1:00 PM, a telephone interview was conducted with Nurse #11. She reported she had worked the 7:00 PM to 7:00 AM shift for several years and previously worked every other weekend and had previously cared for Resident #5. She reported she had not used a declogger herself in a very long time but had assisted another staff in the use. She reported that she understood them to be reusable but would have to ask her supervisor or coworker how many times they could be reused because she had not used one in a very long time. Nurse #11 further stated she had not worked the previous weekend. On 3/31/2026 at 10:00 AM the Central Supply Manager explained that the facility stocked two different sizes of single use feeding tube decloggers. She confirmed the facility only had single-use decloggers and staff were supposed to throw them away after one use. She pointed out the manufacturer's warning label that read the device should be discarded after a single use and showed that ten packages of decloggers were available in the supply room. On 4/1/2026 at 11:40 AM the Long Term Care Unit Manager stated she served as the Unit Manager for all the long term care halls and participated in infection control and environment of care rounds. She reported she had not been at work on 3/30/2026 or 3/31/2026 and stated she was unaware that single use feeding tube decloggers had been reused. She reported that staff received clear instruction during orientation and on their skills checklists on how to administer tube feedings and label supplies. She added nurses were expected to follow physician orders when administering and managing feeding tubes. She stated the reuse of single-use medical devices can cause infections and staff should follow the manufacturer's instructions. On 4/2/2026 at 1:11 PM Nurse Practitioner #2 was made aware of the 3/30/2026 surveyor observation of a soiled bag containing two used decloggers with dried residue in Resident #5's room. She stated she was unaware that staff had been retaining or reusing single use decloggers. She reported that items labeled for single use should be used once and discarded. She stated she was not aware of harm resulting from reuse but identified increased infection risk for residents with gastrostomy tubes because of the high sugar content and the feeding tube sites often get infected easily. On 3/31/2026 at 11:38 AM, an interview was conducted with the Interim Director of Nursing (DON). She reported she was not aware that any staff had reused single use feeding tube decloggers. The Interim DON stated that nursing staff were expected to follow physician orders and follow any manufacturer's instructions for the use of tube feeding supplies.2. Resident #37 was admitted to the facility on [DATE] with diagnoses of gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding).Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was independent with most activities of daily living (ADL). Resident #37 received all nutrition and hydration through the feeding tube. Review of Resident #37's care plan dated 1/19/2026 revealed she was at risk for complications related to the need for a feeding tube. Interventions included: administer tube feedings and flushes per order, head of bed elevated during feedings per order, NPO status (nothing by mouth), if tube becomes dislodged notify the MD (Medical Doctor).Review of a physician order dated 6/19/25 revealed an order for Resident #37 to receive Diabetasource 1.2 at 80 milliliters (ml) per hour (hr.) administered continuously over 20 hours (disconnect at 8:00 PM reconnect at 12:00 AM) with all shifts required to document in the medication administration record (MAR). Record total amount every shift.Review of March 2026 MAR revealed Nurse #3 signed off Resident #37's enteral tube feeding of Diabetasource 1.2 at 80 ml/hr. was started at 12:00 AM on 3/30/2026.An observation of Resident #37's tube feeding formula container was conducted on 3/30/2026 at 12:34 PM. Resident #37 was sitting on her bed in her room while being administered her tube feeding. The tube feeding formula container was labeled, IsoSource 1.5 at 80 ml hourly and dated 3/30/26 at 10:52 AM. Additional observation of Resident #37's tube feeding on 3/30/2026 at 3:39 PM revealed she continued to receive IsoSource 1.5 at 80 ml hourly.An observation and interview with Nurse #1 were conducted on 3/30/2026 at 3:41 PM. During the interview, Nurse #1 stated she hung Resident #37's tube-feeding formula container at 10:52 AM and labeled it as IsoSource 1.5. She reported that she believed IsoSource and Diabetasource were equivalent formulas because they are produced by the same manufacturer. Based on this assumption, Nurse #1 confirmed she hung an IsoSource 1.5 formula container for Resident #37.Nurse #1 stated on 3/30/2026 at 3:45 PM she verified the physician orders, and the proper tube feeding was infusing for Resident #37.An interview with the Registered Dietitian was conducted on 3/31/2026 at 10:35 AM. She stated there was difference with Diabetasource tube feeding formula and IsoSource tube feeding formula. The Registered Dietitian stated Diabetasource 1.2 formula provides less carbohydrates and is used for those who have a diagnosis of diabetes as such with Resident #37. She stated IsoSource 1.5 formula was used for short term use and provides extra nutrition but if Resident #37 received it on a short-term basis this would not have adversely affected her. She further revealed Resident #37 would have had a significant weight gain if she was receiving IsoSource 1.5 instead of physician ordered Diabetasource 1.2 tube feeding formula. The Registered Dietitian confirmed Resident #37 had not had a weight gain.An interview was conducted with the Medical Director on 4/1/2026 at 11:00 AM. He revealed that if Resident #37 received IsoSource 1.5 formula there would not be an adverse outcome if this was administered on a short-term basis. He further revealed he would not order the IsoSource 1.5 tube feeding formula because of Resident #37's diagnosis of diabetes and Diabetasource 1.2 was the proper tube feeding formula.

Based on record review and staff, resident, and Urologist interviews, the facility failed to ensure a follow-up urology appointment was scheduled and completed as ordered for 1 of 3 residents reviewed for urinary catheter (Resident #39).Resident #39 was admitted to the facility on [DATE].Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact.A review of the hospital urology consult after-visit summary dated 01/13/2026 revealed Resident #39's suprapubic catheter was changed, with instructions to follow up on 02/10/2026 for routine catheter replacement.A review of Nurse #1's progress note dated 01/13/2026 revealed the suprapubic catheter was changed, and Resident #39 was to return for a urology follow up appointment on 02/10/2026.A phone interview was attempted with Nurse #1 on 03/30/2026 at 2:00 PM; however, no response was received.A physician's order dated 03/27/2026 indicated Resident #39 had an order to change the catheter as needed (PRN) if it became clogged or dislodged.An interview on 03/30/2026 at 1:26PM with Resident #39 revealed his suprapubic catheter was last changed on 01/13/2026 by a urologist. Resident #39 stated the suprapubic catheter was to be changed monthly by a urologist. Resident #39 further stated he made a nurse aware of the urology appointment in February of 2026 and could not recall who he spoke to. Resident #39 reported he had lower abdominal soreness and believed it was related to the suprapubic catheter not being changed in over a month.A review of Nurse #2's progress note dated 03/22/2026 revealed Resident #39 voiced concerns about the suprapubic catheter not being changed and requested a urology appointment. The progress note also revealed Nurse #2 left a message for the facility Transportation Coordinator to arrange the appointment.An interview with Nurse #2 on 03/31/2026 at 10:24 AM revealed Resident #39 stated he had not been to the urologist in over a month and wanted to have his suprapubic catheter changed. Nurse #2 stated she contacted the facility's Transportation Coordinator to schedule a urology appointment. Nurse #2 further stated Resident #39 had a PRN (as needed) order for the suprapubic catheter to be changed, and she offered to change it; however, Resident #39 refused, stating he preferred for the urologist to perform the suprapubic catheter change. Nurse #2 stated she was not aware of the urology appointment that occurred on 01/13/2026 or of the follow up appointment scheduled for 2/10/2026. Nurse #2 stated that Resident #39 did not report abdominal soreness and she assessed him regularly for pain and cleaned the suprapubic catheter site during care.An interview with the facility's Transportation Coordinator on 03/31/2026 at 10:37 AM revealed she was responsible for scheduling all outside appointments. She stated that once a resident returned from an appointment, the after-visit summary was reviewed by the nurse, who then identified any follow-up appointments. The nurse was then responsible for making a copy of the after-visit summary, highlighting the next appointment, and placing it in a box outside of her office labeled appointments. The Transportation Coordinator stated she then enters the upcoming appointment on a physical calendar and in the electronic health record (EHR) under the resident calendar tab. When asked about Resident #39's urology appointment, she stated the last documented appointment was on 01/13/2026. She reported she did not have an appointment scheduled for February 2026 and stated she was not aware of a follow-up appointment on 2/10/2026. The Transportation Coordinator further stated she scheduled the urology appointment for 03/31/2026 after Nurse #2 informed her of Resident #39 concerns on 03/22/2026.A review of Nurse #2's progress note dated 03/31/2026 revealed Resident #39 was seen by urology, and the suprapubic catheter was changed on 03/31/2026.A phone interview was conducted with the hospital Urologist via telephone on 03/31/2026 at 3:58 PM. The Urologist reported she evaluated Resident #39 on 03/31/2026 and observed discharge and a small amount of blood at the suprapubic urinary catheter insertion site. The Urologist indicated she found no skin breakdown or infection at that time of the evaluation. The Urologist revealed Resident #39 had been scheduled for a suprapubic urinary catheter replacement on 02/10/2026 but did not attend the appointment. The Urologist stated the suprapubic urinary catheter required monthly replacement to prevent infection and tissue breakdown. The Urologist indicated that missing the 02/10/2026 appointment placed Resident #39 at high risk for harm and could have resulted in infection and tissue breakdown.An interview was conducted on 04/02/2026 at 10:30 AM with the Regional Nurse Consultant, who was serving as the acting Director of Nursing (DON). The Regional Nurse Consultant revealed she was not aware of the missed urology appointment on 02/10/2026 for Resident #39. The Regional Nurse Consultant stated her expectation was that nurses were to communicate with the Transportation Coordinator regarding appointments so residents could attend appointments as scheduled.An interview was conducted with the Administrator on 04/02/2026 at 11:00 AM, which revealed she was not aware of the missed urology appointment on 02/10/2026 for Resident #39. The Administrator stated Nurse #1 was an agency nurse and may not have been aware of the process for notifying the Transportation Coordinator. The Administrator stated the expectation was for nursing to notify the Transportation Coordinator of upcoming appointments for residents to ensure appointments were arranged timely so residents could attend appointments as scheduled.

Based on record review, Resident Representative, Nurse Practitioner, and staff interviews, the facility failed to implement their abuse policy and procedures in the areas of reporting, investigation and protection after an allegation of abuse for 1 of 4 residents reviewed for abuse (Resident #1). The findings included:Review of the facility Resident Abuse Policy with the last revision date of 7/11/2024 revealed the following: It is the facility's policy to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property, and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately report begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy.If a staff member is accused or suspected of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property, the facility immediately remove staff member from resident care area and request a written statement from accused staff member. The accused staff member will remain under direct supervision until statement is complete and/or law enforcement arrives if applicable. The accused staff member will then be removed from the facility and the schedule pending the outcome of the investigation.If appropriate the social services department should be notified of the incident so that they may take appropriate interventions to care for the psychosocial needs of any involved resident. The resident's responsible party and the resident's attending physician will be notified of the incident. Documentation in the nurses' notes should include the results of the resident's range of motion, body assessment, vital signs, the notification of the physician and the responsible party and treatment provided. Appropriate quality assurance documentation should be completed as well. All allegation of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable state agency.Resident #1 was readmitted to the facility 1/7/25 with diagnoses including hemiplegia (paralysis on one side of the body), diabetes and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 to be moderately cognitively impaired. The MDS documented Resident #1 had clear speech with distinct intelligible words, and she was usually understood, with difficulty communicating some words or finishing thoughts. The MDS documented Resident #1 had adequate vision and hearing and did not use corrective lens or hearing aids. The MDS documented Resident #1 required substantial assistance with toileting and bed mobility. The MDS documented Resident #1 had limited range of motion for one side on her upper and both sides of her lower body.Review of the medical record for Resident #1 revealed no notes regarding an allegation of abuse by Resident #1.Nursing notes dated 12/25/25 indicated Resident #1 was at her baseline and denied pain.Handwritten statements documented by the Activities Director, the Activities Assistant, and 2 NAs were reviewed. The statements documented on 12/26/25 indicated Resident #1 reported to them that a male NA had hit her face. The statements documented notification of the Administrator of the allegation. The Activities Assistant was interviewed on 1/14/26 at 9:39 AM. The Activities Assistant reported she was passing out the daily newsletter before breakfast on 12/26/25 to residents and when she entered Resident #1's room, she noted that Resident #1 was very upset and crying, and Resident #1 was patting her left cheek with her left hand and saying hit-hit. The Activities Assistant reported the Activities Director was at Resident #1's beside and NA #1 had gone to get the Administrator. The Activities Assistant reported that she saw Resident #1 later in the day on 12/26/25 and she was upset, crying and repeated the same actions of patting her cheek and saying hit-hit. The Activities Assistant reported Resident #1's face was pink on the left side but not bruised.An interview was conducted with NA #1 on 1/13/26 at 6:52 PM. The NA reported she was passing breakfast trays on 12/26/25 and when she entered Resident #1's room, she saw Resident #1 crying with the Activities Director holding her hand. NA #1 reported she approached Resident #1 and Resident #1 said to her [NAME]-[NAME] while patting her left check with her left hand. NA #1 explained that Resident #1 had severe aphasia (difficulty with speech related to a stroke) and needed time to communicate. NA #1 reported that Resident #1 continued to pat her cheek and ask, why he [NAME]-[NAME]? Why he [NAME]-[NAME]? and Resident #1 was crying and upset. NA #1 noted that Resident #1's left cheek was pink and swollen. NA #1 reported she left immediately to get Unit Manager #1 and the Administrator. The Activities Director was interviewed on 1/14/26 at 9:20 AM. The Activities Director reported she was on the 400 hall the morning of 12/26/25 to assist the NAs with breakfast trays and when she entered Resident #1's room, Resident #1 was frantically motioning for the Activities Director to come to her. The Activities Director explained that Resident #1 was crying and her left cheek was red. Resident #1 was very upset and was patting the left side of her face with her left hand and saying hit-hit. The Activities Director reported she asked Resident #1 when and Resident #1 said last night. The Activities Director reported NA #1 entered the room and when NA #1 was told what happened, she left to get Unit Manager #1 and the Administrator. The Activities Director reported that Resident #1 was upset and crying each time the Activities Director saw her on 12/26/25, which was later in the afternoon after lunch and again before the evening meal. The Activities Director described Resident #1's cheek as being pink and swollen but not bruised.The Environmental Supervisor was interviewed on 1/14/26 at 9:53 AM. The Environmental Supervisor explained she was very familiar with Resident #1 and often stopped by to see her. The Environmental Supervisor reported that the morning of 12/26/25 she went in to say good morning to Resident #1, and Resident #1 called the Environmental Supervisor by name and said hit-hit and was very upset and crying. The Environmental Supervisor reported she left the room to notify the Unit Manager #1 and was told by Unit Manager #1 that they were aware of the allegation. The Environmental Supervisor described Resident #1 as having a pink and swollen left cheek but did not observe bruising.NA #2 was interviewed on 1/14/26 at 10:34 AM. NA #2 reported she took a meal into Resident #1 on 12/26/25, (but could not recall which meal it was) and she reported Resident #1 grabbed her hand and said, hit-hit. NA #2 reported Resident #1's left cheek was puffy, red and she noticed a bruise under the left eye, which she reported. NA #2 reported she went to NA #1 and asked if NA #1 knew what was going on with Resident #1 and NA #1 told NA #2 it had been reported to the Unit Manager and Administrator.An interview was conducted with Nurse #3 on 1/14/26 at 11:27 AM. Nurse #3 explained she was assigned to Resident #1 on 12/26/25 and the Unit Manager had informed her of the allegation of abuse by Resident #1. When Nurse #3 went into Resident #1's room, Resident #1 grabbed her hand and said [NAME]. Nurse #3 reported Resident #1 was very upset on 12/26/25. Nurse #3 reported NA #2 reported bruising under Resident #1's eye and she completed a skin assessment and reported she did not observe bruising or injuries. When asked why this assessment was not documented in the medical record, Nurse #3 reported she was told by the DON not to worry about the charting and she would take over the investigation.Unit Manager #1 was interviewed on 1/14/26 at 10:43 AM. Unit Manager #1 reported on 12/26/25 during breakfast, NA #1 reported to her that something was wrong with Resident #1. Unit Manager #1 explained she asked what happened and NA #1 reported Resident #1 said someone hit her. Unit Manager #1 explained she told NA #1 to get the Administrator, and she went to Resident #1's room. Unit Manager #1 described Resident #1's aphasia as having limited speech and confusing yes/no answers at times. Unit Manager #1 explained Resident #1 was patting the left side of her face with her left hand and saying [NAME]-[NAME] my face. Unit Manager #1 explained the Activities Director and Activities Assistant were in the room, and she asked them to leave. Unit Manager #1 described that Resident #1 started to cry and said [NAME]-[NAME] my face, [NAME]-[NAME] my face. He. He. I don't know. Unit Manager #1 reported the Administrator arrived at Resident #1's room and started asking Resident #1 questions. Unit Manager #1 explained that an allegation of abuse usually meant the accused staff member was suspended during an investigation, but NA #3 was not suspended and remained on the schedule to work. Unit Manager #1 reported she did not want NA #3 to work with Resident #1, and she changed his assignment to another hall. Unit Manager #1 reported on 1/10/26 NA #3 reported for work, and she noticed he was assigned to Resident #1 and she told him she was going to change the assignment. When he got upset about the change in assignment, Unit Manager #1 explained he could accept the change or clock out. Unit Manager #1 reported NA #3 clocked out and left the building on 1/10/26. Unit Manager #1 explained that she completed a skin assessment on Resident #1 on 12/26/25 and had a paper copy of the assessment but was waiting for direction from the Administrator regarding documentation in Resident #1's medical record. Unit Manager #1 reported NA #3 was the only white male working on 12/25 to 12/26/25 during the night shift and NA #3 was assigned to Resident #1.A skin assessment dated [DATE] completed by Unit Manager #1 documented no skin issues and no bruising noted.Review of the time sheets for NA #3 revealed he worked 12-hour shifts from 7:00 PM to 7:00 AM on 12/26/25, 12/27/25, 12/28/25, 1/2/26, 1/3/26, and 1/4/26.NA #3 was interviewed by phone on 1/14/26 at 11:58 AM. NA #3 reported he was assigned to Resident #1 on 12/25/25 from 7:00 PM until 7:00 AM on 12/26/25 and there was nothing unusual about that shift. NA #3 reported he and NA #5 had switched assignments because NA #5 had asked him to switch. NA #3 reported he was not aware of Resident #1's allegation of abuse. NA #3 reported the night shift from12/25/25 to 12/26/25 was normal and he provided incontinence care to Resident #1 at least once and he denied harming or hitting Resident #1. NA #3 reported he was told he could not take care of Resident #1, but he didn't receive a reason why his assignment was moved. NA #3 reported he was not interviewed by the Administrator or anyone else or asked to write a statement about what occurred that night shift. NA #3 reported he worked his full shift on 12/26/25, and worked full 12-hour shifts on 12/26/25, 12/27/25, 12/28/25, 1/2/26, 1/3/26, 1/4/26, and when he worked on 1/10/26, his assignment was changed after he had clocked in for 20 minutes by Unit Manager #1. NA #3 explained when he complained to Unit Manager #1 about having his assignment changed, he was told he could either accept the change in schedule or clock out and leave. NA #3 reported he clocked out and left. An interview was conducted with the Social Worker (SW) on 1/14/26 at 10:05 AM. The SW reported she did not work on 12/26/25 and returned to work on 12/29/25. The SW explained she had not been notified of an allegation of abuse from Resident #1. The SW explained she would have completed a trauma response assessment for Resident #1 and made referrals to appropriate providers, as well as interviewed other residents about abuse.The Human Resources (HR) Director was interviewed on 1/14/26 at 10:19 AM. The HR Director explained that she returned to work on 12/29/25 after the holidays and found a written statement by the Activities Director regarding Resident #1's allegation of abuse. The HR Director reported she immediately went to the Administrator, and the Administrator had reported to her that the incident was taken care of. The HR Director explained that as the day passed on 12/29/25 more staff were approaching her and giving her written statements regarding the incident. The HR Director reported that staff were upset that an investigation had not been completed in a manner that they expected and they wanted someone to investigate the incident. The HR Director explained that staff felt that she might be able to have the incident investigated.The Resident Representative was interviewed by phone on 1/15/26 at 3:31 PM. The Representative explained he arrived at the facility on 12/26/25 about lunchtime to see Resident #1 and he could tell something had upset her. The Representative explained that when he arrived, Resident #1 said bam-bam to him and when the Representative questioned Resident #1 if she had hit herself, Resident #1 said no. The Representative reported he spoke to the Administrator and told the Administrator that Resident #1 was able to recall the visitors she had on 12/25/25 and if Resident #1 reported that someone hit her in the face, he believed that someone hit her in the face. The Representative explained that he did not see a bruise on 12/26/25 on Resident #1's face but Resident #1 was very upset and her left cheek was pink. The Representative reported he returned to the facility on [DATE] and there was no bruising on Resident #1's face, but she remained upset. The Representative said he spoke with Unit Manager #1 on 12/29/25 and she had told him NA #3 would not be assigned to Resident #1. The Representative described telling Resident #1 that the NA would not be assigned to her again and she said Thank you! Thank you! and became very emotional and teared up. The Representative reported he was told by the Administrator an investigation was being conducted.The Assistant Director of Nursing (ADON) was interviewed on 1/14/26 at 11:18 AM. The ADON explained that she was not informed of the allegation of abuse from Resident #1, but when she returned to work on 12/29/25, there was talking on the halls by staff about the allegation and the ADON spoke to the Administrator who reported that she had determined that during incontinence care, something had happened to Resident #1's face. The ADON indicated she had not participated in an investigation into the allegation of abuse because she had been told the investigation was complete.The DON was interviewed on 1/14/26 at 12:08 PM. The DON explained she was not working on 12/26/25 and returned to work on 12/29/25. When the DON returned to work, she was told by the Administrator that Resident #1 had indicated that she was hit but the Administrator had determined that during incontinence care, NA #3's arm rested against Resident #1's face. The DON reported she attempted to call NA #3 to interview him, but he did not return her call. The DON reported she had interviewed NA #1 but had not documented the interview. The DON reported that NA #1 told her that Resident #1 had reported that a white male had hit her on the face on 12/26/25 and that NA #1 had reported the allegation to the Administrator. The DON reported to the Administrator lead the investigation for the allegation of abuse and she did not know why NA #3 was not suspended and why the allegation was not reported. The DON explained the Administrator had determined that Resident #1's face was touched during incontinence care and that the investigation was complete. The DON concluded that she had contacted the staff working the night shift on 12/25 to 12/26/25 and all staff reported not seeing or hearing anything unusual during the shift. The DON reported she did not know if she documented the interviews with staff. The DON was unable to provide written documentation of the interviews she conducted.An interview was conducted with the Administrator on 1/14/26 at 1:04 PM. The Administrator reported that she was working 12/26/25 and she was notified by NA #1 that Resident #1 was alleging she had been hit on the face. The Administrator reported she went to Resident #1's room immediately to observe her and ask questions. The Administrator reported that because of Resident #1's impaired cognition, she kept questions to Resident #1 very basic and asked when it happened and if the person was angry. The Administrator reported Resident #1 said [NAME]-[NAME] and when asked to show the part touched, Resident #1 touched her face. The Administrator reported she assisted Resident #1 to roll on her right side towards the Administrator and during the turn, the Administrator's forearm aligned with Resident #1's jawline. The Administrator reported she asked Resident #1 if that is what happened and Resident #1 responded yes. The Administrator explained she talked to the Representative of Resident #1, and he had said he didn't think what happened was abuse. The Administrator reported she did not think that Resident #1's allegation was valid due to her cognitive status. The Administrator explained that she did not feel that it was an allegation of abuse by Resident #1 and did not suspend NA #3 or complete a 24-hour report (initial allegation report).The Nurse Practitioner (NP) was interviewed on 1/15/26 at 4:13 PM. The NP reported he was not notified Resident #1 had made an allegation of abuse on 12/26/25. The NP reported due to Resident #1's severe expressive aphasia, he was not certain if she was reliable due to her cognitive changes and he would have called an expert to examine her to determine what had happened.

Based on observation and staff interviews, the facility failed to label and date leftover food items, remove food items with signs of spoilage and not store staff food in 1 of 2 nourishment room refrigerators (the 600 Hall nourishment room); and failed to remove expired food stored for use in 1 of 1 walk-in coolers. These practices had the potential to affect food served to residents. Findings included: 1. An observation and interview on the 600 hall nourishment room refrigerator conducted with Nurse Aide (NA) #4 and NA #5 on [DATE] at 10:45 AM revealed a bag of croutons not labeled or dated, a quart size sealed plastic bag with strawberries and blueberries that were observed to have discoloration and with fuzzy white substance, a microwavable dinner tray not labeled or dated of meat and broccoli observed to have discoloration and fuzzy substance on the food, a unlabeled and undated plastic container with white substance that resembled mold, and NA #4's lunch bag. NA #4 revealed she put her lunch in the fridge but was aware that it should not be in there. NA #4 and NA #5 nursing staff and dietary were responsible for checking the nourishment rooms daily and ensuring items are labeled, dated and discarded. 2. An observation and interview in the kitchen on [DATE] at 11:35 AM revealed a container of leftover cream of mushroom soup that had a discard date of [DATE] in the walk-in cooler. The Dietary Manager further revealed the soup should have already been discarded and must have been missed when items were checked. A follow up interview conducted with the Dietary Manager on [DATE] at 8:15 AM revealed Dietary Aide #1 oversaw checking nourishment rooms over the weekend. The Dietary Manager further revealed she did not know why the nourishment room on the 600 hall was not checked but expected nourishment rooms and kitchen items to be checked daily for labeling and dating leftover food items. Dietary aide #1 was unable to be interviewed during the survey. An interview conducted with the Administrator on [DATE] at 11:20 AM revealed he expected nourishment rooms to be checked daily and foods be stored and labeled correctly.

Based on record reviews, and residents and staff interviews, the facility failed to honor residents' preferences for a shower for 3 of 3 residents reviewed for choices (Resident #32, Resident #77, and Resident# 24.) The findings included: 1a. Resident #32 was admitted to the facility on [DATE] with diagnoses including dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #32 to be moderately cognitively impaired. The MDS assessed Resident #32 to require substantial assistance with showering/bathing. The MDS documented Resident #32 said it was very important to choose between a shower and a sponge bath. Review of the facility shower schedule revealed Resident #32 (who resided on the 200 hall) was scheduled for a shower on Tuesday and Friday. The Activities of Daily Living log for Resident #32 was reviewed and it was noted on Friday 2/28/25 she did not receive a shower. Resident #32 was interviewed on 3/3/25 at 2:23 PM and she reported she did not get a shower on 2/28/25 and this was upsetting to her. A phone interview was conducted with Nursing Assistant (NA) #3 on 3/6/25 at 8:49 AM. NA #3 reported she was an agency NA, and she was first assigned to the facility on [DATE]. NA #3 reported she was assigned to another hall at the start of the shift at 7:00 AM but soon after, she was moved to the 200 hall and was assigned to provide care to Resident #32. NA #3 reported she had been told by other staff (uncertain of which staff member) that there were no showers for the hall, and she did not offer Resident #32 a shower on 2/28/25. NA #3 reported if she had been told the facility had a shower schedule, she would have checked it to see if any of her assigned residents had a shower scheduled on that date. NA #3 reported Resident #32 did not request a shower from her on 2/28/25. b. Resident #77 was admitted to the facility on [DATE] with diagnoses including asthma. The annual MDS dated [DATE] documented Resident #77 said it was very important to choose between a shower and a sponge bath. The quarterly MDS dated [DATE] assessed Resident #77 to be moderately cognitively impaired and she required substantial assistance with showering/bathing. Review of the facility shower schedule revealed Resident #77 (who resided on the 200 hall) was scheduled for a shower on Tuesday and Friday. The Activities of Daily Living log for Resident #77 was reviewed and she did not receive a shower on 2/28/25. Resident #77 was interviewed on 3/5/25 at 10:25 AM and she reported she did not receive a shower on 2/28/25 and she wanted a shower. Resident #77 reported not receiving her shower was upsetting to her. A phone interview was conducted with Nursing Assistant (NA) #3 on 3/6/25 at 8:49 AM. NA #3 reported she was an agency NA, and she was first assigned to the facility on [DATE]. NA #3 reported she was assigned to another hall at the start of the shift at 7:00 AM but soon after, she was moved to the 200 hall and was assigned to provide care to Resident #77. NA #3 reported she had been told by other staff (uncertain of which staff member) that there were no showers for the hall, and she did not offer Resident #77 a shower on 2/28/25. NA #3 reported if she had been told the facility had a shower schedule, she would have checked it to see if any of her assigned residents had a shower scheduled on that date. NA #3 reported Resident #77 did not request a shower from her on 2/28/25. c. Resident #24 was admitted to the facility 5/12/23 with diagnoses including heart disease. The annual MDS assessment dated [DATE] documented the staff assessment of daily and activity preferences that Resident #24 preferred to receive a shower or a bed bath. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #24 was cognitively intact and she required moderate assistance with showering/bathing. Review of the shower schedule for Resident #24 (who resided on the 200 hall) revealed she was scheduled for a shower on Tuesday and Friday. The Activities of Daily Living log for Resident #24 was reviewed and she did not receive a shower on 2/28/25. Resident #24 was interviewed on 3/5/25 at 10:28 AM. Resident 24 reported she did not receive a shower on 2/28/25 and she wanted a shower. Resident #24 reported she thought she would be offered a shower later on that date, but no one offered her a shower, and this was upsetting to her. A phone interview was conducted with Nursing Assistant (NA) #3 on 3/6/25 at 8:49 AM. NA #3 reported she was an agency NA, and she was first assigned to the facility on [DATE]. NA #3 reported she was assigned to another hall at the start of the shift at 7:00 AM but soon after, she was moved to the 200 hall and was assigned to provide care to Resident #24. NA #3 reported she had been told by other staff (uncertain of which staff member) that there were no showers for the hall, and she did not offer Resident #24 a shower on 2/28/25. NA #3 reported if she had been told the facility had a shower schedule, she would have checked it to see if any of her assigned residents had a shower scheduled on that date. NA #3 reported Resident #24 did not request a shower from her on 2/28/25. The Director of Nursing (DON) was interviewed on 3/6/25 at 9:37 AM. The DON reported NA #3 did not get accurate information from other staff members and Resident #32, Resident #77, and Resident #24 should have been offered a shower on 2/28/25. The DON reported she expected the bathing preferences of residents to be honored. The Administrator was interviewed on 3/6/25 at 2:01 PM and she reported she expected residents to receive showers on their scheduled days if they wanted a shower.

Based on record review, and Responsible Party and staff interviews, the facility failed to make prompt efforts to resolve a grievance 1 of 3 residents reviewed for grievances (Resident #72). The findings included: The facility grievance policy dated 11/2016 and revised 8/2018 read, in part: Upon receipt of an oral, written or anonymous grievance . the Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, if indicated; .the Grievance Committee/Grievance Official shall complete an investigation of the resident's grievance. This may include a review of the facility processes, programs, and policies, as well as interview with staff, residents and visitors, as indicated; Upon completion of the review, the Grievance Official will complete a written grievance decision that includes the following: the date the grievance was received, the summary of the statement of the resident' grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action that was or will be taken, and if corrective action was taken a summary of the corrective action .the Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the grievance was resolved or will be resolved. A copy of the written grievance decision will be provided to the resident upon request. Resident #72 was admitted to the facility 6/29/22 with diagnoses including Parkinson's Disease. The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #72 to be severely cognitively impaired. The Responsible Party provided an email dated 11/11/24 at 2:49 PM from the Responsible Party to Social Worker (SW) #1, read, I received a very concerning call last night that (Resident #72) has no Parkinson's medications to take because (the medications) could not be found. This is obviously a very, very big deal, and I need to know exactly how this happened and what is the solution. From my understanding, she may have already been out of medications for a couple of days before I was notified. Can you please let me know the full details surrounding this situation? Thank you. A grievance dated 11/11/24 filed on behalf of Resident #72 by the Responsible Party documented the Responsible Party reported his concern to SW #1 and indicated he had concerns about medication administration for Resident #72. The concern was assigned to the Director of Nursing (DON) on 11/11/24 and the DON documented on the grievance attempted to call (Responsible Party) time 3 to discuss medications and answer questions. At the bottom of the grievance form it was documented by the DON she had attempted to call the Responsible Party on 11/12/24 at 5:00 PM, 11/12/24 at 5:30 PM, and 11/13/24 at 11:30 AM. The resolution of the concern section of the grievance form had documentation that no the concern was not resolved because the Responsible Party was unable to be reached. The Responsible Party was interviewed by phone on 3/3/25 at 3:07 PM. The Responsible Party reported he had filed a grievance with the facility in November 2024 regarding his mother's medications and the facility had not contacted him regarding the grievance or a resolution. The Responsible Party explained that in addition to emailing SW #1, he had verbally expressed concerns to other staff members, including the floor nurse, and the care planner, and he had not received any resolution to those issues. The Responsible Party explained that he was very busy, and he wanted communication by email so that he was better able to respond to the facility. The Responsible Party explained he had emailed several administrative staff members with his concerns, but no one had reached out to him. SW #2 was interviewed on 3/6/25 at 1:25 PM. SW #2 reported she had been at the facility for 3 weeks and had not been handling the grievance process. SW #2 reported SW #1 had been at the facility when the Resident #72's Responsible Party filed the grievance. SW #1 was not available for interview. The DON was interviewed on 3/6/25 at 1:47 PM. The DON explained because SW #2 was new, she and the Administrator had taken over the Grievance Official responsibilities until SW #2 was ready to take on that responsibility. The DON reported she was told by SW #1 that Resident #72's Responsible Party had told SW #1 he would only accept email and not phone calls from the DON. The DON reported she attempted to contact the Responsible Party three times, and he did not return her calls, and she did not know what concerns he had regarding medication administration. The DON explained she was not aware the Responsible Party wanted email exchanges until after she attempted to call him, and she did not email the Responsible Party about his concerns. The DON reported she thought the Administrator was handling the grievance with Resident #72's Responsible Party and she did not reach out to him to get the details about his grievance filed on 11/11/24. The Administrator was interviewed on 3/6/25 at 2:01 PM and she reported Resident #72's Responsible Party was reporting his concerns to a former Nursing Assistant (NA) who no longer worked at the facility. The Administrator reported that when the NA left the facility, the Responsible Party had complaints that he was reporting to different staff, but when he put the grievance in writing, the DON was unable to contact him by phone to discuss the issues. The Administrator reported she did not feel that email was appropriate to discuss grievances, and the DON had not pursued the investigation because she had been unable to talk to the Responsible Party. The Administrator reported she had not attempted to call or email Resident #72's Responsible Party regarding the grievance he filed on 11/11/24.

Based on record review and staff interviews the facility failed to protect a resident's right to be free from staff to resident abuse. While Nurse Aide (NA) #6 and NA #7 were providing care for a cognitively impaired resident, the resident became agitated. NA #7 slapped the resident on the left upper thigh and NA #6 held the residents' hands during care while the resident was agitated and being combative. This deficient practice was found for 1 of 3 residents reviewed for abuse (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, major depressive disorder, dementia, contracture right knee, and contracture to left knee. Review of Resident #3's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired and required extensive assistance with two people assist for bed mobility and transfers. The MDS further revealed Resident #3 was not coded for any behaviors. Review of Resident #3's care plan revised on 02/13/25 revealed the resident was at risk of adjustment issues due to showing sign and symptoms of depression, anxiety, and psychosocial wellbeing issues. Resident #3 exhibited the following inappropriate behaviors, negative statements, and resistance of care. Resident #3 had the potential to be verbally aggressive, inappropriate, demonstrate physical behavior, wanders the facility, and depression. The goal was for Resident #3 to maintain comfort and dignity daily with calm relaxed manners, clean appearance, positive decision making, maintain psychosocial wellbeing, positive expressions, positive body language. Resident #3 would be monitored and met with appropriate interventions. Interventions included for Resident #3 was to always approach in a calm and relaxed manner, encourage activity distraction, encourage resident to express needs, explain all procedures and care before beginning to assist, monitor and report and mood changes to nurse, and observe and report to the nurse any behavior issues. Review of the initial facility reported incident dated 03/25/25 at 8:00 AM revealed it was reported that an employee stated that they helped another employee with providing incontinence care and during the process the employee slapped the resident with her hand. The accused employee was told to leave the facility and removed from the schedule until the investigation was completed. It further revealed skin assessment did not show any findings. Review of the investigation completed by the Administrator related to Resident #3's incident revealed the following: -Nurse Aide (NA) #6 written statement dated 03/02/25 read in part, around 1:00 AM she and NA #7 went to put Resident #3 in bed. Resident #3 was lying on her left side and NA #6 was on her right side. Resident #3 started to be aggressive and started to hit and cuss and called NA #7 the N Word. NA #7 stated she was proud of her skin. NA #6 and NA #7 continued care and Resident #3 hit NA #6 a few times and as NA #6 was getting the other side of the brief out Resident #3 hit NA #7 and NA #7 let the resident down on the bed and hit her thigh. NA #6 was trying to hold Resident #3's hands trying to prevent but she had let go of hands. NA #6 and NA #7 finished care and left the room. - Nurse Aide (NA) #7 statement dated 03/02/25 read in part, on 03/02/25 NA #6 asked to assist to put Resident 33 in bed around 1:00 AM. NA #7 revealed taking off Resident #3's pants the resident began to hit, and NA #6 stated she is going to try to hit you. Resident #3 tried to hit NA #6 and NA #6 told the resident not to hit her. Resident #3 began to call NA #7 a ni**ger and monkey. NA #7 stated I swear to god I never touched that lady. NA #7 indicated NA #6 never voiced any concerns during care. NA #7 revealed she had tried to leave during care, but NA #6 had begged her to stay and help finish the resident. After care was provided NA #6 and NA #7 went immediately to the nurses' station discussing how Resident #3 had been combative and had called NA #7 names. NA #7 revealed she finished her charting at the nurses' station and passed out ice and did not go back to Resident #3's room. Around 5:00 AM Nurse #7 told NA #7 she had to leave the facility, and she left. - Nurse #7 written statement dated 03/02/25 read in part, Nurse #7 was not in the room of question. NA #6 reported NA #7 hit resident on her left upper thigh. Resident #3 was also combative. Review of NA #7's time sheet revealed she worked on 03/1/25 from 7:00 PM until 5:45 AM on 03/02/25. A phone interview conducted with NA #7 on 03/05/25 at 12:30 PM revealed NA #6 had asked her to assist with Resident #3 to complete incontinence care. NA #7 indicated she had cared for Resident #3 before, and the resident could be combative and resistive to care at time. NA#7 further revealed NA #6 and NA #7 began care and Resident #3 became combative and hit NA #6. NA #7 revealed NA #6 stated, You don't need to hit us were just trying to help you. NA #7 indicated she wanted to stop and walk away from assisting the resident, but NA#6 wanted to complete care due to Resident #3 having a bowel movement. NA #7 stated Resident #3 continued to call her a ni**ger and a monkey, and she replied that she was proud to be a nig**er. NA #7 revealed Resident #3 was combative while she cleaned her. NA #6 held Resident #3's hands for an estimated time of 5 minutes so that she could not hit the NAs during care. NA #7 revealed Resident #3 attempted to hit her but never made contact. NA #7 denied being aggressive or slapping Resident #3. A phone interview conducted with NA #6 on 03/04/25 at 6:40 PM revealed on 03/02/25 she and NA #7 went into Resident #3's room to give incontinence care. NA #6 revealed she had cared for Resident #3 before and was sometimes combative and resistive to care. NA #6 indicated Resident #3 was not cognitively intact and was hard to understand. NA #6 revealed she and NA #7 had used a mechanical lift and got Resident #3 undressed with no issues. It was further revealed when Resident #3 was rolled on her right side she became combative and hit NA #6 in the arm. NA #6 stated she told Resident #3, we don't hit, and everything was okay. NA #6 revealed she and NA #7 continued care and rolled Resident #3 back to her back that Resident #3 was attempting to punch and grab at both NA's. NA #6 stated Resident #3 hit her in the arm again. NA #6 indicated Resident #3 started to grab at herself and she took Resident #3's hands and held them for 2-3 minutes while Resident #3 continued to be combative. NA #6 and NA #7 rolled Resident #3 onto her left hip as NA #6 continued to hold Resident #3's hands. NA #6 indicated Resident #3 fell loose from NA #6's grip and struck at NA #7 hitting her in the arm. NA #6 stated at this time NA #7 laid the residents' leg back down from cleaning her and slapped her on her right upper thigh with an open hand. NA #6 revealed she was in shock and did not say anything to NA #7. NA #6 indicated Resident #3's behavior remained combative throughout care and seemed agitated. NA #6 stated she had been educated to walk away if residents were combative but did not with Resident #3 due to wanting to ensure, she was clean from her bowel movement. NA #6 revealed she and NA #7 completed care on Resident #3 and she did not report until around 5:00 AM to Nurse #7 due to being busy on the floor with residents. NA #6 indicated NA #7 worked the rest of the shift with residents answering call lights. A phone interview conducted with Nurse #7 on 03/05/25 at 11:15 AM revealed on 03/02/25 around 5:00 AM NA #6 reported to her that Resident #3 was combative during care and had called NA #7 a ni**er, and hit the resident on her thigh. Nurse #7 further revealed NA #6 had stated the incident occurred between 1 and 1:30 AM. Nurse #7 stated she conducted a skin assessment on Resident #3 and found no new skin marks or issues. Nurse #7 indicated both NAs had been educated on walking away from residents if they are combative during care. Nurse #7 Indicated Resident #3 could sometimes be combative and resistive during care. An interview conducted with the Director of Nursing (DON) and the Administrator 03/05/25 at 12:00 PM revealed on 03/02/25 at 5:30 PM they were notified NA #6 had observed NA #7 hitting Resident #7 on the upper left thigh. The Administrator and DON were not aware NA #6 had restrained resident #3 during care by holding hands to prevent her from hitting the NA's. The DON further revealed she advised Nurse #7 to take NA #7 off the floor immediately sent her home. The DON revealed that NAs had cared for Resident #3 and the resident could be combative and resistive with care.

Based on record review and staff interviews, the facility failed to follow and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents reviewed for abuse (Resident #3). While Resident # 3 was being abused, Nurse Aide (NA) #6 did not intervene, stop, or report NA #7 when she slapped Resident #3 on the thigh. Also, NA #7 did not intervene or report immediately NA #6 for restraining Resident #3's hands during care when NA #6 held onto Resident #3's hands with her hands. As a result, NA #6 and NA #7 worked the rest of their shift, putting other residents at risk for abuse. The findings included: Review of the facility policy and procedure titled North Carolina Resident Abuse Policy, with a revised date of 07/11/24, read in part 1.) Under Protect the Resident, If the resident is injured. If the resident is injured as a result of the alleged or suspected incident, the facility should take immediate action to treat the resident. Under part a.) Staff should report all incidents immediately to their direct supervisors. Addressed under part 2.) If a staff member is accused or suspected, If a staff member is accused or suspected of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property, the Facility immediately remove staff member from resident care area and request a written statement from accused staff member. Under definitions it reads in part, restraints (physical or chemical) may only be used per MD order in compliance with regulations and guidelines. Review of the investigation completed by the Administrator related to Resident #3's incident revealed the following: -Nurse Aide (NA) #6 written statement dated 03/02/25 read in part, around 1:00 AM she and NA #7 went to put Resident #3 in bed. Resident #3 was lying on her left side and NA #6 was on her right side. Resident #3 started to be aggressive and started to hit and cuss and called NA #7 the N Word. NA #7 stated, She was proud of her skin. NA #6 and NA #7 continued care and Resident #3 hit NA #6 a few times and as NA #6 was getting the other side of the brief out during care Resident #3 hit NA #7 and NA #7 let the resident down on the bed and hit her thigh. NA #6 was trying to hold Resident #3's hands trying to prevent but she had let go of the residents' hands. NA #6 and NA #7 finished care and left the room. - Nurse Aide (NA) #7 statement dated 03/02/25 read in part, on 03/02/25 NA #6 asked to assist to put Resident #3 in bed around 1:00 AM. NA #7 revealed taking off Resident #3's pants the resident began to hit, and NA #6 stated She is going to try to hit you. Resident #3 tried to hit NA #6 and NA #6 told the resident not to hit her. Resident #3 began to call NA #7 a ni**ger and monkey. NA #7 stated I swear to god I never touched that lady. NA #7 indicated NA #6 never voiced any concerns during care. NA #7 revealed she had tried to leave during care, but NA #6 had begged her to stay and help finish the resident. After care was provided NA #6 and NA #7 went immediately to the nurses' station discussing how Resident #3 had been combative and had called NA #7 names. NA #7 revealed she finished her charting at the nurses' station and passed out ice and did not go back to Resident #3's room. Around 5:00 AM Nurse #7 told NA #7 she had to leave the facility, and she left. - Nurse #7 written statement dated 03/02/25 read in part, Nurse #7 was not in the room of question. NA #6 reported, NA #7 hit a resident on her left upper thigh. Resident #3 was also combative. Review of NA #7's timecard revealed she worked on 03/1/24 from 7:00 PM until 5:45 AM on 03/02/25. A phone interview conducted with NA #7 on 03/05/25 at 12:30 PM revealed NA #6 had asked her to assist with Resident #3 to complete incontinence care. NA #7 indicated she had cared for Resident #3 before, and the resident could be combative and resistive to care at times. NA#7 further revealed NA #6 and NA #7 began care and Resident #3 became combative and hit NA #6. NA #7 revealed NA #6 stated, You don't need to hit us were just trying to help you. NA #7 indicated she wanted to stop and walk away from assisting the resident, but NA#6 wanted to complete care due to Resident #3 having a bowel movement. NA #7 stated Resident #3 continued to call her a ni**ger and a monkey, and she replied to the resident She was proud to be a nig**er. NA #7 revealed Resident #3 was combative while she cleaned her. NA #7 explained NA #6 held Resident #3's hands for an estimated time of 5 minutes so that she could not hit the NAs during care. NA #7 revealed Resident #3 attempted to hit her but never made contact. NA #7 denied being aggressive or slapping Resident #3. Review of NA #6's timecard revealed she worked on 03/1/24 from 7:00 PM until 7:45 AM on 03/02/25. A phone interview conducted with NA #6 on 03/04/25 at 6:40 PM revealed on 03/02/25 she and NA #7 went into Resident #3's room to give incontinence care around 1:00 AM. NA #6 revealed she had cared for Resident #3 before, and the resident was sometimes combative and resistive to care. NA #6 indicated Resident #3 was not cognitively intact and was hard to understand. NA #6 revealed she and NA #7 had used a mechanical lift to put the resident into bed and then got Resident #3 undressed with no issues. It was further revealed when Resident #3 was rolled on her right side she became combative and hit NA #6 in the arm. NA #6 stated she told Resident #3, We don't hit, and everything was okay. NA #6 revealed she and NA #7 continued care and rolled Resident #3 back to her back that Resident #3 was attempting to punch and grab at both NA's. #6 stated resident #3 hit her in the arm again. NA #6 indicated Resident #3 started to grab at her own thighs and she took Resident #3's hands and held them for 2-3 minutes while Resident #3 continued to be combative. NA #6 and NA #7 rolled Resident #3 onto her left hip as NA #6 continued to hold Resident #3's hands. NA #6 indicated Resident #3 freed herself loose from NA #6's grip and struck at NA #7 hitting her in the arm. NA #6 stated at this time NA #7 laid the resident's leg back down from cleaning her and slapped her on her right upper thigh with an open hand. NA #6 revealed she was in shock and did not intervene. NA #6 indicated Resident #3's behavior remained combative throughout care and the resident seemed agitated. NA #6 stated she had been educated to walk away if residents were combative but did not with Resident #3 due to wanting to ensure, she was clean from her bowel movement. NA #6 revealed she and NA #7 completed care on Resident #3, and she did not report NA #7 had slapped Resident #3 on the thigh until around 5:00 AM to Nurse #7 due to being busy on the floor with residents. NA #6 indicated NA #7 worked the rest of the shift with residents and answering call lights. A phone interview conducted with Nurse #7 on 05/05/25 at 11:15 AM revealed on 03/02/25 around 5:00 AM NA #6 reported to her that Resident #3 was combative during care and had called NA #7 a ni**er, and NA #7 hit the resident on the resident's thigh. Nurse #7 further revealed NA #6 had stated the incident occurred between 1:00 AM and 1:30 AM. Nurse #7 indicated she educated NA #6 that she should have reported the incident immediately and not later in the shift. Nurse #7 revealed she immediately removed NA #7 from the floor around 5:00 AM once when NA #6 reported the incident. An interview conducted with the Director of Nursing (DON) and the Administrator on 03/05/25 at 12:00 PM revealed on 03/02/25 at 5:30 AM they were notified NA #6 had observed NA #7 hitting Resident #7 on the upper left thigh. The DON further revealed she advised Nurse #7 to take NA #7 off the floor immediately and send her home. The DON indicated NA #6 and NA #7 had been educated on reporting abuse and walking away from residents who were combative during care. The DON revealed NA #6 and NA #7 should have walked away from Resident #3 when she was combative, NA #7 should have intervened and reported immediately when NA #6 restrained Resident #3's hands during care and NA #6 should have intervened and reported immediately when NA #7 slapped Resident #3.

Based on record review, observations, and staff interviews, the facility failed to store an enteral feeding syringe with the plunger separated from the syringe for 2 of 4 residents (Resident #44 and Resident #65) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination. Findings included: a. Resident #44 was admitted to the facility on [DATE] with diagnoses of diabetes and difficulty swallowing. A significant change Minimum Data Set assessment dated [DATE] indicated Resident #44 received 51% of more of her total calories from enteral feedings and 501 milliliter of fluids per day by enteral feedings. On 3/3/2025 an observation was made of Resident #44's a plastic enteral feeding flush syringe, stored in a plastic bag and hanging from the feeding tube pump pole, with the plunger in the syringe with thick white liquid in the tip of the syringe. During an observation on 3/4/2025 at 2:00 pm Resident #44's enteral feeding flush syringe was stored in a plastic bag with the plunger in the syringe, hanging from the feeding tube pump pole. An interview was conducted with Nurse #1 on 3/4/2025 at 2:13 pm and she stated Resident #44 was administered medication and flushes through her enteral feeding tube at 7:30 am. Nurse #1 stated she did not know that the plastic syringe should be stored separately from the plunger to allow the syringe to dry to prevent bacterial growth. b. Resident #65 was admitted to the facility on [DATE] with diagnoses of dementia and difficulty swallowing. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #65 received 51 % or more of her total calories from enteral feedings and 501 milliliters of fluids daily by enteral feedings. Resident #65's enteral feeding flush plastic syringe was observed on 3/3/2025 at 12:04 pm, with the syringe stored in a plastic bag on hanging from the tube feeding pump pole, and plunger was stored inside the syringe with a white liquid in the end of the syringe. Nurse #2 had taken the plastic syringe from the plastic bag and was going to administer Resident #65's flush and was stopped and she stated she was not aware the plunger should not be stored in the syringe. Nurse #2 replaced the plastic syringe and administered the flush. An interview was conducted with the Director of Nursing on 3/6/2025 at 2:56 pm and she stated the enteral feeding plastic syringe should be washed and the plunger left out of the syringe to allow it to air dry to prevent any bacterial growth in the syringe. During an interview with the Administrator on 3/6/2025 at 3:17 pm she stated Nurse #1 and Nurse #2 should have washed the plastic syringe and plunger separately to allow them to dry completely to prevent any bacterial growth.

Based on record review, observations, and staff interviews, the facility failed to provide clean air intake filters on oxygen concentrators for 2 of 4 residents (Resident #34 and Resident #44) reviewed for respiratory care. Findings included: a. Resident #34 was admitted to the facility on [DATE] with respiratory disease. Review of Resident #34's medical record revealed a Physician's Order written on 11/8/2024 which indicated Resident #34 required oxygen at 2 to 4 liters per minute by nasal canula to keep her oxygen saturation above 90%. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #34 was cognitively intact and received oxygen therapy. During an observation of Resident #34 on 3/5/2025 at 6:39 am she was noted in bed with her nasal canula on and her oxygen concentrator machine was set at 2.5 liters per minute. The oxygen concentrator had a film of black dust approximately 1/8 inch thick covering the air intake filter. On 3/6/2025 at 8:45 am Resident #34 was observed up in her wheelchair in her room. Her oxygen concentrator machine was set at 2.5 liters per minute and 1/8 inch of black dust continued to cover the air intake filter. During an interview and observation of Resident #34's oxygen concentrator with Nurse #1 on 3/6/2025 at 2:46 pm she stated she did not know who was responsible for cleaning the air intake filter on the oxygen concentrators. She stated she thought that either a nurse or nurse aide should be responsible, or housekeeping could also clean the concentrator. b. Resident #44 was admitted to the facility on [DATE] with diagnoses of dementia and respiratory disease. A Physician's Order dated 12/18/2024 indicated Resident #44 required oxygen at 2 liters per minute by nasal canula. A significant change Minimum Data Set assessment dated [DATE] indicated Resident #44's was moderately cognitively impaired and received oxygen therapy. On 3/3/2025 at 10:34 am an observation of Resident #44 revealed she was in bed with her oxygen on at 2 liters per minute by nasal cannula. Her oxygen concentrator machine was at her bedside and had a 1/8-inch film of black dust covering the air intake filter. An interview and observation of Resident #44's oxygen concentrator machine was conducted with Nurse #1 on 3/6/2025 at 2:27 pm and Nurse #1 stated the oxygen concentrator's air intake filter was covered with dust and she did not know who should clean them. During an interview with the Housekeeping Supervisor on 3/6/2025 at 2:49 pm she stated nursing staff was responsible for cleaning the oxygen concentrator air intake filters. An interview was conducted with the Director of Nursing on 3/6/2026 at 2:54 pm and she stated the assigned nurse should clean the oxygen concentrators every Sunday night. On 3/6/2025 at 3:15 pm the Administrator was interviewed and stated the nursing staff should clean the oxygen concentrator machines and the air intake filter at least weekly.

Based on record review, and family member, Physician, and staff interviews, the facility failed to ensure a resident was transported to a scheduled neurologist appointment on 2/28/25 for 1 of 1 resident reviewed for medical related social services (Resident #72). The findings included: Resident #72 was admitted to the facility 6/29/22 with diagnoses including Parkinson's disease. Review of Resident #72's medical record revealed a neurologist progress note dated 11/25/24. The note made recommendations for physical therapy, speech therapy, and occupational therapy. The progress note did not mention a follow-up appointment. The quarterly Minimum Data Set assessment dated [DATE] assessed Resident #72 to be severely cognitively impaired. A care plan dated 7/8/24 and a revision date of 2/27/25 addressed Resident #72' Parkinson's disease and that family member prefers Resident to be seen by specialist and facility will provide transport as able. Interventions included monitoring for cognitive changes. Review of Resident #72's medical record did not reveal any documentation related to a neurologist appointment on 2/28/25. Resident #72's family member was interviewed by phone on 3/3/25 at 3:07 PM. The family member reported he takes Resident #72 to a neurologist about every 2 months for medication adjustments and recommendations for therapies to treat her disease progression. The family member explained he made an appointment for Resident #72 for 2/28/25 to see the neurologist and he notified the facility of the appointment in November 2024. The family member explained he received a phone call 2 days before the appointment on 2/26/25 when he was told the facility could not provide transportation to the appointment. The family member reported he met Resident #72 at the appointments, but he was unable to transport her to the appointments and relied on the facility to get her to the neurologist. The family member reported he rescheduled the neurologist appointment, but the only available time was in May 2025 and Resident #72 would have to go almost 6 months without seeing the neurologist and this was very upsetting to him. The facility Transporter was interviewed on 3/5/25 at 2:43 PM. The Transporter reported she was the only driver for the facility van, although the facility did have a contracted transportation company for some transportation. The Transporter explained that about one week before Resident #72's appointment with the neurologist, she realized that she would be unable to take Resident #72 to the appointment because it was approximately 48 miles from the facility to the neurologist and the Transporter had to be close to the facility for another appointment. The Transporter explained she called the contracted transportation company, but they did not have any openings for 2/28/25 to take Resident #72 to her neurologist appointment. The Transporter reported she called Resident #72's family member on 2/26/25 to notify him that the facility would not be able to transport Resident #72 to the neurologist. The Transporter reported the family member was very upset. The Physician was interviewed on 3/6/25 at 11:24 AM. The Physician reported the family member felt that Resident #72 needed to continue the neurologist appointments, but the neurologist had not changed the medications to treat her Parkinson's disease for a long time, and the missed appointment was unlikely to impact her care. The Director of Nursing (DON) was interviewed on 3/6/25 at 1:47 PM. The DON explained that when the Transporter realized she would be unable to take Resident #72 to her neurology appointment, the Transporter attempted to find alternative transportation. The DON reported the contracted transportation company was booked up on 2/28/25 and had been unable to take Resident #72 to the appointment. The DON reported the Transporter communicated this to the family member and the appointment was rescheduled for May 2025. The DON explained that since then, the Transporter has been bringing the transportation schedule for weekly review to identify any conflicts in the schedule, and the DON reported she expected those conflicts to be addressed by arranging transportation with the contracted company. The Administrator was interviewed on 3/6/25 at 2:01 PM. The Administrator reported she discussed the missed appointment with the facility Physician, and he said that the missed appointment had not impacted Resident #72's care. The Administrator reported a transportation conflict prevented the facility from transporting Resident #72 to the appointment and she expected alternative transportation to be arranged if possible for future appointments.

Based on record review and staff, Physician's Assistant interviews, the facility failed to ensure 1 of 4 residents (Resident #72) reviewed for medication administration was provided medication from the pharmacy as ordered by the physician. Findings included: Resident #72 was admitted to the facility on [DATE] with Parkinson's disease a neurocognitive disorder with dementia. A Physician's Order dated 9/11/2024 indicated Resident #72 was prescribed Carbidopa-Levodopa (medication used to manage the symptoms of Parkinson's disease) 25-100 milligrams 2.5 tablets should be given four times a day. A Nurse's Progress Note dated 11/10/2024 at 7:28 pm indicated Nurse #7 discovered there was no Carbidopa-Levodopa 25-100 milligrams for Resident #72, and the correct dose was not available from the facility's electronic emergency medication system. The Progress Note further stated Nurse #7 notified the Director of Nursing and the pharmacy the medication needed to be sent to the facility. Nurse #7's Progress Note further stated she was told by the pharmacy that Resident #72's medication would not be sent to the facility until 11/17/2024 and she called the Physician's Assistant and was told the Carbidopa-Levodopa was an essential medication and to call the pharmacy back. Nurse #7 called the pharmacy again and was told they spoke with the Director of Nursing and a Refill Too Soon form was faxed to the facility and once the form was received by the pharmacy the medication would be sent. During the survey attempts were made to reach Nurse #7 who cared for Resident #72 on 11/10/2024 without success. The Medication Administration Record (MAR) for 11/10/2024 indicated Resident #72's Carbidopa-Levodopa was not available to be administered because it was not available. Nurse #7 had documented on the MAR that the 11/10/2024 the 12:00 pm and 4:00 pm doses were not administered, and the Physician's Assistant was notified but no hold order was given for the medication, and the facility was working to resolve the issue. On 11/11/2024 at 10:49 pm a Nurse's Progress Note written by Nurse #6 indicated Resident #72's Carbidopa-Levodopa was held because Nurse #6 was waiting on it to be delivered by the pharmacy and the provider gave an order for the medication to be held. The Progress Note also stated the Physician and Responsible Party were aware. Nurse #6 documented on the MAR on 11/11/2024 the 8:00 am and 12:00 pm doses of Resident #72's Carbidopa-Levodopa were not available and was on hold. No Physician's Order was found for Resident #72's Carbidopa-Levodopa to be held on 11/11/2024. On 11/20/2024 at 5:39 pm Nurse #6's Progress Note stated Resident #72 did not have a scheduled dose of Carbidopa-Levodopa and the Physician gave an order to hold the medication until it was delivered at midnight from the pharmacy. During a review of the MAR for 11/20/2024 the following doses were documented as not administered by Nurse #6: 11/20/2024 at 12:00 pm, and 11/20/2024 at 4:00 pm. The MAR for 11/20/2024 indicated Resident #72's Carbidopa-Levodopa was on hold. No Physician's Order was found for Resident #72's Carbidopa-Levodopa to be held on 11/20/2024. Nurse #6 was interviewed by phone on 3/6/2025 at 11:52 am and she stated she cared for Resident #72 frequently during November 2024 and remembered there was an issue with getting her Carbidopa-Levodopa from the pharmacy. Nurse #6 stated Resident #72's Carbidopa-Levodopa dose was not available from the electronic emergency medication system, and she reported to the Nurse Practitioner that the medication was not available and got an order to hold the medication. Nurse #6 stated she could not remember the date the medication was not available, but she would have written a nurse note and documented the order to hold Resident #72's medication. During an interview with the Physician's Assistant on 3/6/2025 at 11:18 am she stated Resident #72 had diagnoses of Parkinson's disease with Lewy body dementia and required the physician's ordered Carbidopa-Levodopa. The Physician's Assistant stated she does not remember the staff notifying her Resident #72's Carbidopa-Levodopa was not available or giving an order to hold the medication. During an interview with the Director of Nursing on 3/6/2025 at 2:59 pm she stated she did not recall anyone reporting Resident #72 did not have Carbidopa-Levodopa available for administration. The Director of Nursing stated Nurse #6 and Nurse #7 should have checked the electronic emergency medications and called the pharmacy to ensure Resident #72's medication was sent as soon as possible, and they should have notified the provider. The Administrator was interviewed on 3/6/2025 at 3:15 pm and stated she expected the nursing staff to ensure Resident #72 received her medication from the pharmacy and administered according to the physician's orders.

Based on record review, and staff, Physician's Assistant and Physician interviews, the facility failed to ensure 1 of 4 residents (Resident #72) reviewed for medication administration was free of significant medication errors. Resident #72 was not administered six doses of Carbidopa-Levodopa (a drug that treats Parkinson's disease, a central nervous system disease) 25-100 milligrams 2 1/2 tablets which was ordered four times a day. Findings included: Resident #72 was admitted to the facility on [DATE] with Parkinson's disease a neurocognitive disorder with dementia. A Physician's Order dated 9/11/2024 indicated Resident #72 Carbidopa-Levodopa 25-100 milligrams 2.5 tablets should be given four times a day. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #72 was severely cognitively impaired. A Nurse's Progress Note dated 11/10/2024 at 7:28 pm indicated Nurse #7 discovered there was no Carbidopa-Levodopa 25-100 milligrams for Resident #72, and the correct dose was not available from the facility's electronic emergency medication system. The Progress Note further stated Nurse #7 notified the Director of Nursing and the pharmacy the medication needed to be sent to the facility. Nurse #7's Progress Note indicated she was told by the pharmacy that Resident #72's medication would not be sent to the facility until 11/17/2024 and she called the Physician's Assistant and was told the Carbidopa-Levodopa was an essential medication and to call the pharmacy back. Nurse #7 called the pharmacy again and was told they spoke with the Director of Nursing and a Refill Too Soon form was faxed to the facility and once the form was received by the pharmacy the medication would be sent. Nurse #7 documented on the Medication Administration Record (MAR) on 11/10/2024 at 12:00 pm and 11/10/2024 at 4:00 pm that Resident #72's Carbidopa-Levodopa was not available. The MAR also indicated the dose was not available on 11/10/2024 at 12:00 pm and The Physician's Assistant was notified, and no hold order was given, and the facility was working to resolve the issue. Nurse #7 also documented on the MAR the dose due at 11/10/2024 at 4:00 pm was not administered because it was not available, and the Physician's Assistant and Director of Nursing were notified and the facility continued to work on the issue. During the survey attempts were made to reach Nurse #7 who cared for Resident #72 on 11/10/2024 without success. On 11/11/2024 at 10:49 pm a Nurse's Progress Note written by Nurse #6 indicated Resident #72's Carbidopa-Levodopa was held because Nurse #6 was waiting on it to be delivered by the pharmacy and the provider gave an order for the medication to be held. The Progress Note also stated the Physician and Responsible Party were aware. A review of Resident #72's MAR for 11/11/2024 revealed the following doses of Carbidopa-Levodopa were documented as not administered because the drug was unavailable and was on hold by Nurse #6: 11/11/2024 at 8:00 am, 11/11/2024 at 12:00 pm. An order to hold the Carbidopa-Levodopa on 11/11/2024 at 8:00 am and 12:00 pm was not indicated on Resident #72's Physician's Orders. The Responsible Party provided a copy of an email sent to Social Worker #2 on 11/11/2024 at 2:49 pm which stated he was concerned when he got a call from the facility stating Resident #72 did not have her medication (Carbidopa-Levodopa) and was told she had not had her medication for a couple of days. The Responsible Party's email stated he asked for full details regarding Resident #72 not receiving her medication. During the survey attempts were made to contact Social Worker #2, who no longer worked at the facility, without success. On 11/20/2024 at 5:39 pm Nurse #6's Progress Note stated Resident #72 did not have a scheduled dose of Carbidopa-Levodopa and the Physician gave an order to hold the medication until it was delivered at midnight from the pharmacy. The Progress Note further stated the Responsible Party was made aware the medication would be held. Review of the Medication Administration Record for 11/20/2024 the following doses of Resident #72's Carbidopa-Levodopa were documented as not administered and on hold by Nurse #6: 11/20/2024 at 12:00 pm and 11/20/2024 at 4:00 pm. A Physician's Order was not found to hold Resident #72's Carbidopa-Levodopa. Nurse #6 was interviewed by phone on 3/6/2024 at 11:52 am and stated she cared for Resident #72 frequently during November 2024 and remembered there was an issue with getting her Carbidopa-Levodopa but was not sure about the exact dates of when the medication was not available or when she notified the Physician's Assistant the medication was not available and received a hold order for the medication. Nurse #6 stated she would have documented in a nurse's note on both 11/11/2024 and 11/20/2024 if she documented the medication was not available. During an interview with the Physician's Assistant on 3/6/2025 at 11:18 am she stated Resident #72 had diagnoses of Parkinson's disease with Lewy body dementia and required the physician ordered Carbidopa-Levodopa. The Physician's Assistant stated she did not remember being notified of Resident #72's Carbidopa-Levodopa not being available. The Physician's Assistant stated the missed doses of Carbidopa-Levodopa could have caused problems with Resident #72's mobility, breathing, and swallowing and the dosing and administration of the medication for her Parkinson's disease would have been critical. The Physician's Assistant stated Resident #72 did not have any issues related to the missed doses in November 2024. An interview was conducted with the Physician on 3/6/2025 at 12:30 pm and he stated that although Resident #72's doses of Carbidopa-Levodopa were missed during November 2024 it did not cause her any harm but could have potentially affected her mobility, swallowing and breathing. During an interview with the Director of Nursing on 3/6/2025 at 2:59 pm she stated she did not recall anyone reporting Resident #72 did not have Carbidopa-Levodopa available for administration. The Director of Nursing stated Nurse #6 and Nurse #7 should have checked the electronic emergency medications and called the pharmacy to ensure Resident #72's medication was sent as soon as possible, and they should have notified the provider. The Administrator was interviewed on 3/6/2025 at 3:15 pm and stated she expected the nursing staff to ensure Resident #72 received her medication as ordered by the physician.

Based on staff interview, and record review the facility failed to review and revise comprehensive care plans for 2 of 2 residents reviewed for comprehensive care plan review and revision. The resident's care plan must be reviewed after each Minimum Data Set (MDS) assessment time frame and revised based on changing goals, preferences and needs of the resident and in response to current interventions for the resident to meet resident care needs (Residents # 62 and # 75). Findings included: 1.Resident # 62 was readmitted to the facility on [DATE] with diagnosis that included peripheral vascular disease (PVD),cerebral vascular accident (CVA) and muscle weakness. Review of a Resident # 62's care plan revised most recently on 10/12/23 revealed Resident # 62 was at risk for skin breakdown related to decreased mobility, weakness, CVA and bowel incontinence. Resident # 62 preferred to spend most of his time in bed with the goal that Resident # 62 would have no preventable skin breakdown through the next review. Interventions included to provide an air mattress, diet as ordered, monitor for skin breakdown, and encourage frequent repositioning. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident # 62 had moderate cognitive impairment, required substantial to maximal assist to roll left and right and Resident # 62 developed a stage three pressure ulcer of the right buttock. An interview conducted on 11/09/23 at 9:20 AM with MDS Nurse #1 and MDS Nurse #2 revealed that care plans for Resident # 62 were revised as required (the care plan must be reviewed and revised periodically to include services, measurable objectives, measurable time frames and must describe the services required to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well- being). Resident # 62 developed a stage three pressure ulcer of the right buttock and required weekly wound care assessment by the physician and oral supplements to promote wound healing. MDS Nurse #1 and Nurse # 2 revealed the care plan should have been updated with the development of the stage three pressure ulcer of the right buttock. An interview conducted with the Administrator on 11/09/23 at 12:44 PM revealed care plans were to be revised and reviewed to reflect resident status at any time as per the Resident Assessment Manual (RAI). 32394 2. Resident #75 was admitted to the facility on [DATE] with a cumulative diagnosis which included a history of cerebral infarction (a type of stroke which occurs when blood flow to the brain is disrupted) and dysphagia (difficulty swallowing) status post gastrostomy tube placement. A gastrostomy tube is a feeding tube placed through the skin and directly into the stomach. A review of Resident #75's electronic medical record (EMR) revealed an admission Minimum Data Set (MDS) assessment dated [DATE] was completed for the resident. The assessment indicated Resident #75 was receiving skilled rehabilitation (rehab) services which included Speech Therapy, Occupational Therapy, and Physical Therapy. The resident's care plan included the following area of focus, in part: [Resident #75] is at the facility for short term placement / rehab d/t [due to] stroke and respiratory failure. This area of focus also included a list of Resident #75's preferred activities and was documented as having been initiated on 5/30/23 with revision on 5/30/23. Resident #75's most recent Minimum Data Set (MDS) assessment was a quarterly assessment dated [DATE]. The MDS revealed the resident had moderately impaired cognition. The assessment also indicated Resident #75 continued to receive Physical Therapy. A review of the resident's current care plan revealed it continued to include the following area of focus initiated and revised on 5/30/23: [Resident #75] is at the facility for short term placement / rehab d/t [due to] stroke and respiratory failure . Resident #75's current care plan also included a new area of focus initiated on 8/25/23. This new area of focus indicated, Resident is long term placement at the facility related to his diagnoses and declining health status. An interview was conducted with the facility's MDS nurses on 11/8/23 at 10:30 AM. During the interview, MDS Nurse #1 reported Resident #75 initially came into the facility for short-term rehabilitation. She noted the care plan that indicated he was admitted for short term placement / rehab was authored by the facility's Activities Director on 5/30/23. However, when Resident #75 had his quarterly assessment completed, he was care planned to be a long-term care resident. MDS Nurse #2 stated, I actually told the Activities Director she needed to change the short-term to long-term in the care plan. An interview was conducted on 11/8/23 at 2:40 PM with the facility's Director of Nursing (DON). The DON reported each department (such as Activities, Social Work, and Dietary) reviewed and revised their own care plan during the resident's assessment window. She also stated there were morning meetings when the individual departments came together and communicated the care plan components as a whole. An interview was conducted on 11/9/23 at 8:55 AM with the Activities Director. During the interview, the Activities Director reported she was told about the need to revise her care plan for Resident #75 yesterday (11/8/23) and she stated, I fixed it. The Activities Director stated the overall activity care plan had not changed. However, the discharge plan for the resident had changed where he was now anticipated to remain at the facility for long-term placement. Upon further inquiry, the Activities Director stated the MDS nurses typically reminded her when an upcoming assessment was due for a resident and of the need to review his/her care plan. The Activities Director reported she must have missed it when it came time to review and revise Resident #75's care plan.

Based on staff interviews and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 calendar days for 1 of 1 resident (Resident #37) reviewed who was identified by the facility as having a significant change in condition. The findings included: Resident #37 was admitted to the facility on [DATE] with reentry on 10/11/21 from a hospital. Her cumulative diagnoses included major depressive disorder. A review of Resident #37's electronic medical record (EMR) included a state Medicaid Uniform Screening Tool (NC MUST) form dated 4/5/23. This form indicated a Preadmission Screening and Resident Review (PASRR) screening was completed on 4/5/23 due to a change in the resident's condition. Resident #37's PASRR number ended with the letter B, which was indicative of a PASRR Level II determination with no limitation on the timeframe. Determination of a PASRR Level II status was made by an in-depth evaluation. The results of the evaluation were used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care. Further review of the resident's EMR revealed her care plan included the following area of focus, in part: Resident required a Level II PASRR with no end date. Her diagnoses included major depressive disorder and cerebrovascular disease (Initiated on 4/10/23; Revised on 5/11/23). This area of focus was authored by the facility's Social Worker. Resident #37's EMR also included a significant change Minimum Data Set (MDS) with an Assessment Reference Date (or ARD, which was the last day of the look-back period) of 5/18/23. The MDS assessment reported Resident #37 was determined to have a PASRR Level II status. However, the significant change MDS had an ARD which was 44 days after the resident was determined to have a PASRR Level II status. An interview was conducted with the facility's Social Worker on 11/7/23 at 3:07 PM. During the interview, the Social Worker reported around April of 2023, she reviewed all residents who had not been screened for a long time to be sure their PASRRs were updated. Resident #37 was one of the residents prompted for a review due to having a gradual change in her mental status. During a follow-up interview conducted on 11/8/23 at 11:10 AM, the Social Worker reported she printed out the NC MUST forms after they were received and put the forms in the Medical Record's box to be scanned into the resident's EMR. When asked, the Social Worker stated she was uncertain as to when she informed the MDS nurses of Resident #37's change to a PASRR Level II status. An interview was conducted on 11/8/23 at 10:30 AM with MDS Nurse #1 and MDS Nurse #2. During the interview, MDS Nurse #1 recalled a PASRR assessment was completed for the facility's residents several months ago and a significant change MDS was initiated if a new Level II determination was made for a resident. She stated this was the case for Resident #37 when her PASRR level changed to a PASRR Level II. Upon review of Resident #37's EMR, MDS Nurse #1 reported the resident's PASRR Level II determination was completed on 4/5/23 and the NC MUST documentation of this change was scanned into her EMR on 4/12/23. She stated the significant change MDS should have been completed within 14 days of when the facility became aware of the resident's PASRR Level II determination. She added, Its possible we missed it and caught it later. An interview was conducted on 11/8/23 at 2:40 PM with the facility's Director of Nursing (DON). When asked about the delay in completion of a significant change MDS for Resident #37 after she was determined to be a PASRR Level II, the DON reported there was a communication barrier that delayed the significant change MDS based on her new PASRR determination. She added, When we realized it, we did the sig [significant] change.

Based on observations, staff interviews and record review, the facility failed to keep a urinary catheter bag and/or the catheter tubing from touching the floor to reduce the risk of infection or injury for 1 of 2 residents (Resident #85) reviewed with indwelling urinary catheters. The findings included: Resident #85 was admitted to the facility on [DATE]. His cumulative diagnoses included obstructive uropathy (a structural or functional obstruction of the urinary tract that impedes the flow of urine). A review of Resident #85's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. This MDS indicated the resident had intact cognition. He was reported as having an indwelling urinary catheter. The resident's care plan included the following area of focus, in part: The resident requires a chronic urinary catheter related to benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive uropathy. This area of focus was initiated on 8/24/23 with revision on 8/28/23. An initial observation was made on 11/6/23 at 12:14 PM as Resident #85 sitting in a wheelchair in his room while watching television. The resident's urinary catheter bag was observed to be hanging from the right side of his wheelchair's frame. Both the urinary catheter bag and tubing were observed to be touching the floor. On 11/6/23 at 3:00 PM, another observation was conducted of Resident #85 as the resident was sitting in a wheelchair in his room. The resident's urinary catheter bag was observed to be hanging from the frame of the wheelchair and was positioned approximately 1/2 inch above the floor. However, a portion of the tubing from the urinary catheter was lying on the floor. An observation made on 9/11/23 at 3:15 PM revealed Resident #85's urinary catheter bag was lying on the floor as it hung from the frame of his wheelchair. The resident's urinary catheter tubing was observed to be slightly off the floor at the time of this observation. On 11/7/23 at 2:30 PM, Resident #85 was observed sitting in a wheelchair in his room watching television. Both the resident's catheter bag and tubing were noted to be on the floor. Upon request and accompanied by Nurse #1, an observation was made on 11/7/23 at 2:43 PM of Resident #85's urinary catheter bag and tubing lying on the floor. When asked if they should be touching the floor, the nurse stated, No. Nurse #1 was observed as she donned a pair of gloves in preparation to adjust the catheter bag and tubing so they were no longer touching the floor. An interview was conducted on 11/8/23 at 2:40 PM with the facility's Director of Nursing (DON). During the interview, the observations of Resident #85's urinary catheter bag and/or tubing touching the floor were discussed. The DON reported nursing staff knew they needed to keep the resident's urinary catheter bag and tubing off the floor to the best of their ability. She added, Maybe his should be checked more often.

Based on record reviews, observations, resident and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 2 of 2 sampled residents (Resident # 55 and Resident # 37) who were observed to have a medication at bedside. The findings included: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses to include a chronic non-pressure ulcer and gout. A review of the medical record for Resident #55 revealed a physician order dated 9/2/2022 for a multivitamin tablet to be administered daily for wound healing. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #55 to be cognitively intact. The medical record was reviewed and no assessment for self-administration of medications was in Resident #55's record. There were no physician orders for Resident #55 to self-administer medications, and no care plan that addressed self-administration of medications. Resident #55 was observed on 11/6/2023 at 4:22 PM. A bottle of over-the-counter multivitamin gummies was noted to be on the over the bed table and the bottle appeared to be half full. Resident #55 reported the facility was aware he had multivitamin gummies at the bedside. Another observation of Resident #55 was conducted on 11/7/2023 at 9:33 AM. The multivitamin gummy bottle was reviewed, and the instructions read to take 2 gummies daily. Resident #55 explained he took 2 of the gummies as the directions specified, but he wasn't certain how long he had the multivitamin gummies. During an observation of Resident #55 on 11/8/2023 at 12:21 PM, Medication aide (MA) #1 was interviewed. MA #1 reported she had administered all of Resident #55's medications that date, including his multivitamin tablet. MA #1 reported she was not aware Resident #55 had the multivitamin gummies at his bedside and explained she had not observed the bottle of multivitamin gummies on his over the bed table. MA #1 reported she was not aware Resident #55 was taking the multivitamin in addition to what she administered to him. MA #1 removed the multivitamin gummies from Resident #55's room. The Unit Manager (UM) #1 was interviewed on 11/8/2023 at 12:29 PM. UM #1 reported she was not aware Resident #55 had multivitamin gummies at his bedside and was self-administering the multivitamins. UM #1 reported she was not aware Resident #55 did not have an assessment to self-administer medications. The physician (MD) was interviewed on 11/8/2023 at 1:18 PM by phone. The MD explained he was not aware Resident #55 had multivitamin gummies at his bedside and he was administering the gummies in addition to the tablet he was receiving from staff. The MD reported Resident #55 was cognitively capable of managing an over-the-counter multivitamin, however, the facility should have been aware he had it at the bedside, so he was not receiving double medication. The Director of Nursing (DON) was interviewed on 11/9/2023 at 11:55 AM. The DON confirmed that she was not aware Resident #55 had the multivitamin gummies at the bedside, and that she was not aware he did not have an assessment completed to self-administered medications. The DON explained Resident #55 reported to her he was not aware he had to notify the facility nurses if he ordered over-the-counter medications. 32394 2. Resident #37 was admitted to the facility on [DATE] with reentry on 10/11/21 from a hospital. Her cumulative diagnoses included chronic obstructive pulmonary disease (COPD) and allergic rhinitis (an allergic reaction causing irritation to the nose). A review of Resident #37's electronic medical record (EMR) revealed a physician order was received on 11/23/22 for 137 micrograms (mcg) / spray azelastine solution (an antihistamine nasal spray) to be administered as two sprays into each nostril twice daily for allergic rhinitis times one month. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessed Resident #37 to be cognitively intact. Resident #37's current care plan was reviewed. The resident was not care planned for the self-administration of medications. A review of the resident's EMR revealed no assessments were completed for the self-administration of medications. Also, there were no physician orders for Resident #37 to self-administer medications. An observation was conducted on 11/6/23 at 10:25 AM of Resident #37 as she laid in her bed. At that time, a bottle of azelastine nasal spray was noted to be placed on her bedside tray table within reach of the resident. Upon inquiry, Resident #37 reported she used one spray for each nostril twice daily and had been administering the azelastine nasal spray on her own. On 11/6/23 at 12:26 PM, a second observation was conducted of the resident in her room. Resident #37 was lying in the bed with the azelastine nasal spray observed on her bedside tray table. An observation and interview were conducted with the resident on 11/7/23 at 2:35 PM. During the observation, it was noted the resident's azelastine nasal spray was no longer placed on her bedside table. When asked, the resident reported she gave it (the nasal spray) back to the hall nurse. Upon further inquiry, Resident #37 stated a nurse had left the nasal spray on her bedside table for the last one and one-half (1 and 1/2) to two (2) weeks, so she administered it herself. The resident reported she knew she probably should not have the medication, so she gave the nasal spray back to the nurse earlier that morning (11/7/23). An interview was conducted on 11/8/23 at 11:47 AM with Nurse #1. Nurse #1 was the first shift hall nurse who was assigned to care for Resident #37 on 11/7/23 and 11/8/23. During the interview, an inquiry was made about the azelastine nasal spray the resident reportedly gave to Nurse #1 the morning of 11/7/23. Nurse #1 pulled the nasal spray from the medication cart. She reported that when the resident gave it to her, Resident #37 said she knew she was not supposed to have it. Observation of the nasal spray revealed it was 0.1% azelastine providing 137 mcg per spray. Portions of the pharmacy label placed on the nasal spray appeared worn and the dispensed date was no longer visible on the label. The nurse confirmed this label came from the facility's contracted pharmacy. A telephone interview was conducted on 11/8/23 at 1:20 PM with the facility's Medical Director (who was also the resident's physician). During the interview, the MD stated he would not want Resident #37 to have a medication such as the azelastine at bedside unless she was assessed and care planned for the self-administration of it. An interview was conducted on 11/8/23 at 2:40 PM with the facility's Director of Nursing (DON). At that time, the DON reported the facility had a process that needed to be followed if a resident wished to self-administer a medication. However, she confirmed Resident #37 neither had an order to self-administer a medication nor was she care planned to do so.

Based on record review and staff, Medical Director, Physician Assistant (PA) and Orthopedic Physician Assistant interviews the facility failed to follow a PA's order written on 05/03/23 to arrange for orthopedic follow up within 2 weeks for a resident. The resident was not seen until 05/31/23 and the Orthopedic PA noted drainage from the surgical wound and the staples were still in place and imbedded in the skin. The resident was sent to the hospital due to concern for a periprosthetic joint infection (infection around the hip prosthesis) and on 06/06/23 an incision and drainage was performed to the left hip in the operating room. This deficient practice occurred for 1 of 2 residents reviewed with a surgical wound (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] post Left Hip Revision. The hospital discharge instructions dated 05/01/23 included: Administer Doxycycline Monohydrate (an antibiotic) 100 mg 1 capsule every 12 hours. Call for follow up appointment with primary care provider (PCP) and orthopedic surgeon within 1 week. Record review of the Physician orders entered by Nurse #2 on 05/01/23 included in part: Assess surgical bandage to left hip for drainage, warmth, redness, and s/s (signs and symptoms) of infection and document findings in progress note and notify the physician or physician assistant (MD/PA-C) every shift monitoring. Physical therapy (PT) evaluation and treatment. Vital signs and O2 Sats (Oxygen saturation - measures oxygen content in blood) every night shift for monitoring Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) to monitor for infection every Tuesday morning. Administer Doxycycline Monohydrated Oral Capsule 100 mg two times a day for surgical incision prophylaxis (for infection prevention) until 05/31/23. Record review of the Medication Regimen Review and Medication Order Recap for May 2023 revealed there was no entry by Nurse #2 to call for a follow up with the orthopedic surgeon within one week. A telephone interview was conducted on 06/29/23 at 9:22 AM. Nurse #2 stated that she reviewed Resident #1's hospital discharge summary and entered the 05/01/23 orders on in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). A copy of the hospital discharge summary contained an appointment on 05/31/23 that was put it into the transportation department's box. Nurse #2 explained the Transportation Aide picked up the appointment orders from box and scheduled all appointments. She remembered appointment for 05/31/23 on Resident #1's hospital discharge summary but did not recall an order for a 1 week follow up appointment with the primary care provider and the orthopedic surgeon. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. She required assist with activities of daily living (bathing, personal hygiene, dressing, and grooming) and had occasional incontinent bowel or bladder episodes. She used a walker or a wheelchair for mobility. Her diagnoses included Unspecified Dislocation of Left (L) Hip, subsequent encounter; Presence of Artificial Hip Joint; Unilateral Primary Osteoarthritis of the L Hip; Stroke and Anxiety Disorder. Resident #1's care plan dated 05/07/2023 indicated to readmit after total revision of left hip arthroplasty-surgical incision with dressing in place to be removed and follow up with orthopedics. Interventions included: Assess and document the status of the area (healing vs declining). Monitor, document, and report to Physician changes in color, temperature, sensation, pain, or presence of drainage and/or odor. Vital signs / labs as ordered. Consult MD (physician) with any abnormal values. Wound documentation per protocol. Record review of the Treatment Administration. Record review of the Treatment Administration Record for May 2023 indicated that the surgical dressing was checked every day on first shift as indicated by nurses' initials. Record view of the Medication Administration Record for May 2023 indicated assess surgical bandage to left hip for drainage, warmth, redness, and signs and symptoms of infection. Document findings in progress note and notify the Physician or Physician Assistant every shift, for monitoring. Review of Resident #1's May 2023 MAR revealed nurses' initials confirming that the surgical bandage was checked every shift. In addition, Resident #1 was administered one Doxycycline 100 mg capsule every 12 hours daily as prescribed. Resident #1's weekly skin assessments completed by the nurses dated 05/01/23, 05/08/23, 05/15/23, 05/22/23, 05/29/23 and 05/30/23 revealed left hip dressing was intact and with no signs and symptoms of infection. Record review of Resident #1's Complete Blood Count (CBC) revealed a white blood count (WBC- a measurement used to determine infection with normal range of 3.8-10.8 K/uL). WBC on 05/02/23 - 5.4 K/uL (thousands per cubic milliliter). Review of the Physician Assistant's (PA) progress note dated 05/02/23 revealed Resident #1 was alert and oriented to self alone. She was up in her wheelchair and her vital signs were stable. Resident #1 had pain with movement of the LLE (left lower extremity) but no longer with pain during palpation of the left calf/thigh. Plan included follow up with Ortho within 2 weeks and strict posterior hip precaution measures. A small WC cushion was placed that day but Resident #1 did not have adequate recall/compliance with the cushion. Staff to continue the best they can to always encourage placement. Left hip surgical dressing to be assessed every day by nursing and wound care RN as well and to notify ortho of any compromise. Resident #1 remains on post-op Abx (antibiotics) per ortho through the end of May. Review of PA orders dated 05/03/23 included: Assess L hip surgical dressing once daily. Notify Orthopedics if any compromise every day for wound care. Arrange for orthopedic follow up within 2 weeks regarding L hip Arthroplasty. During a telephone interview on 06/27/23 at 3:30PM, the Physician's Assistant stated that she had ordered the nurses on 05/03/23 to obtain a 2 week follow up appointment at the orthopedic office. She was not aware of any compromise of the surgical incision or the dressing. Record review of Nurse #1's progress note dated 05/03/23 revealed PA came in for readmission visit and wrote orders to assess the left hip incision daily and to make a follow up appointment with the orthopedic office. On a telephone interview on 06/29/23 at 10:48 AM with Nurse #1, she recalled the 05/03/23 PA order and stated she made a copy of the follow up appointment order and put it into the transportation department's box. Vital signs on 05/03/23 at 3:49 AM: BP (Blood pressure) 113/74; T (Temperature) 97.4; P (Pulse) 67; R (Respiration) 18; O2 Sat (Oxygen Saturation - blood oxygen level) 98% on room air (RA). Review of the May 2023 transportation calendar revealed no appointment was scheduled for Resident #1's follow-up appointment between May 1st through the 14th. An interview on 06/27/23 at 9:25 AM with the Scheduler/Transportation Aide indicated the nurses put the copy of the appointment order in the transportation box and she checked the box daily. Orders were written on her calendar, and she also made the up follow up appointments as ordered. She stated that the only appointment she received for Resident #1 with the orthopedic surgeon was for 05/31/23. A follow up telephone interview with the Scheduler/Transportation Aide was completed on 06/29/23 at 9:32 AM. She clarified that she did not receive the order dated 05/03/23 to make a 2-week orthopedic follow up. Review of PA notes on 05/16/23 indicated in part Resident #1 was alert, oriented to self alone and had short recall. She was up in her wheelchair working with therapy and tolerating well. Pain was stable and minimal when changing from sitting to standing position. Resident was eating/drinking and tolerating diet. Orthopedic follow up in place per staff. Plan included a follow up with Ortho within 2 weeks and strict posterior hip precaution measures. Resident continued to have small WC cushion, but resident did not have adequate recall/compliance with using it. Staff was to continue to do the best they can to always encourage placement. Dressing was to be assessed every day by nursing and wound care RN as well and to notify orthopedic providers of any compromise. Pain management was in place. Weight bearing as tolerated (WBAT). Resident #1 remained on post-op antibiotics through 05/31/23. WBC on 05/04/23 was 5.4 K/uL. Vital signs on 05/04/23 at 5:35 AM: BP 114/72; T 97.7; P 80; R 16; O2 Sat 98% on RA. WBC on 05/09/23 was 9.4 K/uL. Vital signs on 05/09 at 4:49 AM: BP 134/85; T 96.8; P 78; R 18; O2 Sat 99% on RA. WBC on 05/11/23 was 6.3 K/uL. Vital signs on 05/10/23 at 6:09 AM: BP 136/76; T 97.5; P 78; R 18; O2 Sat 98% on RA. WBC on 05/18/23 was 6.9 K/uL. Vital signs on 05/18/23 at 5:09 AM: BP 124/74; T 97.8; P 76; R 18; O2 Sat 97% on RA. WBC on 05/25/23 was elevated to 15.1 K/uL. Vital signs on 05/25/23 at 2:29 AM: BP 130/74; T 97.2; P 72; R 18; O2 Sat 97% on RA. During an interview with Nurse #4 on 07/05/23 at 9:50 AM, she stated she notified the facility medical director of the increased WBC on Resident #1 on 05/25/23. She printed out the lab result and Medical Director signed the hard copy when he was rounding that day. She added that there were no orders written by Medical Director that day. She denied notifying the surgeon since their facility protocol was to notify Medical Director or PA of abnormal laboratory results. An interview was completed on 06/27/23 at 4:15 PM with Nurse #2. She revealed that when she completed Resident's #1 skin evaluation on 05/29/23, the surgical dressing was not the original dressing It was dry and had no odor. Nurse #2 assisted Resident #1 to stand to assess the dressing on the hip. During a follow-up telephone interview on 06/29/23 at 9:22 AM Nurse #2, revealed she completed skilled note dated 05/29/23 and marked a checkbox indicating the incision on the left hip was intact and well approximated. She stated she did not look at the actual wound. Vital signs on 05/30/23 at 12:02 AM: BP 128/70; T 97.9; P 74; R 16; O2 Sat 95% on RA. Vital signs on 05/31/23 at 3:03 AM: BP 130/70; T 97.9; P 74; R 18; O2 Sat 96% on RA. Record review of skilled nursing notes completed Nurse #1 on 05/30/23 and 05/31/23 revealed Resident #1 was alert and oriented. She had clear speech and needed assistance with activities of daily living (ADL) and transfers, but she was able to propel herself in a wheelchair. She had incontinent episodes at times. Dressing to L hip was clean dry and intact. Left hip incision was intact and edges were well approximated. Skin was warm and dry to touch. A telephone interview on 07/05/23 at 2:37 PM Nurse #1 indicated no recall of Resident #1's incision on 5/30/23 or 5/31/23. She stated she assumed the checkbox on the skilled notes forms were to verify that the dressing was dry and intact. She did not recall a malodor. She stated the orthopedic physician was called when a resident had drainage or odor in a wound. In addition, the wound care nurse was notified if the dressing was saturated. Record review of Physical Therapy Discharge Summary dated 05/31/23 at 10:09 AM revealed Resident #1 has met her maximum potential and did not require further skilled PT at that time. During an interview on 06/27/23 at 9:50 AM the Physical Therapist (PT) revealed Resident # 1 as having some cognitive or memory issues, impulsive at times, but followed commands. She had high anxiety, was unstable and was still high risk for falls but displayed improvement. She walked 225 steps with the use of a walker with contact guard by 05/31/23. PT stated they do not assess surgical wounds, but they notified nurses when there were issues with dressings. The PT stated he notified the nurse of Resident #1's dressing coming loose on 05/31/23. An interview was completed on 06/27/23 at 8:50 AM with the Wound Care Nurse (WCN). She indicated she had changed Resident #1's dressing one morning when the PT notified her of the dressing coming loose. She did not recall when this was. She observed the staples were intact, and she noted a small amount of clear drainage. She did not observe any odor and did not document in Resident #1's progress notes. She stated Resident #1 did have the original dressing and that she monitored her dressing daily. She was aware of a follow up appointment with Resident #1's surgeon for 05/31/23 and added that was what the surgeon's office had set up. A follow up telephone interview with the WCN on 6/28/23 at 9:05 AM revealed that monitoring of the surgical site was completed every shift. This was documented by nurses on the TAR that was checked daily. If there were changes, she documented on the progress note, and notified the physician. An additional follow up telephone interview was completed with WCN on 07/3/23 at 10:00AM which revealed the surgical site was clean, dry, and intact, no scabs, no swelling, no odor on 05/31/23. This was when she became aware there were staples. She revealed that the order was to keep the area clean dry and protected. She put an absorbent pad over the surgical wound to keep it clean. A telephone interview was conducted on 07/06/23 at 8:49 AM with Nurse Aide #2. She stated she assisted Resident #1 the morning of 5/31/23. Resident #1 was assisted in ambulating to the bathroom and in getting dressed for her doctor's appointment. She added that Resident #1 was behaving as usual and did not complain of any pain or discomfort. She did not recall the dressing being soiled or any bad odor from the wound on 05/31/23. Nurse Aide #2 explained if she observed odor from a wound or if there were any changes in a resident's condition, she notified the nurse. Resident #1 had no complaints on 5/31/23. Record review of the Orthopedic Physician Assistant note dated 05/31/23 revealed Resident #1 did not follow up with her routine 2-week postoperative appointment. The surgical dressing to the left hip was soiled, malodorous and saturated with serosanguinous fluid (clear fluid mixed with some blood). The surgical staples were still in place and embedded on the skin. The upper wound was fully healed but the lower incision showed a persistently draining sinus tract/fistula. Resident #1 was doing well on examination and denied any numbness, tingling, fevers/chills, nausea or vomiting (N/V), swelling, shortness of breath, or chest pain. The staples were removed during this visit and Resident #1 was subsequently sent to the emergency department for concern of a periprosthetic joint infection. A telephone interview with Orthopedic Physician Assistant (PA) on 07/05/23 at 9:12 AM revealed he had noted the odor coming from Resident #1 surgical wound from across the room when he assessed Resident #1 on 05/31/23. The dressing was reinforced with tape, and it was soiled with malodorous drainage. He stated that the purpose of the follow up 2-week appointment was to remove the staples and evaluate the wound. The staples were imbedded into the wound and overgrown. The wound was 4 weeks old and serosanguinous drainage saturated the dressing. The nursing home did not report any elevated labs or drainage to the orthopedic office. He indicated that hospitalization may have been avoided if Resident #1 had been brought in for her two week follow up appointment. He stated he expected a call from the nursing home with a draining wound and staples still intact after 4 weeks. The PA did not say that the staples not being removed were the cause of infection. Review of hospital records dated 05/31/23 revealed Resident #1 was initially evaluated in the emergency department (ED) for Left Hip Prosthetic Joint Infection. Examination by physician revealed Resident #1 had a normal mood and behavior. She was sitting comfortably in a chair with stable blood pressure, temperature, pulse and breathing. Review of systems were negative for fever. VS obtained at 17:32: BP 120/78, P 66, R 16, T 97.6 F and O2 Sat 100 % on RA. There was no shortness of breath, and no chest pain. She was alert and stood with assistance. The left hip incision was healed from the top of the incision but had a small opening at the bottom of the incision. There was a purulent (sign of infection) discharge on dressing. The staples were out of the incision and there was no obvious cellulitis or edema. Resident #1's skin was warm, dry not diaphoretic and not cyanotic. The CBC on 05/31/23 revealed a normal white count at 8.3 K/uL. Her C-Reactive Protein (CRP - protein released by liver into the bloodstream in the presence of inflammation) was high at 27.75 mg/dl (milligram per deciliter, the normal level was below 0.3 mg/dl; serious level is above 50 mg/dl). Blood culture specimen was also drawn that day on 05/31/23. The final result for the blood culture was negative. Review of hospitalist's progress note on 06/01/23 indicate Resident #1 had no acute events overnight and Resident #1 denied hip pain or discomfort. There was persistent serosanguinous drainage. Resident #1 denied any sensation of swelling, fevers or chills, nausea or vomiting, malaise, fatigue, or any other symptoms. A wound culture collected on 6/2/23 revealed light growth of pseudomonas aeruginosa (gram-negative, aerobic, non-spore forming rod that could cause a variety of infections) which was indicative of a bacterial infection. Review of a computerized tomography scan (series of x-rays) on 06/03/23 of the left hip identified cellulitis. Record review of the surgical note dated 06/06/23 revealed an incision and drainage was performed to the left hip in the operating room. A large collection of subcutaneous purulent drainage or pus was noted extending to the posterior capsule into the hip joint where the prosthesis was. The area was irrigated (washed out), and antibiotic beads were implanted in the surrounding tissues. A tissue culture of debris was obtained during the incision and drainage. The tissue culture result was negative for any infection. During a telephone interview on 06/27/23 at 3:50 PM with the facility's Medical Director, he stated Resident #1 was initially admitted on [DATE]. She exhibited cognitive decline and had a poor functional level. He explained that this back-to-back surgery worsened Resident #1's cognitive ability and there was already a concern for infection setting up when he spoke with Orthopedic Physician on 05/01/23. Additionally Resident # 1 was readmitted on [DATE] on chronic antibiotic therapy due to the high risk of infection, especially with the third surgery. He indicated his impression was that the follow up appointment was 05/31/23. A follow up telephone interview was completed with the facility's Medical Director on 06/29/23 at 10:55 AM. He stated there was a mix up with the follow up appointment on Resident #1's discharge summary. The PA clarified the order on 05/03/23 and wrote for an Orthopedic follow up within 2 weeks. He explained Resident #1 was already on chronic antibiotic therapy when readmitted on [DATE]. He stated she went to the appointment on the 05/31/23 and directly to the hospital from the office due to a strong suspicion of internal infection. He indicated that the facility monitored the complete blood count (CBC) weekly. He stated that on 05/25/23 her white count went up to 15,000. A follow up CBC was already scheduled for 06/01/23 and that she was already on an antibiotic. He stated he was not aware the staples had not been removed until 5/31/23 but stated this had no negative impact on the wound. The Medical Director stated this did not play a big part in the infection but stated they should have been removed in 2 weeks. The Director of Nursing (DON) was not available for interview during the investigation. A telephone interview on 07/10/23 at 12:23 PM Administrator revealed that physician orders need to be followed and to clarify if there were questions.

Based on record reviews and staff interviews, the facility failed to protect a cognitively impaired resident from verbal and physical abuse from a staff member for 1 of 4 resident's reviewed for employee to resident abuse. Resident #1. The findings include: Resident #1 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Medicare 5 day Minimum Data Set, dated dated dated [DATE], Resident #1 was cognitively impaired, independent with transfers, required extensive assistance with bed mobility, and was independent with mobility in his room and on the unit. Review of Resident #1's care plan dated 1/13/21 revealed a goal for the resident to have no behaviors and to maintain behavioral manifestation to a minimum. Interventions included encouraging the resident to express feelings (anger, sadness, guilt) and help to come up with alternative ways to handle feelings of anger and frustration. Maintain a calm, non-threatening manner while working with the resident. Provide reassurance and comfort measures and to use short simple sentences. During an interview on 4/6/21 at 2:08 PM, NA #1 revealed the incident happened on second shift. She stated Resident #1 was standing at the nurse's station. She stated Resident #1 was told to go to his room by Nurse #1, and Resident #1 said no. She revealed Nurse #1 said I'll beat your (derogatory word) and grabbed Resident #1 by the arm and dragged him down the 600 hall. She stated she kept yelling at Nurse #1 to walk away. She stated Nurse #1 held his hands behind his back and said to Resident #1, hit me, hit me. NA #1 said she told Nurse #1 to let Resident #1 go. NA#1 stated NA#5 intervened and got Resident #1 away from Nurse #1 and escorted him to his room. She stated she told Nurse #2 and Nurse #2 sent Nurse #1 home. During an interview on 4/6/21 at 2:21 PM, NA#2 stated she was sitting at the computer charting when Nurse #1 stood up and told Resident #1 to go to bed. NA#2 said Nurse #2 grabbed Resident #1's arm and walked him down the hallway and she heard Resident #1 yelling, let go, you're hurting me. She revealed NA #1 told Nurse #1 three times to let go of Resident #1. She said Nurse #1 told Resident #1 to go to his room and Resident #1 said I'm not going. She revealed Nurse #1said, Oh you're going to your room. NA#2 stated by that time, NA#5 came around the corner and got Resident #1 and took him to his room. During an interview on 4/6/21 at 3:08 PM, NA#3 revealed she was sitting at the nurse's station and she heard a commotion on the 600 hall. She stated she saw Nurse #1 with his hands behind his back, standing in front of Resident #1. She revealed she could not see much because she was so far away. She said she was almost a whole hall away. She said she did not have to say or do anything because Nurse #2 handled the situation. During an interview on 4/6/21at 4:15 PM, NA#4 revealed she was sitting at the nurse's station charting and she observed Nurse #1 with his hands behind his back standing in front of Resident #1 and asking the resident if he was going to hit him. During an interview on 4/6/21 at 4:30 PM Nurse #2 revealed she was charting at the nurse's station and NA#1 informed her that she witnessed abuse and she needed to report it. She revealed NA#1 explained that the incident happened between Nurse #1 and Resident #1. She stated Resident #1 came down to the nurse's station, holding up his catheter bag in his hand and Nurse #1 approached him and asked him to go to his room to drain the catheter. Nurse #2 said NA#1 told her Nurse #1 grabbed Resident #1's arm and led him down the hallway. Nurse #2 said she went down to the 600 hall medication cart to take Nurse #1's keys and escorted him to the time clock and out of the facility. Nurse #2 stated NA#1 notified the DON after she walked Nurse #1 out of the building. She said she completed Resident #1's skin assessment and there were no bumps or bruises. Nurse #2 stated Resident #1 did not appear to be upset and he did not remember anything that happened. She stated he was perfectly pleasant. During an interview on 4/6/21 at 7:00 PM, NA# 5 stated Resident #1 was standing at the nurse's station and he was talking about going home. She revealed she and other staff were encouraging him to go to his room. NA#5 said Nurse #1 was sitting at the desk charting and he stood up, slammed his chair and said, I'm going to beat your, (derogatory words) grabbed Resident # 1 by his arm and dragged him half way down the 600 hall and cornered him in the hallway. She stated Resident #1 kept saying, let me go. Let go or I'll punch you. NA #5 revealed Nurse #1 said, hit me, hit me, hit me, I dare you to hit me. She said NA#1 told Nurse #1 at least three times to walk away. NA#5 stated she and three other staff escorted Resident #1 to his room. She stated she called Nurse #2 and Nurse #2 escorted Nurse #1 out of the building. Nurse #1 was not available for interview. Nurse #1's written statement read in part, At approximately 9:15 PM on January 25th, Resident #1 was walking the 600 wing hallway unassisted as he does every night. He wandered around the 600 hall nurse's station and was holding up his foley catheter bag folded and crumpled up in his hand as he always does. Approximately 9:30 PM, Resident #1 stopped at the nurse's station and asked me questions about exiting the building. I stated it was 9:30 PM at night and that he needed to go back to his room and sit or lie down so that the foley catheter bag could drain because it shouldn't be crumpled up in his fist. I told him that his family member wanted him to be in bed because it was after 9:30. I approached him and explained that because the foley catheter bag was wadded up that it's not doing its job and it could cause him health issues. He argued with me that it was just fine. I placed my hand on his back and said Come on, we need to get you up to your room so that you can sit or lie down. I was speaking firmly and matter- of -factly. He stated something contradictory and wasn't budging. This technique has worked fine several nights in the past to successfully motivate him towards his room and once we get him sat down and the foley draining properly, he's in a pleasant mood and generally ready for bed. The evening of the 25th was different. He seemed to be in a more bullish mood and refused to budge. I took his free right hand in mine and continued holding my left hand on his back. I firmly stated, come on, it's time to go up to your room. We both got about 2 steps pulling against each other for a few seconds and he jerked away and told me to get my hands off of him or he was going to (assault) me. I completely released him with my hands open, in the air by my head, and my hands away from him. I told him to go ahead and hit me if that's what he wanted to do. At that point, NA#1 said, Just walk away, just walk away. That is exactly what I did. I turned around and walked away. Approximately 15 minutes after the incident, while I was giving report to Nurse #2, Resident #1 walked by the nurse's station again, smiled and asked, How are y'all doing! His normal friendly manner. During an interview with the Director of Nursing (DON) and the Administrator on 4/6/21 at 3:24 PM, the Director of Nursing revealed the incident was immediately reported by NA #1. The DON revealed Nurse #2 was also notified. She stated she told Nurse #2 to clock Nurse #1 out to go home. The DON revealed Resident # 1 was assessed, but the resident did not recall what happened. She stated Nurse #1 was suspended, the report was called in, skin checks were done, statements were gathered from witnesses and the cardex care plan was updated. The DON revealed they monitored Resident #1's psychological well being. She revealed every morning they reviewed residents to determine if they had any concerns and skin checks and weights were reviewed. The DON revealed the residents were aware of their rights. The Administrator revealed Nurse #1 was terminated, 24 hour and 5 day reports were completed with a confirmation fax. He stated 100% of all staff were inserviced on the abuse policy of reporting abuse, and a Qapi (Quality Assurance Performance Improvement) meeting was held on January, 27th. The Administrator stated the medical doctor and family was notified. He revealed resident's rights were reviewed in Resident Council meetings. He stated thirteen residents were interviewed and asked if they felt respected by staff. The Administrator revealed there was ongoing education on resident's rights and abuse. He revealed they had not done any monitoring or audits regarding staff to resident abuse.

Based on observations, record reviews, and staff interviews the facility failed to implement their COVID19 screening policy when a nursing assistant (NA) reported to work and did not provide accurate information when being screened for the COVID 19 virus for 1 of 23 staff reviewed for COVID19 screening. NA #1, prior to beginning her eight-hour shift on 11/16/20, did not report to the COVID19 screener that she recently had a fever and was currently experiencing signs and symptoms of the COVID19 virus which included; a loss of taste and smell. On 11/20/2020 NA #1 tested positive for the COVID19 virus. Since 11/20/20 the facility had a COVID19 outbreak with 33 of 73 residents and 21 staff testing positive for the COVID19 virus. This failure occurred during the COVID19 pandemic. Immediate Jeopardy began on 11/16/2020 when NA #1 reported for work and did not inform the COVID screener that she had a fever on 11/13/20 and had signs and symptoms of COVID-19 virus including a loss of taste and smell when she was being screened on 11/16/20. Immediate Jeopardy was removed on 12/5/2020 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of E (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. Findings included: A facility policy Facility Entry Screening for COVID-19 dated 3/9/2020 and revised 3/20/2020 read that all employees, visitors, providers and anyone else requesting entry to the facility will be actively screened using the latest COVID-19 screening tool before entry into the building. The policy specified that anyone with a positive screen would not be allowed entry into the building. The facility COVID-19 screening tool for employees dated 5/13/2020 and updated 11/4/2020 was reviewed. The facility name, date, employee name and phone number were at the top of the form and the following questions: 1. Does this individual currently have or have they had in the last 14 days any of the following symptoms: cough, new loss of taste, sore throat, muscle or body ache, diarrhea, fever (greater than 100.0 degrees), shortness of breath or difficulty breathing, chills, new loss of smell, nausea or vomiting, headache, fatigue, congestion or runny nose. 2. Document the temperature of the employee and indicate if greater than 100.0 degrees. The form further documented employees/providers answering YES to questions 1 or 2 may not enter the facility. Instruct the employee/provider to contact their physician for guidance. Report all employees who are unable to work to the facility ' s human resources generalist and department scheduler. The Administrator reported during a phone interview on 12/4/2020 at 12:14 PM that NA #1 start date with the facility was 11/3/2020. Included in the orientation materials was information regarding the screening process to enter the building dated 10/29/2020 with NA #1 ' s signature. Review of the nursing schedule for 11/16/20 and the time card report confirmed NA #1 worked the entire 3rd (11:00 PM to 7:00 AM) shift on the 800 general population hall. Review of the staffing schedule revealed NA #1 was assigned to the 800 hall with NA #3 who floated between 800 and 400 hall. NA #1 ' s facility employee screening tool dated 11/16/2020 was reviewed. NA #1 ' s answers were documented as no for all of the screening questions including new loss of taste, smell and fever greater than 100.0 degrees. NA #1 ' s temperature was documented as 97.5 degrees. A list of residents who tested positive for COVID-19 on 11/22/2020 revealed 8 of 8 residents who resided on the 800 hall on 11/16/2020 and NA #1 provided care tested positive for the COVID19 virus. (Resident #1, #2, #3, #4, #5, #6, #7, #8.) COVID-19 testing results from 11/22/2020 to 12/3/2020 revealed a total of 33 residents out of 73 residents tested positive for COVID-19, and 21 staff tested positive for COVID-19. A phone interview was conducted with NA #1 on 12/3/2020 at 4:06 PM. NA #1 reported she been employed at the facility since 11/3/2020 and she received training on the screening process prior to her first day of work. NA #1 reported that she had received education regarding the signs and symptoms of COVID-19 and the screening process to enter the facility for work. NA #1 reported she had called out of work on 11/13/2020 because she had a fever of 99.8 degrees Fahrenheit. NA #1 reported on 11/14/2020 and 11/15/2020 she did not have any other fevers but had lost her sense of smell and taste. NA #1 stated she returned to work on 11/16/2020 and worked 3rd shift on the general population 800 hall. NA #1 reported she had a loss of taste and smell or taste, but she did not remember how she answered the screening questions. NA #1 reported she had not told the screener or the charge nurse or any other employee she had a fever on 11/13/2020 or that she had lost her sense of taste and smell. NA #1 reported she worked 3rd shift on 800 hall and she wore the KN95 mask all shift. NA #1 reported when her shift ended at 7:00 AM on 11/17/2020, she was feeling poorly and told the scheduler she needed to be tested for COVID. A rapid test was conducted on 11/17/2020 and the results in 15 minutes and the results were negative. NA #1 reported she had a 2nd test at the facility the morning of 11/17/2020 which was also negative. NA #1 reported she did not return to work after 11/17/2020 because she felt so poorly, and she went to her personal physician on 11/20/2020 and had another rapid test performed with positive COVID-19 results. NA #1 reported she contacted the facility to notify the administration of her positive COVID test results. NA #1 was interviewed by phone on 12/3/2020 at 11:41 PM. NA #1 clarified that she had a headache at the end of her shift during the morning of 11/17/2020 and she asked Nurse #2 for medicine. NA #1 stated she was aware that fever, loss of taste and smell, and headache were signs of COVID-19, but she did not think she could have been infected. NA #1 reported she thought she had a cold or the flu. NA #1 reported that she answered the screening questions no because she was worried if she told them she had a fever over the weekend she would have disciplinary action related to calling out. NA #1 reported she was aware all of her symptoms may have been COVID-19 related but did not believe she was infected until she received the positive test result 11/20/2020. Interview with NA #2 on 12/3/20 at 5:17 PM revealed she was scheduled to work as screener on 11/16/2020. NA #2 reported she frequently worked as screener on 2nd shift (3:00 PM to 11:00 PM) and screened 3rd shift staff coming into work. NA #2 reported she had screened NA #1 into work on 11/16/2020 for 3rd shift. NA #2 reported she asked the screening questions and NA #1 reported no for all questions, including fever, loss of smell and taste. NA #2 reported NA #1 did not appear sick. NA #2 reported if NA #1 had reported a fever or loss of taste and smell in the past 14 days she would have informed the charge nurse on duty and would not have allowed her to enter the facility. Nurse #2 was interviewed by phone on 12/4/2020 at 11:42 AM. Nurse #2 reported she was the charge nurse on 3rd shift on 11/16/2020. Nurse #2 reported that NA #1 did not report feeling sick, having no sense of smell or taste or any other symptoms of COVID to her during the night of 11/16/2020. Nurse #2 reported she did not recall giving medication to NA #1 during the shift on 11/16/2020. Nurse #3 was interviewed by phone on 12/4/2020 at 11:36 AM. Nurse #3 reported she usually worked day shift (7:00 AM to 3:00 PM) and she was responsible for staff education and performing testing on staff and residents for COVID. Nurse #3 reported she did not recall performing a COVID 19 test on NA #1 on 11/16/2020 because of the number of tests she had performed. Nurse #3 reported NA #1 had not told her that she felt sick or that she had a loss of taste and smell or had a fever on 11/17/2020. A phone interview was conducted with the facility scheduler on 12/4/2020 at 10:30 AM. The Scheduler reported that NA #1 had sent her a text message on 11/13/2020 that said she did not feel well but did not report a fever or any symptoms in the text message. The Scheduler reported she had texted instructions for NA# 1 to call the facility if she was not going to come into work on 11/13/2020. The scheduler reported she had not told the DON about NA #1 not feeling well because she had not reported specific symptoms to the scheduler. Nurse #5 was interviewed by phone on 12/4/2020 at 4:25 PM. Nurse #5 reported she was working 11/13/2020 on 2nd shift when NA #1 had called out sick for 3rd shift on 11/13/2020. Nurse #5 reported NA #1 told her she had talked to the scheduler and let her know she had a fever. Nurse #5 reported she completed the call-out sheet for NA #1 and put it on the clipboard. Nurse #5 reported she may have been told to report all signs and symptoms of COVID to the DON, but she forgot, and she presumed that because the Scheduler had talked to NA #1, the information regarding her fever was communicated to the DON. Nurse #5 reported that she thought the call-out sheets were reviewed by the DON the next day. The Director of Nursing (DON) was interviewed on 12/2/2020 at 2:30 PM. The DON reported that NA #1 called out of work on Friday, 11/13/2020 and then returned to work on 11/16/2020. The DON felt that NA #1 was the cause of the COVID-19 outbreak at the facility since 11/20/2020 because she was the first staff to test positive. During a follow-up interview with the DON on 12/4/2020 at 10:29 AM, the DON reported she was not aware that NA #1 had a temperature on 11/13/2020 and NA #1 had not reported to her that she had been sick over the weekend and had lost her sense of taste and smell. The DON reported had she been aware of this information she would have advised NA #1 to see her physician and NA #1 would not have been allowed to work. The DON reported she was notified on 11/20/2020 by NA #1 of her positive COVID test result. The DON reported that when staff call out of work for illness and report symptoms of COVID-19, the staff taking the call are supposed to notify her or the Administrator. The DON reported that she had not been notified that NA #1 had a fever on 11/13/2020, or NA #1 lost her sense of taste or smell, or NA #1 had a headache at the end of the shift on 11/17/2020. The DON was interviewed by phone on 12/4/2020 at 4:42 PM. The DON reported that the call-out sheets were given to Human Resources, but she reviewed the sheets every morning. The DON reported that she was not told by the Scheduler that NA #1 had a fever and she had not reviewed the call-out sheet for NA #1. The DON reported had she been aware that NA #1 had a fever, she would have been directed to go to the physician to find the reason for the fever. The DON reported that she was unaware that NA #1 had lost her sense of taste or smell until this week. The DON reported that had she been aware of all of the symptoms NA #1 had, NA #1 would not have been allowed to work. The Administrator was interviewed on 12/4/2020 at 12:14 PM. The Administrator reported that NA #1 ' s screening form for 11/16/2020 revealed she did not have an active fever and her temperature was 97.5 upon arrival to the facility and NA #1 had answered the screening questions no for fever because her temperature did not get above 100 degrees. The Administrator reported the staff had been educated on the signs and symptoms to report to nursing staff and to not work if they had any symptoms of COVID 19, including loss of taste, smell and a fever. The Administrator reported he was not certain why NA #1 had not provided that information to the facility during her screening process and he expected all staff to recognize and report the signs and symptoms of COVID to nursing before entering the building. The Administrator was notified of Immediate Jeopardy on 12/4/2020 at 5:52 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 12/5/2020 at 6:14 PM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to review the call out log and staff did not report new symptoms of loss of taste, smell and a temperature of 99.8 on 11/13/2020 when NA#1 reported to work on 11/16/2020 likely causing the transmission of COVID-19 virus to residents and staff. NA #1 called out to Nurse #5 on 11/13/2020 stating that she had a temperature of 99.8 and felt bad. Nurse #5 completed the call out sheet for NA #1 and put on clipboard. Nurse #5 could not recall whether she had been taught to notify the Director of Nursing upon identification of an employee with symptoms. Nurse #5 thought that because scheduler was made aware of NA#1 condition that she would notify Director of Nursing and that the call out logs were reviewed by the Director of Nursing the following day. NA #1 also texted the scheduler and stated she had a temperature of 99.5 and woke-up feeling horrible and weak. NA#1 reported to work on 11/16/2020 for 3rd shift and healthcare screener was completed by NA#2. It stated that she had no signs and symptoms and had a temperature of 97.5. She reported to her assigned unit on the 800 hall. At the end of NA#1 shift on the morning of 11/17/2020, NA#1 reported to the nurse she had a headache and requested Tylenol. NA#1 reported to the scheduler she was feeling poorly at the end of her shift. NA#1 was tested on [DATE] at the end of her 11/16/2020 shift for COVID19 and was negative. NA#1 did not return to work because she felt poorly and went to her personal physician on 11/20/2020 and had another COVID-19 test with positive results. As of 12/3/2020; 33 residents out of 73 residents tested positive for COVID19, 21 staff tested positive for COVID19 and the facility had 2 deaths related to COVID19 with the potential for all staff and residents to be affected. The Regional Director of Clinical Services completed a review on 12/4/2020 of the past 14 days of call out sheets and all issues identified were investigated and corrected at time of identification. All other call outs had either tested positive and not allowed in building for 10 days or were not allowed entry to the building without clearance from Director of Nursing. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete All staff in all departments were educated by the Director of Nursing or designee by 12/5/2020 regarding the signs and symptoms of COVID19 listed on the [NAME] Healthcare Screening tools. The symptoms include cough, new loss of taste or smell, sore throat, muscle or body ache, diarrhea, Fever greater than 100, shortness of breath or difficulty breathing, nausea or vomiting, headache, fatigue, congestion or runny nose. Education was also completed by Director of Nursing or Designee on the [NAME] Screening Policy by 12/5/2020 which states, all employees, visitors, providers and anyone else requesting entry to the facility will be actively screened using the latest COVID-19 screening tool before each entry into the building. Anyone answering yes to questions will be denied entry and referred to physician or physician extender for further guidance. Any employee screened and answering yes to questions will also be reported to the facility Human Resource Generalist. The Director of Nursing and/or Administrator is to be contacted immediately regarding anyone that answers yes to screening questions, positive employee or any employee experiencing symptoms. All new hires and agency staff will be required to be educated prior to starting their assigned shift. All staff that are conducting the screening process will receive education by 12/5/2020 on completion of the form and process for allowing employees, vendors or visitors entrance to the facility, as well as, denial of entry due to a yes answer on the screening document. Screeners or an employee on duty will be identified on the nursing schedule to cover 24 hours a day, 7 days a week. No employees will be allowed to self- screen. They will be educated 12/5/2020 to report any yes answers to the Director of Nursing or Administrator and not allow anyone entry that answers yes to screening questions. If the Director of Nursing or Administrator are not in the facility, the screener will report the findings to the charge nurse. The charge nurse will ensure the person does not enter the facility and is instructed to see a physician or physician extender and not allowed to work until medically clear. The charge nurse will contact the Director of Nursing or Administrator by phone and report findings. The Director of Nursing or Administrator will educate nurses of the new responsibility 12/5/2020 and will notify them, assignments will be placed on the nursing schedule. All new hires and any agency staff will be required to be educated prior to starting their first assigned shift. The employee sign- off list for completion of education will be monitored as employees are screened to ensure no employee works without being properly educated. The Director of Nursing or Designee will provide education 12/5/2020 for the staff who receives call outs to ask the same questions as on the COVID-19 screening tool. Staff accepting call outs will include departments heads, nurses, scheduler, Director of Nursing or Administrator. This information is to be recorded on call out sheets, which will be located at each nurse ' s station, charge office, department head offices, and scheduler office. If any question is answered yes, they will report it to the Director of Nursing or Administrator immediately upon identification during business and off hours. They will also instruct the employee to see a physician or physician extender and not be allowed to work until medically cleared. The Human Resource Coordinator will be trained 12/5/2020 to ensure the Director of Nursing and Administrator receive copies of call out slips Monday thru Friday. No employee will be allowed to work, without proper clearance from the Administrator or Director of Nursing and will be required to go to a physician or physician extender before returning to work. Director of Nursing or designee will provide education to all staff in all departments by 12/5/2020 on the importance of truthfulness when completing [NAME] Healthcare Screening form utilizing the following Screening Integrity Statement, which states: It is the responsibility of all staff at Autumn Care of Salisbury to protect our residents. The importance of being honest on your screening tools is the difference between our residents being exposed to COVID19 and not. The morale standard of being truthful is at its utmost importance when dealing with the care of others. The facility will not retaliate against any employee experiencing symptoms or positive with COVID19. Effective immediately, any employee experiencing symptoms related to COVID19; it is the responsibility of the employee, the facility screener, scheduler, charge nurse and any other individual aware of these symptoms to notify the Administrator or Director of Nursing immediately. If both are not in building, they will be notified by phone. In the Screening Integrity Statement, the staff were educated that there will not be any retaliation for calling out due to any sign or symptom of COVID-19. The departments heads, scheduler, and charge nurses that receive staff call outs will be educated 12/5/2020 on completing the call out form, asking if the employee has signs or symptoms of COVID-19 and if so to have them see their physician and will not be able to return to work until they receive medical clearance. The schedule or charge nurse will notify the Director of Nursing or Administrator of any employee call outs that answers yes to questions regarding signs and symptoms of COVID-19. If the Director of Nursing and Administrator are not in the facility, they will contact them via telephone when the call out is received. The Facility alleges the removal of the immediate jeopardy on 12/5/2020. As part of the on-site validation process on 12/8/2020, the plan of correction was reviewed which included dates and content of the in-services that were conducted, an updated call-out documentation sheet and audit of call-outs, and a staff member scheduled as screener for each shift. Multiple staff were interviewed and verified they had received education on screening before entering the building, calling out sick with signs or symptoms of COVID and documenting the reasons for calling out sick. Observations revealed staff performing correct screening procedures for staff entering the facility for work. The facility ' s IJ removal date of 12/5/2020 was validated.