Every finding on record at Black Mountain Neuro-Medical Treatment Center

Based on observations and staff interviews the facility failed to discard food items past the use by date in 1 of 2 reach-in coolers; discard food with signs of spoilage in 2 of 2 walk-in coolers; and label and date two bags of unidentifiable frozen food items that had been removed from the original container in 1 of 1 reach-in freezer. This failure had the potential to affect food served to residents. Findings included: a. An observation with the Food Service Director of the reach-in cooler on [DATE] at 9:27 AM revealed the following: A package of sliced white cheese with an opened date of [DATE]. A package of sliced yellow cheese with an opened date of [DATE]. A 4.5 ounce jar of minced garlic with an open date of [DATE]. A package of sliced provolone cheese with an opened date of [DATE]. A bag of grated parmesan cheese with an opened date of [DATE]. A 16-ounce container of chicken base stock with an opened date of [DATE]. A one-pound package of sliced ham with an opened date of [DATE]. During interviews on [DATE] at 9:30 AM and [DATE] at 10:10 AM, the Food Service Director revealed for prepared food items, the use-by date was 3 days from the date prepared and for other items, the use-by-date was 7 days from the date the food item was opened. The Food Service Director stated dietary staff were responsible for checking their assigned coolers daily and discarding any food items that were past the 7-day use-by-date. During an interview on [DATE] at 4:29 PM, the Administrator revealed she expected dietary staff to discard food items that were expired or with visible signs of spoilage. b. An observation with the Food Service Director of the walk-in coolers on [DATE] at 09:40 AM revealed the following: One half of a 5-pound block of ham covered with plastic wrap and dated [DATE]. A box containing several red onions that had visible white spots with fuzzy matter. During interviews on [DATE] at 9:30 AM and [DATE] at 10:10 AM, the Food Service Director revealed for prepared food items, the use-by date was 3 days from the date prepared and for other items, the use-by date was 7 days from the date the food item was opened. The Food Service Director stated dietary staff were responsible for checking their assigned coolers daily and discarding any food items that were past the 7 day use-by-date or had visible signs of spoilage. During an interview on [DATE] at 4:29 PM, the Administrator revealed she expected dietary staff to discard food items that were expired or with visible signs of spoilage. c. An observation with the Food Service Director of the walk-in cooler on [DATE] at 09:45 AM revealed on the shelf were two small, clear bags containing frozen food items that were not labeled with the product name or dated. During interviews on [DATE] at 09:30 AM and [DATE] at 10:10 AM, the Food Service Director revealed for prepared food items, the use-by date was 3 days from the date prepared and for other items, the use-by date was 7 days from the date the food item was opened. The Food Service Director stated dietary staff were responsible for labeling and dating food items when removed from the original container. During an interview on [DATE] at 4:29 PM, the Administrator revealed she expected dietary staff to label and date food items when opened.

Based on record review and interviews with staff and the Nurse Practitioner, the facility failed to protect the resident's right to be free from neglect when Nurse Aide (NA) #1 started providing incontinence care for Resident #2 without assistance and was aware of the plan of care instructions for 2-person assist. NA #1 turned away from the bed to reach supplies and Resident #2 rolled off the raised bed onto the fall mat. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury and osteoporosis. The activities of daily living (ADL) care plan dated 2/21/24 identified Resident #2 was unable to complete ADL without assistance and for nursing staff to refer to the resident's care tracker profile for current recommendations. The care plan further noted Resident #2 was non-ambulatory but had the ability and did slide down but was unable to reposition herself and at risk for falls related to the use of psychotropic medications, incontinence, a history of falls, and poor safety awareness. Interventions included eliminate potential hazards as needed, provide toileting and change every 2 hours and as needed and place the bed in a low position with fall mats at the bedside. Review of the facility's online resident plan of care called care tracker utilized by Nurse Aide (NA) staff to ensure they provide the level of assistance needed for ADL care, revealed Resident #2 required 2-person extensive assistance for incontinence care and bed mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely impaired cognitively, always incontinent of bladder and bowel, and needed substantial to maximal assistance with rolling from the left to the right and toileting hygiene. The MDS indicated one fall with no injury had occurred since Resident #2's last assessment. Review of the fall incident report dated 6/25/24 at 9:15 AM revealed NA #1 had changed Resident #2 in the bed and as she turned away to grab some wipes the resident rolled off the bed and onto the floor. The incident report noted Resident #2 rolled onto her back on the fall mat, denied pain, and the physician was notified. The report was completed by Nurse #1. Review of Nurse #1's progress notes dated 6/25/24 revealed at 9:15 AM Resident #2 fell from the bed and rolled onto the bedside mat. The fall was witnessed and there were no injuries noted. Resident #2 denied pain and did not demonstrate signs of pain. The Nurse Practitioner (NP) was notified of the fall and ordered an x-ray of lumbar (L) spine (lower part of the back) and to give as needed pain medication as ordered. During an interview on 08/14/24 at 1:14 PM Nurse #1 revealed NA #1 notified him Resident #2 had rolled out of bed and when he asked how it happened NA #1 said, I was changing her. Nurse #1 asked how that happened because the resident was 2-person assist and stated NA #1 told him, she did it by herself and when she reached for the wipes Resident #2 rolled herself off the bed. Nurse #1 did a head-to-toe assessment and stated Resident #2 did not have any signs of injury or complaints of pain after the fall and he notified the Nurse Supervisor. Nurse #1 revealed Resident #2 was known for rolling herself out of bed and would slowly inch herself out of the bed onto the floor. Nurse #1 revealed staff were provided in-service education to always have 2 people for check and change care for all residents requiring 2-person assistance. Review of the facility's self-reported incident dated 6/25/24 at 9:15 AM revealed the facility became aware and submitted an allegation of neglect to the state agency that involved NA #1 and Resident #2. The report revealed NA #1 started to provide 1-person assistance with incontinence care for Resident #2 who required 2-person assist, and as a result the resident fell from the bed. NA#1 was placed on leave on 6/25/24 for the facility to complete an investigation of the incident. The facility's 5-day investigation revealed NA #1 reported she was providing 1-person assist even though she was aware Resident #2 required 2-person assistance and the allegation of neglect was substantiated. Both the initial and 5-day reports were completed by the Nurse Supervisor. Review of NA #1's written statement dated 6/25/24 revealed she was interviewed by the Nurse Supervisor and read in part, I went into Resident #2's room to change her. NA #2 was in the bathroom changing another resident. I pulled the covers back and undid the brief and reached behind me on the dresser for wipes and Resident #2 rolled off the bed onto the mat. Resident #2 said I rolled off. NA #2 turned on the call light and Nurse #1 came in, so I told him what happened. NA #3 walked by, I called her into the room, and she called NA #2 in the room. During an interview on 8/14/24 at 8:28 AM NA #1 stated she had started incontinence care for Resident #2 and described the resident had taken part of the brief off, had a bowel movement, and she was getting Resident #2 prepared for incontinence care. NA #1 explained Resident #2 was laying on her back and it was after she had elevated the bed and turned away towards the dresser, that was close to the bed, when Resident #2 rolled herself off the bed. NA #1 revealed she was aware Resident #2 had a history of rolling herself off the bed. Prior to the fall NA #1 had reviewed the care tracker plan of care and stated she knew Resident #2 was a 2-person assist with incontinence care and NA #2 had said she would be right back to help. After the fall NA #1 turned the call light on and Nurse #1 came into the room and checked Resident #2 for injury. NA #1 revealed the Nurse Supervisor spoke to her about the incident and explained Resident #2 needed 2-person assistance and it was expected a partner was with her. NA #1 stated she wasn't attempting to change Resident #2 by herself she was just getting the resident ready. Review of NA #2's written statement dated 6/25/24 revealed she was in the bathroom changing another resident and she did not know anything was happening and never heard NA #1 call for help or anything. Her statement indicated the only reason she found out was when NA #3 came out of the room and asked for help to get Resident #2 off the floor. During an interview on 08/14/24 at 3:53 PM NA #2 stated NA #1 did not ask her for help with incontinence care and she didn't even know NA #1 was in the room with Resident #2 when the fall happened. She described being in the bathroom that adjoined Resident #2's room and she was providing care for another resident. When NA #2 was finished she came out of that room and saw NA #1 and two other staff members (she did not recall) in the room, and Resident #2 was laying on the mat on the floor beside the bed. NA #2 revealed she did receive in-service education after the fall related to Resident #2's care plan for 2-person assistance with incontinence care and where to locate that information in care tracker. NA #2 stated she knew Resident #2 needed 2-person assistance with incontinence care prior to the fall and after it happened, she was monitored by her supervisor who checked if 2-person assistance was being provided during care. Review of NA #3's written statement dated 6/25/24 revealed she had gone on break, and it was approximately 9:00 AM or 9:15 AM when she came back on the floor. She stopped NA #2 in the hall and asked what residents needed to be checked and changed then went right to Resident #2's room. She saw NA #1 standing by the resident who was lying beside the bed on a mat and asked if the nurse was needed. NA #1 said Nurse #1 had already been in the room to check Resident #2. She called NA #2 for help with transferring and they along with other staff put Resident #2 back to bed. She and NA #1 then provided incontinence care for Resident #2. During a phone interview on 08/13/24 at 6:10 PM NA #3 revealed when she entered Resident #2 ' s room on 6/25/24, she saw the resident laying on her back on the mat on the floor and NA #1 was in the room. She asked NA #1 what happened and was told when she reached for the wipes the resident rolled herself off the bed. NA #3 stated at times Resident #2 would roll herself off the bed and prior to the fall was a 2-person assist with incontinence care. After the fall her and the other nursing staff used the mechanical lift to transfer Resident #2 back to bed. NA #3 revealed 6/25/24 was her last shift and she did not recall receiving training afterward the fall but upon hire her training included where to locate residents' level of assistance needed when providing care on their care tracker profile for activities of daily living and always have a nurse or another NA available to assist with 2-person check and change if required. Review of the x-ray results for Resident #2 completed on 6/25/24 revealed no acute fracture was identified. During an interview on 08/15/24 at 11:35 AM the Nurse Practitioner (NP) revealed she was notified on 6/25/24 and ordered the x-ray due to Resident #2's diagnosis of osteoporosis (deterioration of bone tissue). She revealed the Medical Doctor saw Resident #2 the next day on 6/26/24 and noted there was no complaint of pain and reviewed the x-ray results with no acute fracture identified. During an interview on 08/14/24 at 10:15 AM the Nurse Supervisor confirmed he was informed about the fall on 6/25/24 at 9:15 AM. He spoke with Nurse #1 first and asked who was with NA #1 when the fall occurred and was told no one. He spoke with NA #1 and asked who was with her to help provide care and NA #1 stated nobody came in to help her and at the time of the fall NA #2 was assisting another resident with toileting and NA #3 was on break. The Nurse Supervisor confirmed NA #1 told him she had asked NA #2 to help, and he questioned her about that statement because NA #2 was assisting another resident. He asked NA #1 if she was aware Resident #2 needed 2-person assistance with incontinence care and she stated yes. NA #1 had explained she checked Resident #2 and realized incontinence care was needed and when she turned to get the brief and wipes, that's when she heard Resident #2 rolling out of bed. The Nurse Supervisor confirmed NA #1 had raised the bed and was getting Resident #2 ready for incontinence care. He described Resident #2 did have a history of putting herself on the floor and would put her feet over the side of the bed and slide to the floor and was not able to make good choices for her safety. They considered NA #1's actions neglect as she made a poor decision about her time management, and it was poor conduct on her part, and she was removed from the unit and sent home on 6/25/24. He reported the fall to the Administrator, and their investigation determined it was a policy violation when Resident #2's care plan was in place to provide 2-person assistance with incontinence care and NA #1 started the care without a second person present. NA #2 returned to work third shift on 6/27/24 and was counseled and provided training along with all nursing staff related to 2-person assistance. The Nursing Supervisor revealed observations were made of 2-person care to ensure it was done correctly and it was emphasized not to start care without a second person with you. During an interview on 08/15/24 at 4:55 PM the Administrator was aware of Resident #2's behavior of putting herself on the floor and explained the fall occurred because NA #1 was doing 1-person care for the resident when the care plan was to provide 2-person assist. She stated adaptive equipment was already in place for fall preventions and neglect was clear when 2-person assist was not done based on the care plan. She revealed Quality Assurance and Performance Improvement (QAPI) implemented a plan of correction on 6/25/24 that included training and audits of all staff on each shift to look for areas staff needed more support and if needed ongoing training was provided. The facility provided the following corrective action plan with a completion date of 7/2/24: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 6/25/24 the nurse immediately assessed Resident #2 for injury. The Nurse Supervisor provided training on 2-person care for Nurses and Nurse Aide staff on the unit where the fall occurred. The training elements and objectives included: ensure safety and dignity of residents and provide proper and safe resident care; review of location of ADL assistance information (Care Tracker Profile and Messages, Community Updates, and Care Plan). When providing care, know the level of assistance needs for residents in their Care Tracker profile prior to providing care and asking coworkers for assistance when appropriate. A Physical Therapy (PT) evaluation of Resident #2's mattress type and fall mats was completed on 6/25/24 to ensure safety measures for activities of daily living care were in place. How corrective action will be accomplished for the residents having the potential to be affected by the same deficient practice: Training was implemented on 6/25/24 for all unit staff Nurses and Nurse Aides including temporary agency staff on 2-person care that included elements and objectives to ensure safety and dignity of residents and provide proper and safe resident care; review of location of ADL assistance information (Care Tracker Profile and Messages, Community Updates, and Care Plan); when providing care, know the level of assistance needs for residents in their Care Tracker prior to providing care and asking coworkers for assistance when appropriate. Nurse Supervisors were educated and provided with audit tasks on 6/25/24. Audits started on 6/25/24 for residents who require 2-person care and were conducted by each Nurse Supervisor three times per shift for 1 week. Audits included review of the following: the individualized Care Plan, utilization of correct transfers, following all safety measures on transferring and repositioning, and maintaining dignity. Issues identified during audits immediate training was completed with that staff. The projected completion date of the audits was 7/2/24 and reported to Quality Assurance (QA). Measures that will be put into place and/or what systematic changes will be made to ensure that the deficient practice does not recur: On 6/26/24 any unit-based Nurses and Nurse Aides including agency staff who were unavailable (vacation, sick, etc.) were trained prior to starting their next scheduled shift. New Hires are trained on 2-person care on the first day of hire by PT and Occupational Therapy. Additional on-unit training occurs for the first 2 weeks of employment which includes return demonstration. Weekly Community Update Meetings for unit staff occur on all 3 units and 3 shifts to train on any Care Plan changes. How will the facility monitor performance to ensure that solutions are sustained. QA was implemented on the date of the incident 6/25/24 when the Plan of Correction was established. Two-person care was added to QA standing agenda and reported by the Assistant Director of Nursing (ADON) for compliance with 2-person care at each QA meeting. Audits were completed from 6/25/24 to 7/2/24 and ongoing for report to QA. QA audits will be required for 12 months. Date of completion: 7/2/24. The facility's corrective action plan with a completion date of 7/2/24 was validated onsite on 8/14/24 and 8/15/24 by record review, observations and staff interviews. Review of the nursing staff in-service training started on 6/25/24 included the objective was to provide proper and safe resident care and the goal was to know the level of assistance needed by residents and where to find that information on the care tracker profile. In-service training included names, signature acknowledgement and dates. The training encompassed all three units and nursing staff on first, second, and third shifts. Review of the check and change audits started on 6/25/24 included all three units and nursing staff on first, second, and third shift. Observations included: did staff follow the individualized care plan, was the correct transfer device used, was safety measures followed while transferring/repositioning the resident, was dignity maintained throughout the interaction, and was staff teaching performed for any discrepancies noted during care. An observation was conducted on 08/14/24 at 12:51 PM of two NA staff assist Resident #2 with bed mobility, incontinence care, and mechanical lift transfer to the chair. The two NA staff entered the room together and one stood at each side of the bed at the start of care. Resident #2 was rolled towards the NA to help prevent a fall from the bed. Fall mats were placed on the floor by both sides of the bed prior to care. During interviews nurses and NA staff confirmed they received in-service training to review the resident's care plan information on care tracker that included if 2-person assistance was required and always have a nurse or another NA to assist, and if not available to wait for a second person before starting care. Nurses and NA staff revealed audits were randomly done to ensure they provided 2-person assistance. The completion date of 7/02/24 was validated.

Based on record review, staff and physician interviews, the facility failed to prevent a significant medication error when Nurse #1 administered medications to Resident #8 that were prescribed for Resident #58 for 1 of 2 sampled residents reviewed for hospitalization . On the morning of 11/23/22, Resident #8 received six medications which included Depakote (mood stabilizer), Bumex (diuretic), Gabapentin (used to treat nerve pain), Metoprolol (used to treat blood pressure), Risperdal (antipsychotic), and Sertraline (antidepressant). On 11/23/22 at 11:50 AM, Resident #8 appeared lethargic (decreased alertness) and was assessed by Nurse #1 to have a heart rate of 43 and her blood pressure reading could not be obtained. Resident #8 was transported to the Emergency Department (ED) for evaluation and subsequently admitted to the hospital for bradycardia (low heart rate) and hypotension (low blood pressure). Findings included: Resident #8 was admitted to the facility on [DATE]. Her diagnoses included seizure disorder, depression, and dementia. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #8 as severely impaired with cognitive skills for daily decision making and noted she received antidepressant medication daily during the 7-day MDS assessment period. Review of the November 2022 Medication Administration Record (MAR) for Resident #8 revealed physician orders for the following routine morning medications: Acetaminophen (pain reliever) 325 milligrams (mg): take two tablets (650 mg) three times daily at 7:30 AM, 1:30 PM and 8:30 PM. Calcium Citrate plus Vitamin D: take two tablets twice daily for supplement at 7:30 AM and 8:30 PM. Depakote 125 mg: take four capsules (500 mg) three times daily at 7:30 AM, 1:30 PM, and 8:30 PM. Namenda (used to treat symptoms of dementia) 10 mg: take one tablet twice daily at 7:30 AM and 8:30 PM for dementia. Multivitamin daily in the morning for supplement. Omeprazole (used to decrease the amount of acid in the stomach) 20 mg daily in the morning for gastroesophageal reflux disease (digestive disorder). Topiramate (used to treat seizures) 10mg: take one tablet twice daily at 7:30 AM and 8:30 PM for seizure disorder. Vitamin D 1,000 international units (IU) daily for supplement. Review of the November 2022 MAR for Resident #58 revealed the following morning medications prescribed to Resident #58 and administered to Resident #8 in error on 11/23/22: Depakote 875 mg for mood and behaviors. Gabapentin 600 mg for pain. Metoprolol 25 mg for blood pressure (BP). Bumex 1 mg for edema. Risperidone (antipsychotic) 3 mg for mood. Sertraline (antidepressant) 225 mg for depression. A nurse progress note dated 11/23/22 at 2:40 PM written by Nurse #1 read in part, went into Resident #8's room to administer afternoon medications. Resident #8 appeared lethargic and hard to arouse. Vital signs were taken at 11:50 AM, could not get BP and heart rate 43. This Nurse thought Resident #8 could have received extra medications from AM administration due to another resident with similar name. Resident #8 could have received Gabapentin 600 mg, Metoprolol 25 mg, and Risperidone 3 mg. During an interview on 03/22/23 at 8:51 AM, Nurse #1 recalled when she arrived at the unit the morning of 11/23/22 to begin her shift, Nurse #2 had already started on the medication cart preparing resident medications but was being pulled to work another unit, so Nurse #2 explained where she was at with the residents' medications and then Nurse #1 took over the medication cart from there. Nurse #1 explained when she took over the medication cart, Nurse #2 had already pre-pulled a lot of the residents' medications for the AM medication pass and put them in medication cups labeled with the resident's first name. Nurse #1 stated when she started the medication pass, she looked down at the medication cups and picked up ones that were labeled with a name starting with the letters MAR thinking she was grabbing Resident #8's medications. Nurse #1 stated she knew the volume of medications for the residents and as she was going into Resident #8's room to administer the medications, she kind of noticed there were a lot of medications in the cup, one cup even had pudding and wondered why but didn't think much else about it at the time. Nurse #1 stated for the remainder of the morning, Resident #8 appeared at baseline and it wasn't until around lunchtime when she went into the room to administer the afternoon medications she noticed Resident #8 was very lethargic and hard to arouse. Nurse #1 stated when she assessed Resident #8 to try and figure out what was going on and she took Resident #8's vitals, she was unable to obtain a BP and Resident #8's heart rate was 43. Nurse #1 stated she immediately contacted Physician #1 who came to the unit right away to assess Resident #8. Nurse #1 stated she started retracing her steps from that morning, got to thinking about the amount of medications in the cup she administered to Resident #8 and realized she must have grabbed another resident's medication cup in error whose name had the same first three initials as Resident #8. Nurse #1 stated when she explained to Physician #1 that Resident #8 may have gotten another resident's medications in error, Physician #1 gave orders to send Resident #8 out to the hospital for evaluation and Physician #1 contacted the hospital to let them know what they thought had happened. During an interview on 03/24/23 at 10:12 AM, Nurse #2 confirmed on the morning of 11/23/22, she had started preparing medications for the morning medication pass on the unit where Resident #8 resided. Nurse #2 explained at that point in time most nurses on the unit, including herself, got the medication cart ready by pre-pulling the residents' medications and labeling the medication cups with the residents' first name and initial of their last name prior to starting the medication pass. Nurse #2 stated on 11/23/22, she seemed to recall she had gotten the medication cart ready but had not yet administered any of the residents' medications when she was notified to go to another unit. Nurse #2 stated she gave report to Nurse #1, showed Nurse #1 where she was at with getting the medications prepared and then left the unit. A progress note for Resident #8 dated 11/23/22 at 12:20 PM written by facility Physician #1 read in part, Medications switched accidentally with another resident. Medication list reviewed. She is now very sedated. Heart rate 43 and unable to get BP. Sleeping heavily, does not awaken to stimuli. Place Intravenous (IV) fluids, hold sedating medications, to ED if vital signs worsen. A progress note dated 11/23/22 at 3:25 PM written by Nurse #1 read, Resident #8 sent to hospital. The hospital discharge summary dated 11/26/22 read in part, Resident #8 presented to the ED on 11/23/22 3:51 PM with bradycardia and hypotension following a medication error at the skilled nursing facility and reportedly received Tylenol 650 mg, aspirin 81 mg, Bumex 1 mg, Depakote 1000 mg, Gabapentin 600 mg, Levothyroxine 200 mg, Metoprolol 25 mg, Misoprostol 200 mcg, Omeprazole 40 mg, Risperdal 3 mg, and Sertraline 225mg. Resident #8 takes no diuretics or antihypertensives at baseline. In route to ED, Resident #8 was bradycardic and hypotensive to 60-70's systolic requiring atropine (medication used to treat symptoms of low heart rate). In the ED, Resident #8 was initially hypotensive despite fluid resuscitation and sedated on Levophed (medication used to treat low blood pressure and heart failure). Intensive Care Unit initially consulted for admission, however Resident #8's blood pressure improved dramatically and was able to be weaned off Levophed completely. The hospital discharge summary further noted Resident #8 was deemed stable and discharged back to the skilled nursing facility on 11/26/22. During an interview on 03/22/23 at 1:44 PM, Physician #1 recalled on 11/23/22 she was informed by Nurse #1 that Resident #8 received Resident #58's medications in error. Physician #1 stated she came to the unit and assessed Resident #8, her BP and heart rate were too low and IV fluids were started. Physician #1 explained when she reviewed the list of Resident #58's medications that Resident #8 received in error, she was more concerned about the antipsychotic medication which could cause QT suppression (abnormal electrical conduction in the heart). Physician #1 stated as the morning progressed, Resident #8's condition did not improve so she ordered an electrocardiogram (test used to monitor and record the heart's rhythm) which showed a first degree atrioventricular (AV) block (causes the heart to beat slower than it should) and Resident #8 was sent out to the hospital due to bradycardia and hypotension. Physician #1 explained the medications Resident #8 received at the hospital, Atropine and Levophed, were medications used to help stabilize the heart rate and blood pressure. Physician #1 stated it was a significant error that Resident #8 was administered medications prescribed to Resident #58 which caused bradycardia and hypotension. During a joint interview with the Administrator on 03/22/23 at 1:13 PM, the Director of Nursing (DON) recalled on 11/23/22 Nurse #1 informed her that she potentially did something that could have harmed someone and indicated she could have given the wrong medications to Resident #8 but wasn't sure and the incident was treated as if Nurse #1 had administered the wrong medications. The DON stated staff had been checking on Resident #8 during rounds and when they checked on her around lunchtime, she was lethargic. The DON added Nurse #1 immediately notified Physician #1 who came to the unit to assess Resident #8 and later sent her out to the hospital for evaluation. The DON explained when discussing the incident with Nurse #1 to figure out what may have happened, they determined another nurse had pulled some of the resident's medications on the medication cart prior to Nurse #1 taking it over and had labeled the medications cups with the resident's first names. The DON stated the initials of Resident #8 and Resident #58's first names were similar. During a joint interview with the DON on 03/22/23 at 1:13 PM, the Administrator explained the investigation regarding the medication error that occurred on 11/23/22 was conducted as part of their Patient Safety Evaluation System to determine a root cause. She explained the root cause analysis completed as part of the Patient Safety Evaluation System investigation was protected information and all that could be shared were the action items. The Administrator stated they always encouraged nursing staff to report any concerns that a medication error could have occurred and Nurse #1 had reported her concerns through the proper channels. The Administrator explained when the team met the following Monday (11/28/22) to discuss the incident and try to determine a root cause, they looked at the whole system to try and get to the bottom of what happened and what they needed to do to try and prevent it from happening again. The Administrator stated they determined the immediate re-training of nursing staff regarding medication administration procedures was the main action item they needed to address. During a follow-up interview on 03/24/23 at 1:35 PM, the DON stated prior to the incident on 11/23/22 involving Resident #8, she was unaware nursing staff were pre-pulling residents' medications for the administration pass and nursing staff knew better. The DON added pre-pulling medications was not the facility's standard practice and since 11/23/22, they have reinforced the facility's medication administration procedures. The Administrator and DON were notified of immediate jeopardy on 03/22/23 at 4:13 PM. The facility provided the following corrective action plan with a completion date of 02/01/23: How corrective action will be accomplished for those residents found to have been affected by the deficient practice: Unit Nursing staff received additional training and education regarding medication administration. Implementation date: 11/23/22. Projected completion date: 11/23/22. DON and Director talked with responsible nurse to determine root cause of medication error and provided immediate education regarding medication administration practices. Implementation date: 11/23/22. Projected completion date: 11/23/22. Building Nurse Supervisor met with nurses on duty to ensure they were following proper medication administration principles. Implementation date: 11/23/22. Projected completion date: 11/23/22. How corrective action will be accomplished for the residents having the potential to be affected by the same deficient practice: Nurse Educator will assign all nursing staff on medication administration best practices in Elsevier (computer training modules). Implementation date: 11/23/22. Projected completion date 12/15/22. Safety Event System review began for root cause analysis investigation. Implementation date: 11/23/22. Projected completion date 11/23/22. Measures that will be put into place and/or what systematic changes will be made to ensure that the deficient practice does not recur: Pharmacist will perform monthly random monitoring during medication administration on all shifts. Documentation will be provided by Pharmacy staff. Implementation date: 12/12/22. Projected completion date: ongoing. Assistant Director of Nursing (ADON) will hold weekly meetings with nursing staff to discuss medication errors. Meeting minutes will be provided. Implementation date: 01/17/23. Projected completion date: ongoing. Nursing staff reviewed the NCVIP (North Carolina Valuing Individual Performance) goal regarding Resident Safety and medication errors. Implementation date: 01/19/23. Projected completion date: ongoing. Pharmacist to train nursing staff on MAR documentation and medication pass principles. Implementation date: 01/24/23. Projected completion date: 01/30/23. ADON to hold monthly meetings with Nurse Supervisors with agenda items including medication administration. Implementation date: 01/31/23. Projected completion date: ongoing. How will the facility monitor performance to ensure that solutions are sustained? What is the plan to ensure that corrective action is achieved and sustained? The plan must be implemented and the correction action evaluated for effectiveness. Director of Pharmacy in conjunction with the DON will review current Quality Assurance and Performance Improvement (QAPI) audit items in regard to medication administration errors and report in quarterly QAPI meetings. Implementation date: 01/18/23. Projected completion date: ongoing. Director of Pharmacy will review the medication variance report with monthly QA committee. Implementation date: 01/24/23. Projected completion date: ongoing. The facility's corrective action plan with a correction date of 02/01/23 was validated onsite by record review, observations and interviews with the Pharmacy Director and nursing staff. Nursing staff confirmed they received in-service training and in-person audits related to medication administration conducted by the ADON and Pharmacy Director. Nursing staff stated the training included a PowerPoint presentation by the Pharmacy Director with multiple examples and scenarios regarding the proper way of pulling medications, better communication among the nurses, and making sure medications were pulled and administered by the same nurse. Nursing staff also stated they were instructed to match the resident's picture located in the medication cart to the resident's picture on the MAR prior to administering the medication. The facility's Pharmacy Director revealed she conducted on unit re-training of nursing staff that focused on proper procedure and proper identification of the resident receiving the medications. The Pharmacy Director stated the facility Pharmacists conducted additional monitoring of the medication carts on each unit to ensure medications were not pre-pulled for medication administration and nurses were following the facility's medication administration procedures. Medication Administration observations were conducted 03/21/23 to 03/23/23 and consisted of 25 medications, 7 different residents, and 5 Nurses. There were no medication errors or concerns identified.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the area of Preadmission Screening and Resident Review (PASRR) for 6 of 6 sampled residents reviewed for PASRR (Residents #4, #11, #12, #15, #16, and #37). Findings included: 1. Resident #4 was admitted to the facility on [DATE]. His diagnoses included schizophrenia, anxiety disorder, and depression. The annual MDS assessment dated [DATE] indicated Resident #4 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 03/22/23 revealed Resident #4 had a Level II PASSR effective 01/11/12. During an interview on 03/23/23 at 11:32 AM, Social Worker (SW) #1 revealed she completed the section related to Level II PASRR on the MDS assessments for the residential unit she was assigned. SW #1 explained the information prepopulated from the previous MDS assessment and it was an oversight that Resident #4's MDS assessment dated [DATE] did not accurately reflect he had a Level II PASRR determination. During an interview on 03/24/23 at 1:35 PM, the Administrator stated it was an oversight that Resident #4's MDS assessment did not reflect he had a Level II PASRR determination. 2. Resident #11 admitted to the facility on [DATE]. Her diagnoses included depression and anxiety disorder. The annual MDS assessment dated [DATE] indicated Resident #11 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 03/22/23 revealed Resident #11 had a Level II PASSR effective 10/26/09. During an interview on 03/23/23 at 11:32 AM, Social Worker (SW) #1 revealed she completed the section related to Level II PASRR on the MDS assessments for the residential unit she was assigned. SW #1 explained the information prepopulated from the previous MDS assessment and it was an oversight that Resident #11's MDS assessment dated [DATE] did not accurately reflect she had a Level II PASRR determination. During an interview on 03/24/23 at 1:35 PM, the Administrator stated it was an oversight that Resident #11's MDS assessment did not reflect she had a Level II PASRR determination. 3. Resident #12 was admitted to the facility on [DATE]. His diagnoses included anxiety disorder and psychotic disorder. The annual MDS assessment dated [DATE] indicated Resident #12 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 03/22/23 revealed Resident #12 had a Level II PASSR effective 10/23/09. During an interview on 03/23/23 at 11:32 AM, Social Worker (SW) #1 revealed she completed the section related to Level II PASRR on the MDS assessments for the residential unit she was assigned. SW #1 explained the information prepopulated from the previous MDS assessment and it was an oversight that Resident #12's MDS assessment dated [DATE] did not accurately reflect he had a Level II PASRR determination. During an interview on 03/24/23 at 1:35 PM, the Administrator stated it was an oversight that Resident #12's MDS assessment did not reflect he had a Level II PASRR determination. 4. Resident #15 was admitted to the facility on [DATE]. His diagnoses included depression and anxiety disorder. The annual MDS assessment dated [DATE] indicated Resident #15 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 03/22/23 revealed Resident #15 had a Level II PASSR effective 11/06/09. During an interview on 03/23/23 at 11:32 AM, Social Worker (SW) #1 revealed she completed the section related to Level II PASRR on the MDS assessments for the residential unit she was assigned. SW #1 explained the information prepopulated from the previous MDS assessment and it was an oversight that Resident #15's MDS assessment dated [DATE] did not accurately reflect he had a Level II PASRR determination. During an interview on 03/24/23 at 1:35 PM, the Administrator stated it was an oversight that Resident #15's MDS assessment did not reflect he had a Level II PASRR determination. 5. Resident #16 was admitted to the facility on [DATE]. His diagnoses included psychotic disorder. The annual MDS assessment dated [DATE] indicated Resident #16 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 03/22/23 revealed Resident #16 had a Level II PASSR effective 04/13/09. During an interview on 03/23/23 at 11:32 AM, Social Worker (SW) #1 revealed she completed the section related to Level II PASRR on the MDS assessments for the residential unit she was assigned. SW #1 explained the information prepopulated from the previous MDS assessment and it was an oversight that Resident #16's MDS assessment dated [DATE] did not accurately reflect he had a Level II PASRR determination. During an interview on 03/24/23 at 1:35 PM, the Administrator stated it was an oversight that Resident #16's MDS assessment did not reflect he had a Level II PASRR determination. 6. Resident #37 was admitted to the facility on [DATE]. His diagnoses included anxiety disorder, bipolar disorder, depression, psychotic disorder, and post-traumatic stress disorder. The annual MDS assessment dated [DATE] indicated Resident #37 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. Review of a North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 03/22/23 revealed Resident #37 had a Level II PASSR effective 09/05/12. During an interview on 03/23/23 at 11:32 AM, Social Worker (SW) #1 revealed she completed the section related to Level II PASRR on the MDS assessments for the residential unit she was assigned. SW #1 explained the information prepopulated from the previous MDS assessment and it was an oversight that Resident #37's MDS assessment dated [DATE] did not accurately reflect he had a Level II PASRR determination. During an interview on 03/24/23 at 1:35 PM, the Administrator stated it was an oversight that Resident #37's MDS assessment did not reflect he had a Level II PASRR determination.

Based on record reviews and interviews with staff, Consultant Pharmacist, and Medical Director, the facility failed to monitor the cholesterol level for 1 of 5 residents reviewed for unnecessary medications (Resident #68). The findings included: Review of lipid guidelines published in 2019 by American College of Cardiology and American Heart Association indicated lipid panel should be conducted at baseline, then 4 to 12 weeks after statin therapy was started or when dosage was adjusted. Afterwards, lipid panel test should be repeated once every 3 to 12 months or as needed. Resident #68 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, coronary artery disease, high blood pressure, and hyperlipidemia. Review of the physician's orders dated 06/16/20 revealed Resident #68 had an order to receive 1 tablet of pravastatin 40 milligrams (mg) once daily for atherosclerotic cardiovascular disease. Review of medication administration records (MARs) from January 2023 through March 2023 indicated Resident #68 had received pravastatin as ordered. Review of labs for Resident #68 revealed a lipid panel test had not been done since 10/19/21. Review of the most recent annual health and physical (H&P) exam dated 08/03/22 revealed hyperlipidemia remained one of Resident #68's active diagnoses and the provider had ordered to check his cholesterol levels. During a joint interview conducted with Nurse #3 and Nurse #4 on 03/23/23 at 9:17 AM, both nurses did not recall performing a lipid panel test for Resident #68 in the past 1 year and could not find any records of a lipid panel test in the chart. Both nurses added it should be completed at least once yearly on a regular basis. During an interview conducted on 03/23/23 at 9:50 AM, the Medical Director stated Resident #68 should have his lipid panel checked at least once a year as he was having statin therapy. He explained the facility did not have an electronic record system that would trigger the lab order automatically at certain fixed intervals on a regular basis, and they had to depend on paper notes. During an interview conducted with the Consultant Pharmacist on 03/23/23 at 10:33 AM, she stated the labs would normally being ordered for Resident #68 during his annual H&P exam around August 2022. She recommended to the provider to have a low-density lipoprotein (LDL) cholesterol monitoring in her medication regimen review dated 10/28/22 as it was not in place after the annual H&P exam. She explained Resident #68 tested positive for COVID-19 on 10/13/22 and was under isolation. Otherwise, the lipid panel test could have been done last October. During an interview conducted with the Director of Nursing (DON) on 03/24/23 at 1:39 PM, she stated she expected the facility to have the lipid panel test in place for all residents with statin therapy in timely manner for cholesterol monitoring according to the guidelines. Interview conducted with the Administrator on 03/24/23 at 1:40 PM revealed it was her expectation for the facility to monitor the cholesterol level for all the residents with statin therapy in a timely manner per the guidelines.

Based on observations, staff interviews, and record review, the facility failed to ensure a resident at risk for choking was positioned upright during feeding to maximize eating abilities for 1 of 18 residents reviewed for dining (Resident #1) . The findings included: Resident #1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired with memory problems. She was totally dependent on one staff member for eating and had loss of liquids/solids from her mouth when eating or drinking. The current care plan (unable to determine the date when the care plan was last reviewed) for Resident #1 initially dated 7/20/18 was reviewed and revealed she required total assistance for all activities of daily living (ADL) related to [CONDITION(S)]. Resident #1 required total assistance for eating and staff were directed to follow the Dining Guidelines (separate document) due to her being an extreme choke hazard. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Dining Guidelines dated 3/10/21 for Resident #1 revealed she required total assistance for feeding, was to be seated in an upright position in her wheelchair, and not to be served by trained paid feeding assistants. On 6/14/21 at 11:56 AM, an observation of Resident #1 was done during lunch meal. Nurse Aide (NA) #1 was feeding Resident #1 in the dining room while she was laying on her right side with her right ear against the arm rest of the wheelchair. Shirt protectors were placed by NA #1 on the armrest while dark, brown pureed food was observed running out of Resident #1's mouth. NA #1 used 3 shirt protectors to clean up the mess from the uneaten food running out of her mouth onto the armrest. While feeding Resident #1, NA#1 did not attempt to reposition her upright in her wheelchair. An interview with Nurse #1 took place on 6/16/21 at 9:39 AM. She revealed Resident #1's head should be upright while being fed during meals. She stated if Resident #1 was laying on the arm rest or sideways, then she would not feed her for safety purposes. Nurse #1 indicated she would hold Resident #1's head up gently and try to feed her best she could. On 6/16/21 at 3:35 PM, NA #1 was interviewed and revealed he passed the NA certification exam last week and completed the required training for feeding residents, which included positioning, timing, and aspiration prevention. He recalled feeding Resident #1 on 6/14/21 during lunch meal. He stated Resident #1 was being fed on her right side laying on the armrest because she was flip flopping around and cannot control anything. He provided protection so food wouldn't get on her because lots of food was running out of her mouth. He further stated even if he had moved her upright or repositioned her, she would still try and go back to that lying down position. NA #1 indicated Resident #1 lying down during meals was not a safe feeding position but that was the only way he could get her to eat. He stated there was not much you could do to keep her in an upright position. NA #1 further stated he was not sure about the Dining Guidelines of positioning for Resident #1 because he was still learning. However, he did recall there was a folder in the dining room that showed NAs Dining Guidelines for adaptive equipment, positioning, and thickened liquids. He indicated he felt like she was safe, and he was doing his best. During an interview with Speech Therapist (ST) #1 on 6/16/21 2:36 PM, she revealed Resident #1 should be positioned as upright as possible during meals without restricting her movements. If Resident #1 was laying on the armrest during feeding, she would have attempted to reposition her to an upright position before the next bite was served. ST #1 stated Resident #1 was not cleared to be fed laying down. She further stated Resident #1 was a severe choking risk, and NAs were directed to Dining Guidelines as reference. The Dining Guidelines were updated every few months and placed in a binder in the dining room. The ST stated she was the primary instructor for feeding assistant training during the NA program, as well as for new employee orientation. On 6/17/21 at 11:39 AM, an interview was conducted with Occupational Therapy (OT) #2. She revealed per the Dining Guidelines, Resident #1 should be sitting upright while being fed during meals. It is normal for her to sway and throw herself uncontrollably and she favored the right side, which helps her swallow. OT #2 stated if Resident #1 was laying on her right-side during a meal, she would prop her back to an upright position (center of the chair) and observe her movements. If food was running out of her mouth, she would stop serving and give Resident #1 a break and reassess. An interview with Nurse #2 (unit manager) was conducted on 6/16/21 at 03:58 PM. She revealed Resident #1 was to be positioned upright during meals. Nurse #2 stated the book of Dining Guidelines was located in every dining room on each unit for each individual resident as a feeding reference for nurse aides and feeding assistants. If she saw NA #1 feeding Resident #1 while she was lying down, she would assist him to reposition her so that she could be fed properly. During an interview with the Director of Nursing (DON) on 6/17/21 at 9:04 AM, she revealed the way NA #1 was feeding Resident #1 on 6/14/21 was not ideal and unacceptable. She stated she would have educated and redirected NA #1 if she had observed him feeding her laying down. The DON indicated NA #1 should have asked for help to get Resident #1 straightened up if he couldn't do it himself. On 6/17/21 at 9:29 AM the Administrator was interviewed, and she revealed if she observed NA #1 feeding Resident #1 while she was laying down on her right side, she would have asked him to stop feeding and reassess the Dining Guidelines. She would then have provided him with further education and instruction immediately before he continued to feed Resident #1. The Administrator stated that her background was speech therapy, and she participated in the instruction of the feeding assistant training for the NA program.

Based on observation and staff interviews the facility failed to discard 1 opened bottle of expired antifungal powder for 1 of 10 medication carts (East Medication Cart at the third floor of [NAME] Hall). The findings included: Review of the facility's Medical Procedure Manual that was updated on 02/12/2021, under drug maintenance and disposal, recorded in part, All medications which have reached their expiration date, should be returned to the pharmacy for disposal. During a medication storage check for the East medication cart at the third floor of [NAME] Hall on 06/16/21 at 11:11 AM, an opened bottle of antifungal powder with active ingredient of [MEDICATION(S)] 2% expired on 10/31/20 was found in the medication cart and ready to be used. A handwriting with black marker of Opened 06/02/21 was seen on the bottle. Approximately 85% of the original weight of 71 gram of this antifungal powder had been used. During an interview with Nurse #3 on 06/16/21 at 11:16 AM he stated he had been checking the expiration date of every medication each time before administering to the resident. In addition, he had checked the medication cart at least once daily. He did not know why he missed the antifungal and attributed the incident as an oversight. He did not know who had opened and dated the antifungal powder on 06/02/21. He acknowledged that nursing staff who had opened the antifungal should check the expiration date and return it to the pharmacy. During an interview with the Pharmacy Manager on 06/16/21 at 1:48 PM she stated pharmacy staff had performed nursing unit inspections routinely to check each medication cart thoroughly for expired medication at least once per month or as needed. She did not know why this expired antifungal powder was not identified during the routine checks. It was her expectation for the expired antifungal to be removed from the medication cart before it was used. During an interview with the Director or Nursing (DON) on 06/16/21 at 2:30 PM she stated the expired antifungal powder should not be stored in the medication cart or been in use. All nursing staff should check the expiration date of each medication before administration. It was her expectation for the facility to be free of expired medications. During an interview with the Administrator on 06/17/21 at 11:36 AM she stated each medication cart should be checked at least once daily. It was her expectation for the facility to be free of expired medications.

Based on observations, record review, staff and physician interviews, the facility failed to secure a resident in a mechanical lift for 1 of 3 sampled residents (Resident #1) reviewed for supervision to prevent accidents during transfers. The resident fell from the total mechanical lift, landed on her left side and sustained bruising of the mid-spine and tenderness to the left chest wall. The findings included: Review of the Mechanical Lift Policy, last reviewed 01/09/20 indicated there were to be at least two staff members present to perform all aspects of the mechanical lift procedure. The Mechanical Lift Competency sheet further specified that the transfer process began with the placing of the sling and ended with appropriate positioning on final surface. When attaching a resident to the mechanical lift staff were to recheck the clips and report all clear upon completion. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired. She required extensive assistance with bed mobility and was totally dependent on 2+ staff members for transfers. The resident had not experienced any falls since the prior assessment. It was not noted that the resident had any involuntary movements related to her [MEDICAL CONDITION]. The Care Area Assessment (CAA) for falls from the most recent annual MDS dated [DATE] indicated Resident #1 was not ambulatory, she required total assistance from staff with transfers and staff used the mechanical lift for all her transfers. Resident #1's Care Plan initiated 12/29/17, and last reviewed on 02/15/19, indicated Resident #1 was unable to perform Activities of Daily Living (ADL) without limited to extensive assistance from staff. Staff were to assist the resident with ADL to the extend needed as outlined in the resident care tracker profile. Another problem area indicated Resident #1 was at risk for falls and needed assistance with mobility and locomotion. Staff were to safely transfer the resident from one surface to another using the mechanical lift and a medium size sling. The resident care tracker profile last reviewed on 06/05/20 indicated Resident #1 was dependent for transport and required the use of a mechanical lift with medium sling size. The Nursing Summary of Care assessment dated [DATE] was reviewed. This assessment tool outlined all nursing areas of care for the resident for the previous 3 months (January 2020-March 2020). The assessment indicated Resident #1 required two-person assistance and use of a mechanical lift for moving and lifting, it further indicated the resident was non-ambulatory. On 06/03/20 a nursing progress note by Nurse #1 detailed that Resident #1 had fallen from the lift during transfer when the strap that runs between the legs on resident's left side came loose resulting in resident on the floor, on left hip. Review of the facility investigation of the incident indicated that on 06/03/20 at 6:55 pm, Resident #1 fell from the mechanical lift while being transferred from the wheelchair to the bed by Nurse Aide #1 (NA). The incident was witnessed by NA #2. The on-call medical provider was notified of the fall on 06/03/20 at 7:20 PM and an order was written for a left hip x-ray. Review of progress notes by the Medical Doctor (MD) revealed a note dated 06/04/20. The MD assessed Resident #1 and reported the resident had bruising noted to the left of mid spine and a smaller bruise on the right. The resident's bilateral hips moved without apparent pain. It was noted that the resident did react with discomfort with compression of left ribs. X-rays were ordered of the spine, left ribs and bilateral hips. 06/05/20 an additional progress note was documented by the MD and indicated that x-ray imaging showed the resident had fractures of the left 8th, 9th and 10 th ribs and three compression fractures of the spine (at T11, L3 and L4), all fractures were noted to be of indeterminate age. The MD went on to explain that since the resident did not express any discomfort in the spinal area, it was likely that the spinal compression fractures were old. The MD further explained that the rib fractures may have been new since the resident expressed some discomfort with compression of that side of her thorax. Review of the radiology report for Resident #1 dated 06/04/20 displayed mildly displaced fractures of the lateral aspects of the eighth, ninth and tenth left ribs of indeterminate age. A written statement dated 06/03/20 provided by NA #1 who operated the lift at the time of the fall. NA #1 recalled that she had taken the resident and the mechanical lift into the residents room to get her ready for bed. The CNA stated she intended to change the resident's shirt and then planned to go get a second staff member to assist with transfer. The NA reported that while she was in the room with the resident the NA working as hall monitor (NA #2) came into the room and offered assistance with transfer which she accepted. NA #1 reported she hooked the resident up to the mechanical lift (while NA #2 was in the room) and admitted ly did not double check that the clips were secure. NA #1 indicated that one of the clips on the leg portion came unclipped and the resident fell to the floor before it was noticed. NA #1 recalled the incident on 06/03/20 in an interview on 06/23/20 at 11:48 AM and reported she had taken Resident #1 into her room to put her to bed. She was in the room with the resident when NA #2 (who was working as hall monitor at the time) knocked on the door and asked if she needed a spot for transfer. NA #1stated that NA #2 stood back by the door while NA #1 hooked Resident #1's sling to the lift (the sling was already under the resident as it stayed with her in the wheelchair between transfers). NA #1 indicated that she did not double check the security of the clips, nor did NA #2. NA #1 explained she started lifting the resident and watched to make sure she was clearing the wheelchair and did not notice the clip at her leg had come unattached from the lift until the resident was slipping out of the sling onto the floor. According to NA #1, she had been trained to have two staff members present for all parts of the transfer process and that she had failed to double check the security of the sling to the lift. Following the incident, NA #1 stated she was prohibited from using the mechanical lift until she was retrained on proper use of it. She has had 2 trainings on lift use since the incident including return demonstration with therapy services. In a written statement dated 06/03/20 provided by NA #2 it was reported that NA #1 was observed taking Resident #1 and the mechanical lift into the room alone and shut the door. NA #2 knocked on the door and asked if NA #1 needed assistance and NA #1 said well, yeah. NA #2 entered the room and at that time the resident was already hooked up to the lift and NA #1 was attempting to lift Resident #1 using the mechanical lift. NA #2 stated that before she knew what was happening, Resident #1 was falling in the floor. NA #2 instructed NA #1 to stay with the resident while she went to get a nurse. An interview was completed with NA #2 on 06/23/20 at 10:53 AM and reported that at the time of the incident she was working as hall monitor. As hall monitor she was responsible for completing 15 minute checks on all residents, monitoring for any aggressive behaviors, etc. While she was going around and observing residents when she noticed NA #1 had went into Resident #1's room with the resident and the mechanical lift. The NA knew there was no one else in the room to assist with transfer so she went to the room, knocked on the door and upon entry observed NA #1 attempting to lift Resident #1 alone. NA #2 said whoa, do you need a spot to which NA #1 replied well, yeah. The NA stated she got approximately 2 steps into the room and Resident #1 fell from the lift. Per NA #2, NA #1 had already clipped the sling to the lift when she entered the room and she was beginning to lift the resident. She did not have a chance to double check the security of the sling to the lift. It was reported by the NA that she had been trained to have 2 staff members present for the entire transfer process. She stated that NA #1 should have known that she needed a second person in the room while initiating the transfer process, including when the sling clips were being attached to the mechanical lift. Nurse #1 who was working the night of the incident was interviewed on 06/23/20 at 11:38 AM. He recalled he was notified Resident #1 had fallen from the mechanical lift by NA #2. He went to the residents room and found her on the floor, lying on her left hip and left shoulder between the legs of the lift. He assessed her and did not find any indication of fracture. Her range of motion in her hips was maintained. Her vitals were normal. After he assessed her and felt she was safe to move, he assisted getting her into bed and notified the on-call provider of the fall. The on-call provider ordered an x-ray of the left hip. Nurse #1 spoke with NA #2 who reported she had walked into Resident #1's room and found NA #1 operating the lift alone when a clip holding a strap had come unattached and the resident fell from the sling onto the floor. Nurse #1 did not get a report regarding the incident from NA #1. An interview was completed with the Medical Doctor (MD) on 06/23/20 at 11:30 AM who reported she examined Resident #1 the morning after the fall. The MD stated that the on-call provider had been notified the evening of the incident and ordered an X-ray of the left hip. When the MD evaluated her the next morning she took note of some bruising higher up on the spine and wanted to do more thorough imaging so she ordered additional x-rays. When the x-ray report came back it indicated Resident #1 had indeterminate age compression fractures of the spine. The MD noted the resident displayed no soreness in that area so the MD thought those to be older. The x-ray also showed age indeterminate fractures of the eighth, ninth and tenth left ribs. The MD stated it was impossible to determine if those fractures resulted from the fall but she felt it was a good possibility because Resident #1 winced when the MD put pressure on that area during examination, indicating she had some pain there. The resident also displayed signs of pain when the MD compressed on the left thorax region. On 06/25/20 at 1:24 PM the Director of Nursing (DON) was interviewed and recalled that while the two NAs involved in the incident reported different stories leading up to the incident it was noted that the clips from the sling to the mechanical lift had not been double checked and the resident fell due to a clip coming unbuckled during transfer. The DON assessed the resident the next morning and recounted some bruising above her hip, along her side. The DON recalled the MD noted the resident expressed some pain with pressure on the ribs. The DON reported staff were expected to have at least 2 staff members present in the room at the same time for the entire transfer process and they were to be checking behind one another. Review of the facility investigation into the fall on 06/03/20 concluded NA #1 neglected to provide two-person care as required in the care plan and failed to check the mechanical lift clips a second time. The investigation noted NA #1 stated she did not check the clips a second time and that NA #2 who witnessed the incident had entered the room just as NA #1 was lifting Resident #1, contradicting NA #1's statements. The facility's corrective actions implemented after the incident to prevent a reoccurrence included the following: The corrective action for the alleged deficient practice was accomplished by: The resident was seen by the MD on 06/04/20, the resident was noted to have bruising of the mid-spine and tenderness to the left chest wall. X-ray results revealed indeterminate age compression fractures of the spine (T11, L3, and L4) and fractures of the eighth, ninth, and tenth ribs of indeterminate age. The Physical Therapist and Occupational Therapist re-assessed the resident transfer status and sling lift size fit. NA #1 was prohibited from using the mechanical lift until she was retrained and completed return demonstration of proper use of the mechanical lift. All nurse supervisors, nurses and NAs on Raspberry-2 Unit completed mandatory competency Mechanical Lift training with the Physical therapists (PT) and Occupational Therapists (OT). Residents with potential to be affected by alleged deficient practice: Facility-wide Mechanical Lift return demonstration completed for nurse supervisors, peer mentors and Health Care Tech II's (HCT). Facility wide competency Mechanical Lift competency training for all nursing staff (nurse supervisors, nurses, NA's). The re-education and return demonstration began on 06/09/20 and was completed 06/17/20. Systemic changes: Minimum Data Set employees and Social workers to ensure care plans were updated with transfer information and sling size. PT/OT to ensure Resident Profile and Care Tracker system is current with transfer status and sling size. Restorative Aides will ensure the Quick Reference Tool for Adaptive Equipment is updated at least monthly. Nurse supervisors to be conducting monthly Transfer and Repositioning Audits. Each staff member will have at least 1 audit/quarter. Nurse supervisors would complete Mechanical Lift Competency with all new employees within the first 30 days of employment. Monitoring of performance: The Quality Assurance (QA) Department in conjunction with the nursing department developed Quality Assurance and Performance Improvement (QAPI) plan regarding the nurse supervisor training of new NA's compliance, and NA transfer and repositioning audits. The plan would be reviewed for a minimum of 12 months, dropping off if compliance is greater than 95%. A Safe Resident Handling Task Force was established to examine ongoing strategies, monitoring, and accountability for safe resident handling. The facility's corrective actions were verified on 06/22/20-06/25/20 by observations, record review and staff interviews. As part of the validation process on 06/22/20-06/25/20 the plan of correction was reviewed including the re-education of staff and observations of interventions put into place to ensure correct use of the mechanical lift. All staff signed attendance sheets with in-services addressing proper mechanical lift use and review of the Mechanical Lift Policy, PRO 421. Observations were made of staff transferring dependent residents utilizing the mechanical lift were made. No concerns were identified. Nurses and nursing assistants were interviewed and verified they received in-service on transferring residents with a lift with emphasis on always having two staff present and double-checking security of the sling attachment behind one another. The Nurse Supervisor for the Raspberry-2 Unit reported since 06/03/20 there had been no reports of a nursing assistant transferring a resident independently with a lift. The monitoring tools were reviewed and included audits of staff from all shifts. The monitoring was to be ongoing, in accordance with the policy and discussed at QAPI on a monthly basis for at least 12 months. The facility alleges full compliance with this plan of correction effective 06/17/20.

Based on policy and record review and family and staff interviews the facility failed to implement their abuse policies and procedures in the areas of reporting and investigating for 1 of 1 sampled residents (Resident #30) who had a bruise of unknown origin to the inner left thigh. The Findings Included: A review of the facility policy titled Protecting Residents From Rights Infringement dated 3/17/2017, read in part: All residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Identification: If the source of the injury was not observed and could not be explained by the residents and the injury is suspicious because of the locations of the injury, the nurse will immediately contact and report the injury to the facility Advocate and a member of management staff. Notification: Designated staff will report to the State Survey Agency injury of unknown source. Investigation: The investigation team will ensure information is gathered from all involved staff through investigative interviews and results of this investigation will be reported the State Survey Agency. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed that Resident #30 had severely impaired cognition. Further review revealed she had physical and verbal behaviors that occurred 1 to 3 days and wandering and rejection of care behaviors that occurred 1 to 3 days. The assessment also revealed the resident required extensive assistance with bed mobility, dressing, toileting, hygiene and transfers, and supervision for walking. She was assessed as always being incontinent of bowel and bladder and as having 2 or more falls with no injury since her last assessment. The assessment was also coded as Resident #30 not receiving any anticoagulant medications. A review of Resident #30's care plan, dated 4/25/18 revealed a concern with bruising and interventions listed were to monitor, observe and report any bruising. Review of a nursing note dated 4/22/2018 read in part: bruise to Resident's left inner thigh, purple in color, finger shaped of unknown etiology. Review of the facility document titled Nurses Rounds Report for Resident #30 dated 4/22/2018 read in part: finger length purple bruise to left upper thigh. Review of the facility abuse allegations and investigations failed to reveal any investigation into the left inner thigh bruise of Resident #30. An interview was conducted with the Director of Quality Assurance (QA) on 5/2/18 at 2:29PM. During this interview, the QA director stated that the facility Advocate would investigate any injury of unknown origin. The QA Director further stated that management may also do their own investigation, but stated it was the advocacy staff that would do the investigation. The QA Director stated during this interview that she was not aware of the bruise and the facility had not investigated the left inner thigh bruise to Resident #30 nor had the facility completed the 24 hour and 5 days reporting to the State Survey Agency. An interview was conducted with the 1st shift nurse manager on 5/2/18 at 2:55PM. During this interview she stated that she vaguely recalled the bruised area to Resident #30 but could not remember any specifics about the bruise and did not know how the bruise occurred. She further stated that she did not see or investigate the bruise to Resident #30. An interview was conducted with QA Director and Director of Nursing (DON) on 5/2/18 at 3:30PM. The DON stated bruise of unknown origin to left thigh of Resident #30 was unknown as to how it occurred and stated it was not reported to State Survey Agency and it was not investigated. The QA Director further stated she understood how it could be reported to the State Survey Agency, but stated that she did not think it was a suspicious bruise. A telephone interview was conducted on 5/2/18 at 3:35PM with Nurse #6, who authored the nurses note on 4/22/18 about the bruise to the left inner thigh of Resident #30. During this interview she stated that she recalled the note about the bruised finger shaped area on Resident #30's inner thigh. She further stated she did not know how the bruise occurred and that she reported it to the oncoming nurse at the end of her shift. She also stated that a finger shaped bruise to a resident's inner thigh would be looked into as it is something to be concerned of and that no management staff followed up with her investigating the bruise. During an interview with the Assistant Director of Nursing on 5/2/18 at 4:32PM she stated, anything finger shaped is a red flag to us and should be investigated. An interview was conducted with the Responsible Party of Resident #30 on 5/2/18 a 5:35PM. The Responsible Party stated she was told of the bruise but was not told the bruise was on the resident's inner thigh or how it the bruise occurred. An interview was conducted with Advocate #1 on 5/3/18 at 9:00AM. During this interview she stated that her job responsibilities was to ensure the rights of the residents were not violated. She further stated employees are instructed to notify the Advocates of any rights violations to include injuries of unknown origin and that a bruise in the inner thigh of unknown origin to Resident #30 should have been reported to them and they should have investigated it. She stated she was not aware of the bruise and that it had not been reported to her to investigate. An interview was conducted with Nurse #7 on 5/3/18 at 11:02AM. She stated that she somewhat remembered the bruise to Resident #30's left inner thigh being mentioned to her during shift change. She further stated that she did not report the bruise to any management and that she was unaware of any investigation into how the bruise occurred. During a follow-up interview with the QA Director on 5/3/18 at 3:10PM, she stated that there was no investigation and no 24 hour and 5-day reports were submitted to the State Survey Agency for the bruise of unknown origin to the inner thigh of Resident #30.

Based on record review and family and staff interviews the facility failed to submit a 24 hour and 5-day report to the State Survey Agency and failed to investigate a bruise of unknown origin for 1 of 1 sampled residents. (Resident #30) The Findings Included: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed that Resident #30 had severely impaired cognition. Further review revealed she had physical and verbal behaviors that occurred 1 to 3 days and wandering and rejection of care behaviors that occurred 1 to 3 days. The assessment also revealed the resident required extensive assistance with bed mobility, dressing, toileting, hygiene and transfers, and supervision for walking. She was assessed as always being incontinent of bowel and bladder and as having 2 or more falls with no injury since her last assessment. The assessment was also coded as Resident #30 not receiving any anticoagulant medications. A review of Resident #30's care plan, dated 4/25/18 revealed a concern with bruising and interventions listed were to monitor, observe and report any bruising. Review of a nursing note dated 4/22/2018 read in part: bruise to Resident's left inner thigh, purple in color, finger shaped of unknown etiology. Review of the facility document titled Nurses Rounds Report for Resident #30 dated 4/22/2018 read in part: finger length purple bruise to left upper thigh. Review of the facility abuse allegations and investigations failed to reveal any investigation into the left inner thigh bruise of Resident #30. An interview was conducted with the Director of Quality Assurance (QA) on 5/2/18 at 2:29PM. During this interview, the QA director stated that the facility Advocate would investigate any injury of unknown origin. The QA Director further stated that management may also do their own investigation, but stated it was the advocacy staff that would do the investigation. The QA Director stated during this interview that she was not aware of the bruise and the facility had not investigated the left inner thigh bruise to Resident #30 nor had the facility completed the 24 hour and 5 days reporting to the State Survey Agency. An interview was conducted with the 1st shift nurse manager on 5/2/18 at 2:55PM. During this interview she stated that she vaguely recalled the bruised area to Resident #30 but could not remember any specifics about the bruise and did not know how the bruise occurred. She further stated that she did not see or investigate the bruise to Resident #30. An interview was conducted with QA Director and Director of Nursing (DON) on 5/2/18 at 3:30PM. The DON stated bruise of unknown origin to left thigh of Resident #30 was unknown as to how it occurred and stated it was not reported to State Survey Agency and it was not investigated. The QA Director further stated she understood how it could be reported to the State Survey Agency, but stated that she did not think it was a suspicious bruise. A telephone interview was conducted on 5/2/18 at 3:35PM with Nurse #6, who authored the nurses note on 4/22/18 about the bruise to the left inner thigh of Resident #30. During this interview she stated that she recalled the note about the bruised finger shaped area on Resident #30's inner thigh. She further stated she did not know how the bruise occurred and that she reported it to the oncoming nurse at the end of her shift. She also stated that a finger shaped bruise to a resident's inner thigh would be looked into as it is something to be concerned of and that no management staff followed up with her investigating the bruise. During an interview with the Assistant Director of Nursing on 5/2/18 at 4:32PM she stated, anything finger shaped is a red flag to us and should be investigated. An interview was conducted with the Responsible Party of Resident #30 on 5/2/18 a 5:35PM. The Responsible Party stated she was told of the bruise but was not told the bruise was on the resident's inner thigh or how it the bruise occurred. An interview was conducted with Advocate #1 on 5/3/18 at 9:00AM. During this interview she stated that her job responsibilities was to ensure the rights of the residents were not violated. She further stated employees are instructed to notify the Advocates of any rights violations to include injuries of unknown origin and that a bruise in the inner thigh of unknown origin to Resident #30 should have been reported to them and they should have investigated it. She stated she was not aware of the bruise and that it had not been reported to her to investigate. An interview was conducted with Nurse #7 on 5/3/18 at 11:02AM. She stated that she somewhat remembered the bruise to Resident #30's left inner thigh being mentioned to her during shift change. She further stated that she did not report the bruise to any management and that she was unaware of any investigation into how the bruise occurred. During a follow-up interview with the QA Director on 5/3/18 at 3:10PM, she stated there was no investigation and no 24 hour and 5-day reports were submitted to the State Survey Agency for the bruise of unknown origin to the inner thigh of Resident #30.

Based on record review and family and staff interviews the facility failed to investigate a bruised area to the inner left thigh for 1 of 1 residents (Resident #30) sampled for a bruise of unknown origin. The Findings Included: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed that Resident #30 had severely impaired cognition. Further review revealed she had physical and verbal behaviors that occurred 1 to 3 days and wandering and rejection of care behaviors that occurred 1 to 3 days. The assessment also revealed the resident required extensive assistance with bed mobility, dressing, toileting, hygiene and transfers, and supervision for walking. She was assessed as always being incontinent of bowel and bladder and as having 2 or more falls with no injury since her last assessment. The assessment was also coded as Resident #30 not receiving any anticoagulant medications. A review of Resident #30's care plan, dated 4/25/18 revealed a concern with bruising and interventions listed were to monitor, observe and report any bruising. Review of a nursing note dated 4/22/2018 read in part: bruise to Resident's left inner thigh, purple in color, finger shaped of unknown etiology. Review of the facility document titled Nurses Rounds Report for Resident #30 dated 4/22/2018 read in part: finger length purple bruise to left upper thigh. Review of the facility abuse allegations and investigations failed to reveal any investigation into the left inner thigh bruise of Resident #30. An interview was conducted with the Director of Quality Assurance (QA) on 5/2/18 at 2:29PM. During this interview, the QA director stated that the facility Advocate would investigate any injury of unknown origin. The QA Director further stated that management may also do their own investigation, but stated it was the advocacy staff that would do the investigation. The QA Director stated during this interview that she was not aware of the bruise and the facility had not investigated the left inner thigh bruise to Resident #30. An interview was conducted with the 1st shift nurse manager on 5/2/18 at 2:55PM. During this interview she stated that she vaguely recalled the bruised area to Resident #30 but could not remember any specifics about the bruise and did not know how the bruise occurred. She further stated that she did not see or investigate the bruise to Resident #30. An interview was conducted with QA Director and Director of Nursing (DON) on 5/2/18 at 3:30PM. The DON stated bruise of unknown origin to left thigh of Resident #30 was unknown as to how it occurred and stated it was not reported to state and investigated. The QA Director further stated she understood how it could be reported, but stated that she did not think it was a suspicious bruise. A telephone interview was conducted on 5/2/18 at 3:35PM with Nurse #6, who authored the nurses note on 4/22/18 about the bruise to the left inner thigh of Resident #30. During this interview she stated that she recalled the note about the bruised finger shaped area on Resident #30's inner thigh. She further stated she did not know how the bruise occurred and that she reported it to the oncoming nurse at the end of her shift. She also stated that a finger shaped bruise to a resident's inner thigh would be looked into as it is something to be concerned of and that no management staff followed up with her investigating the bruise. During an interview with the Assistant Director of Nursing on 5/2/18 at 4:32PM she stated, anything finger shaped is a red flag to us and should be investigated. An interview was conducted with the Responsible Party of Resident #30 on 5/2/18 a 5:35PM. The Responsible Party stated she was told of the bruise but was not told the bruise was on the resident's inner thigh or how it the bruise occurred. An interview was conducted with Advocate #1 on 5/3/18 at 9:00AM. During this interview she stated that her job responsibilities was to ensure the rights of the residents were not violated. She further stated employees are instructed to notify the Advocates of any rights violations to include injuries of unknown origin and that a bruise in the inner thigh of unknown origin to Resident #30 should have been reported to them and they should have investigated it. She stated she was not aware of the bruise and that it had not been reported to her to investigate. An interview was conducted with Nurse #7 on 5/3/18 at 11:02AM. She stated that she somewhat remembered the bruise to Resident #30's left inner thigh being mentioned to her during shift change. She further stated that she did not report the bruise to any management and that she was unaware of any investigation into how the bruise occurred. During a follow-up interview with the QA Director on 5/3/18 at 3:10PM, she stated that there was no complete and thorough investigation for the bruise of unknown origin to the inner thigh of Resident #30.

Based on record reviews and staff interviews, the facility failed to accurately code the MDS (Minimum Data Set) for 2 of 2 residents (Resident #140 and #73 ) reviewed for accuracy of assessments. Findings included: 1. Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review was completed of Resident #140's most recent MDS dated [DATE] coded as an annual assessment. The assessment coded the resident as having received an anticoagulant for 7 out of 7 days of the assessment period. A review was also completed of Resident #140's previous MDS dated [DATE] coded as a quarterly. The assessment coded the resident as having received an anticoagulant for 7 out of 7 days of the assessment period. A review of Resident #140's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) physician orders [REDACTED].#140 did not receive any anticoagulant medication during the assessment period of the MDS. An interview was conducted on 5/2/18 at 5:23 pm with the Director of Quality Assurance, who is currently responsible for completing the MDS assessments. During this interview she stated that she coded the MDS for anticoagulant use on both assessments in error and stated she would modify the assessments. 2. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review was completed of Resident #73's most recent MDS dated [DATE] coded as a quarterly assessment. The assessment coded the resident as having received an anticoagulant for 7 out of 7 days of the assessment period. A review of Resident #73's (MONTH) (YEAR) and (MONTH) (YEAR) physician orders [REDACTED].#73 did not receive any anticoagulant medication during the assessment period of the MDS. An interview was conducted on 5/3/18 at 10:15 am with the Director of Quality Assurance, who is currently responsible for completing the MDS assessments. During this interview she stated that she coded the MDS for anticoagulant use on the assessment in error and stated she would modify the assessments.

Based on observation and staff interviews, the facility failed to dispose/discard out of date medications in 1 of 3 medication rooms and in 1 of 5 medication carts reviewed for medication storage. Findings included: The facility policy provided by the Director of Nursing (DON) for disposal of drugs revised on (MONTH) 28. (YEAR) read in part: 4. All medications which have reached their expiration date should be returned to the pharmacy for disposal. 8. Nursing staff will check all medication rooms and storage areas for medications on a weekly basis, any expired medications will be remove. 9. Nursing unit inspections will also be conducted monthly by pharmacy staff. Stock supplies and night drug cabinet contents will also be checked for expiration date. 1. An observation on G1 medication room was conducted on 5/3/18 at 8:45 AM. There were two [MEDICATION NAME] 0.3mg injection box (for life threatening allergic reaction) were found. One [MEDICATION NAME] box (two injection doses in a box) with an expiration date of (MONTH) (YEAR) and another [MEDICATION NAME] box (two injection doses in a box) with an expiration date of (MONTH) (YEAR). An interview with Nurse #5 revealed that nursing staff should be checking the medication room stock weekly and remove all out of date medications. Nurse #5 also stated that the [MEDICATION NAME] injection should have been removed and returned to pharmacy. 2. An observation was conducted on 5/3/18 at 8:32 AM in G1 West medication cart. A bottle of [MEDICATION NAME] eye drops (use for [MEDICAL CONDITION]) for Resident #137 was found in use and in the medication cart. The eye drop bottle dated to be discarded on 4/15/18. An interview with Nurse #5 revealed the eye drop was given by another nurse and she was not aware that it was out of date. Nurse #5 also stated the [MEDICATION NAME] eye drop should have been discarded on the expiration date. An interview with the DON on 5/3/18 at 11:13 AM revealed her expectation for medication storage was for the nurses to check the medication cart and medication room weekly. The pharmacy staff also check the medication storage monthly. She further stated that nurses should follow the facility procedure for removing the out of date medications.

Based on observation and staff interviews the facility failed to ensure blood glucose meters (glucometers) were properly disinfected/sanitized after use during 3 of 3 observations of a glucometer use. Findings included: The facility policy provided by the Director of Nursing (DON) for cleaning multiuse test device with a revised date of (MONTH) 28, (YEAR) read in part: 1. Following each use of glucometer will be cleaned with a germicidal disposable cloth to remove any large contaminates. 2. A second germicidal disposable cloth will be used to clean the exterior again. 3. The device will be placed on a clean surface and allowed to air dry then placed back in case. A review of manufacturer's instruction label for germicidal wipes read in part: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let it air dry. 1.A. An observation was conducted on 5/1/18 at 4:43 PM of Nurse #1 when obtaining a Finger Stick Blood Sugar (FSBS) for Resident #135. The nurse entered the resident's room and followed the proper procedure for handwashing and gloving before taking the FSBS. The nurse returned to the medication cart and placed the glucometer in the glucometer carrying case. The nurse proceeded to place the glucometer in the medication cart without disinfecting/sanitizing. The nurse was interviewed right after and she stated that she will disinfect the glucometer before she leaves her shift that evening like around 11 PM. Nurse #1 further stated that she doesn't disinfect the glucometer after use except she'll clean the before her shift ends. B. Nurse #2 was observed obtaining FSBS on 5/2/18 at 10:42 AM for Resident #136. The nurse entered the resident's room and followed proper procedure for handwashing and gloving before taking FSBS. Nurse #2 returned to the medication cart and wiped the glucometer with a germicidal wipe. He then tossed the wipe into the trash bin, and placed the glucometer on top of the table in the medication room. Continuous observation of the glucometer revealed the surface appeared dry in less than a minute. Nurse #2 did not ensure the glucometer remained wet with germicidal solution for a full 2 minutes. An interview with Nurse #2 revealed it was the facility's procedure to wipe glucometer after each use with germicidal wipes. Nurse #2 indicated he was not aware of the procedure for the germicidal wipe to leave it wet for full 2 minutes. Nurse #2 also acknowledged that the glucometer was not left wet for 2 minutes after he wiped it. C. An observation was conducted on 5/2/18 at 11:27 AM with Nurse #3. The nurse entered Resident #126's room and proceeded to do FSBS. He followed the proper procedure for handwashing and gloving before taking FSBS. Nurse #2 returned to the medication cart, wiped the glucometer with a germicidal wipe. He then tossed the wipe into the trash bin, and placed the glucometer on top of the medication cart. Continuous observation of the glucometer revealed the surface appeared dry in less than a minute. Nurse #2 did not ensure the glucometer remained wet with germicidal solution for a full 2 minutes. Nurse #3 was interviewed and he indicated that the facility instruction for glucometer be disinfected after each use. Nurse #3 also indicated he was not aware of the germicidal wipe instruction to leave wet for full 2 minutes for disinfection. An interview with the DON on 5/3/18 at 10:41 AM revealed her expectation regarding cleaning glucometer was for the nursing staff to follow the facility procedure and the manufacturer's instruction of the germicidal wipe. The DON also indicated that they needed to review and that they will change their facility policy regarding cleaning of glucometer.

Based on record review and staff interview the facility failed to provide one of 3 residents (Resident #124) privacy during incontinence care. The findings included: Resident #124 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#124 required extensive assistance in the areas of toileting with the use of 1 staff person. The MDS indicated Resident #124 was frequently incontinent of bladder and always incontinent of bowel. The Resident was coded on the MDS as cognitively impaired as evidenced by a brief interview for mental status (BIMS) score of 00. Review of the facility advocates internal investigation summary dated 3/4/16 revealed findings that included Staff #1 reported that on 3/4/16 after lunch Resident #124 had lied naked and had a bowel movement. The summary indicated Resident #124 was left exposed and was visible to others. Interview with staff #3 on 6/9/16 at 1:16pm revealed on 3/4/16 staff#1 was providing Resident #124 with 1:1 care and supervision. Staff #3 indicated she had checked on Staff #1 to inquire if she needed any assistance with resident #124. Staff #3 indicated he had stopped by the room to inquire if she needed assistance because Resident #124 was unclothed, the door was open, privacy curtain was not drawn and the resident had a bowel movement on himself in bed. Interview with staff #4 on 6/9/16 at 1:28pm revealed on 3/4/16 staff #1 was providing Resident #124 with 1:1 care and supervision. She indicted she had observed Resident #124 had a bowel movement in his bed. She stated Resident #124 ' s door was open and the privacy curtain was not drawn. Resident was naked as evidenced by the resident ' s sheets being pushed to the end of his bed. Staff #4 indicated that she and another nursing staff asked staff #1 if she needed any assistance because occasionally Resident #2 required 2 staff persons. Staff #1 indicated she did not need any assistance. Interview with the Administrator on 6/9/16 at 4:21pm revealed it was her expectation that residents are afforded privacy while care is being rendered. The Administrator further revealed staff #1 was no longer employed by the facility. An interview was attempted with Staff #1 on 6/9/16 at 12:30pm and 1:00pm. Staff #1 was not able to be reached.

Based on observation, record review and staff interview the facility failed to submit a 5 day working report for 1 of 3 sampled Residents (Resident #2) who had an injury of unknown origin. The findings included: Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Resident #2 ' s Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was moderately cognitively impaired. Resident #2 was not taking medications that would cause bruising. Review of nursing note dated 6/1/16 at 5:00pm revealed Resident #2 had bruises that appeared fresh on his upper right arm frontally near his axilla. The note stated the etiology of the bruises was unknown. Resident #2 was attempting to reach down over right side of bed to pick up star may be related to this quarter size bruise. No discomfort and no signs of distress or deeper injury. Review of nursing note dated 6/1/16 at 5:45am revealed Resident #2 had pulled out his [DEVICE]. The area was cleaned with soap and water. Resident #2 ' s [DEVICE] was reinserted without difficulty. Several bruises noted were noted on Resident #2 ' s left arm. Possibly from banging his arms on wheelchair earlier. The exact etiology of Resident #2 ' s bruising was unknown. The resident was currently on the hallway. Review of nursing note dated 6/2/16 at 6:00am revealed Resident #2 had considerable bruising bilaterally over arms and legs and several bruised areas on his trunk. The bruising was in different stages of healing with no signs of additional bruises. Resident #2 had no complaints of pain or discomfort. Review of nursing note dated 6/3/16 at 2:55am revealed Resident #2 had multiple bruising over both upper and lower extremities bilaterally as well as over his chest and abdomen. The bruises appeared to be older and resolving. The note continued with some areas of bruising appeared to blend together and unable to distinguish one from another. Resident denied pain. Review of nursing note dated 6/3/16 at 3:00pm revealed a body check was conducted. The note continued with Resident #2 had multiple bruises on both arms, both legs, almost all surfaces, hands, and abdomen. The bruises vary in color and size as well as stage. Some bruises looked newer and some bruises look older. Interview with the facility Advocate #1 on 6/9/16 at 5:20pm revealed she was approached by Nurse #1 on 6/1/16 and was notified that she had observed bruising on resident #2 ' s body. The Advocate indicated Nurse#1 revealed although Resident #2 had self-injurious behaviors, Nurse #1 felt as though the there was too much bruising and wanted to get the Advocate involved. The facility Advocate described Resident #2 ' s bruising as scattered and resembled finger prints. She revealed that although she had not finished her detailed report her interviews founded that staff were aware he had bruising but indicated resident #2 always had bruising. She revealed she had talked with the facility physician and the physician communicated that he would run labs to identify if the bruising was medically related. The physician indicated that although people with [MEDICAL CONDITION] bruised easier the bruising on Resident #2 was inconsistent. The Advocate revealed she would finalize the detailed report following interviews with physical therapy and the psychologist. The advocate revealed she was going on vacation and would finalize the investigation upon her return. An observation of photos of Resident #2 were provided by the facility Advocate on 6/09/16 at 5:20pm during the Advocates interview about her investigation. The photos were observed to be dated 6/1/16 as evidenced by facility labeling. The photos were retrieved from the Advocates receptionists ' computer/photo data base. The pictures revealed Resident #2 to have several scattered bruises to his upper extremities. The bruises were small and circular in shape. Resident #2 ' s legs, chest and abdomen were also observed as having bruising that were circular in appearance. The bruising appeared to be in various stages of healing as evidenced by bruises fading and some bruises being dark in color. Review of the internal investigation summary report revealed an internal investigation was initiated on 6/1/16 and indicated the investigation concluded on 6/9/16. The allegation/incident description stated on 6/1/16 Nurse#1 reported that Resident #2 had multiple bruising on his arm and legs in various stages of healing. Resident #2 was known to be resistant to care, but the bruising appeared to be excessive. Resident #2 stated that someone beat him up. An investigation of the alleged physical abuse of Resident #2 had been initiated. The investigation stated the physician indicated that the spotted marks were unusual and he could offer no explanation for them. The medical doctor also stated that Resident #2 threw himself a lot. He stated that if Resident #2 was being bruised as a result of how they are intervening with Resident #2 then perhaps a new approach would need to be used. The investigation summary reveled staff interviews that indicated the resident was resistive to care during bathing. The resident had recently put himself on the floor; tried to roll off the flat tub on 5/30/16. The bruises may have resulted from bath time and it usually took three people to roll Resident #2 over and assist him with bathing and check and change. The summary concluded that based on the location and the amount of bruising on Resident #2 ' s body it was more likely than not that Resident #2 may have been restrained during times when he may have been resistant to care. Staff indicated that Resident #2 had bruising for some time and yet they did not bring this information forward. The neglect and rights violation of Resident #2 was substantiated. Interview with the Administrator on 6/10/16 at 2:13pm am revealed concerns of alleged abuse or bruises of unknown origin are brought to the facilities attention through the supervisors and the Advocate. A 24 hour report was completed by the facility on 6/1/16 in regards to the bruises of unknown origin for Resident #2. The Administrator indicated Resident #2 had come to the facility with bruising and had a history of [REDACTED].#2 had end stage [MEDICAL CONDITION] and the bruising could have been a result of his medical condition. She indicated the facility had statements from staff that were taken on 6/1/16 and 6/2/16. The administrator indicated that she had sent the Department of Health and Human Services (DHHS) an extension due to the 5 day working report not being completed. The 5 day working report was a combination of the Advocate ' s investigations and the Administrators investigation. The 5 day working report required the advocacy report finalizing the investigation. The staff statements indicated where the bruises could have come from. Resident #2 ' s bruises were not consider to have occurred from abuse and was identified as a result of Resident #2 ' s behaviors.

Based on observation, record review and staff interview the facility failed to follow their abuse policy in the area of reporting the 5 day investigation report to the state Health Care Personnel Registry (HCPR) for 1 of 3 residents with injuries of unknown origin (Resident #2) The findings included: Facility policy for protecting residents from rights infringements dated [DATE] revealed designated facility management staff would make a second report, the 5 day working repot to the Health Care Personal Registry (HCPR) on the 5th working day for any incidents that required an initial 24 hour report to the HCPR. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Resident #2 ' s Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was moderately cognitively impaired. Review of nursing note dated [DATE] at 5:00pm revealed Resident #2 had bruises that appeared fresh on his upper right arm frontally near his axilla. The note stated the etiology of the bruises was unknown. Resident #2 was attempting to reach down over right side of bed to pick up a star. The note revealed that picking up the star may be related to this quarter size bruise. Resident #2 had no discomfort and no signs of distress or deeper injury. Review of nursing note dated [DATE] at 5:45am revealed Resident #2 had pulled out his [DEVICE]. The area was cleaned with soap and water. Resident #2 ' s [DEVICE] reinserted without difficulty. Several bruises noted on Resident #2 ' s left arm. Possibly from banging his arms on wheelchair earlier. The bruises etiology was unknown. Resident was currently on the hallway. Review of nursing note dated [DATE] at 6:00am revealed Resident #2 had considerable bruising bilaterally over arms and legs and serval bruised areas on his trunk. The bruises were in different stages of healing with no signs of additional bruises. Resident #2 had no complaints of pain or discomfort. Review of nursing note dated [DATE] at 10:30am revealed an order for [REDACTED].>Review of nursing note dated [DATE] at 2:55am revealed Resident #2 had multiple bruising over both upper and lower extremities bilaterally as well as over his chest and abdomen. Bruises appeared to be older and resolving. The note continued with some areas of Resident #2 ' s bruising appears to blend together. Unable to distinguish bruises from one another. Resident #2 denied pain. Interview with the facility Advocate #1 on [DATE] at 5:20pm revealed she was approached by RN #1 on [DATE] and was notified that she had observed bruising on resident #2 ' s body. The Advocate indicated Nurse #1 revealed although Resident #2 had self-injurious behaviors, Nurse#1 felt as though the there was too much bruising and wanted to get the Advocate involved. The facility Advocate described Resident #2 ' s bruising as scattered and resembled finger prints. She revealed that although she had not finished her detailed report her interviews founded that staff were aware he had bruising but indicated resident #2 always had bruising. She revealed she had talked with the facility physician and the physician communicated that he would run labs to identify if the bruising was medically related. The physician indicated that although people with [MEDICAL CONDITION] bruised easier the bruising on Resident #2 was inconsistent. The Advocate revealed she would finalize the detailed report following interviews with physical therapy and the psychologist. The Advocate revealed she was going on vacation and would finalize the investigation upon her return. An observation of photos of Resident #2 were provided by the facility Advocate on [DATE] at 5:20pm during the Advocates interview about her investigation. The photos were observed to be dated [DATE] as evidenced by facility labeling. The photos were retrieved from the Advocates receptionists ' computer/photo data base. The pictures revealed Resident #2 to have several scattered bruises to his upper extremities. The bruises were small and circular in shape. Resident #2 ' s legs, chest and abdomen were also observed as having bruising that were circular in appearance. The bruising appeared to be in various stages of healing as evidenced by bruises fading and some bruises being dark in color. Interview with the Administrator on [DATE] at 11:29am revealed it was the facilities responsibly to complete and send a 24 hour report to DHHS and it was the Advocate ' s responsibility was to complete and finalize the 5 day working report. She indicated that it had not been completed. She revealed the facility did not write up the investigation. She further revealed that the facility waited on the Advocate to finish her investigation so the information included in the investigation could be added to the 5 day working report. Interview with the Administrator on [DATE] at 2:13pm am revealed concerns of alleged abuse or bruises of unknown origin are brought to the facilities attention through the supervisors and the Advocate. A 24 hour report was completed by the facility on [DATE] in regards to the bruises of unknown origin for Resident #2. The Administrator indicated Resident #2 had come to the facility with bruising and had a history of [REDACTED].#2 had end stage [MEDICAL CONDITION] and the bruising could have been a result of his medical condition. She indicated the facility had statements from staff that were taken on [DATE] and [DATE]. The Administrator indicated that she had sent DHHS an extension due to the 5 day working report not being completed. The 5 day working report was a combination of the Advocate ' s investigations and the Administrators investigation. The 5 day working report required the advocacy report finalizing the investigation and was not submitted. Resident #2 ' s bruises were not considered to have occurred from abuse and was identified as a result of Resident #2 ' s behaviors.

Based on observations and staff interview the facility failed to label 4 bottles of eye drops on 4 of 10 medication carts with the date the medication was opened and put in use and failed to remove those drops from the medication carts after they had been in use 42 days, as recommended by the manufacturer. (Medication carts: Gravely #1, Raspberry #2 East, Raspberry #3 East and Raspberry #3 West). The findings included: Review of manufacturer recommendations for Xalatan and Lumigan eye drops revealed the ophthalmic solution should not be used more than 42 days after opening. 1. Observation of the Raspberry #2 East Medication Cart on 05/19/15 at 3:03 PM revealed it contained a bottle of Xalatan (a medicated eye drop used to treat glaucoma) eye drops with a pharmacy label that indicated it was dispensed on 11/20/14 for Resident #135. The bottle was opened and currently in use. There was no date on the bottle to indicate when is was opened and put into use. A manufacturer stamp on the bottle indicated an expiration date of November 2015. An interview on 05/19/15 at 3:22 PM with Nurse #1 revealed Resident #135 was still receiving the Xalatan eye drops. Nurse #1 was asked if she had a reference tool for expiration dates or knew how long the Xalatan could remain in use after if was opened. Nurse #1 stated she didn't know how long the Xalatan eye drops could remain in use after opening and she didn't have a reference tool as far as she knew. Nurse #1 was asked if staff were expected to label mulitdose containers when they were opened and she stated the nurse who opened the container of eye drops should have labeled the bottle with the date it was opened. Nurse #1 was asked if she knew when the Xalatan was opened and she stated she didn't know. 2. Observation of Raspberry #3 East Medication Cart on 05/19/15 at 3:45 PM revealed it contained a bottle of Lumigan (a medicated eye drop used to treat glaucoma) eye drops with a pharmacy label that indicated it was dispensed on 03/06/15 for Resident #120. The bottle was opened and currently in use. There was no date on the bottle to indicate when it was opened and put into use. A manufacturer stamp on the bottle indicated an expiration date of October 2016. An interview on 05/19/15 at 3:52 PM with Nurse #2 revealed Resident #120 was still receiving the Lumigan eye drops. Nurse #2 was asked if she had a reference tool for expiration dates or knew how long the Lumigan could remain in use after it was opened. Nurse #2 stated she didn't know how long the Lumigan eye drops could remain in use after opening and she stated she didn't have a reference tool as far as she knew. Nurse #2 was asked if staff were expected to label multidose containers when they were opened and she stated the nurse who opened the container of eye drops should have labeled the bottle with the date it was opened. Nurse #2 was asked if she knew when the Lumigan eye drops were opened and she stated she didn't know. 3. Observation of Raspberry #3 West Medication Cart on 05/19/15 at 3:50 PM revealed it contained a bottle of Xalatan eye drops with a pharmacy label that indicated it was dispensed on 03/12/15 for Resident #90. The bottle was opened and currently in use. There was no date on the bottle to indicate when it was opened and put into use. A manufacturer stamp on the bottle indicated an expiration date of December 2015. An interview on 05/19/15 at 3:52 PM with Nurse #2 revealed Resident #90 was still receiving the Xalatan eye drops. Nurse #2 was asked if she had a reference tool for expiration dates or knew how long the Xalatan could remain in use after it was opened. Nurse #2 stated she didn't know how long the Xalatan eye drops could remain in use after opening and she didn't have a reference tool as far as she knew. Nurse #2 was asked if staff were expected to label multidose containers when they were opened and she stated the nurse who opened the container of eye drops should have labeled the bottle with the date it was opened. Nurse #2 was asked if she knew when the Xalatan eye drops were opened and she stated she didn't know. 4. Observation of Gravelly #1 Medication Cart on 05/21/15 at 9:30 AM revealed it contained a bottle of Lumigan eye drops with a pharmacy label that indicated it was dispensed on 01/26/15 for Resident #12. The bottle was opened and currently in use. There was no date on the bottle to indicate when it was opened and put into use. An interview on 05/21/15 at 10:05 AM with Nurse #3 revealed Resident #12 was still receiving the Lumigan eye drops. Nurse #3 stated she was unaware there was a limitation on how long the medication could be used after opening. Nurse #3 was unable to state when the bottle was opened and put into use and stated it probably was within 3 to 7 days of when it was dispensed. An interview on 05/21/15 at 8:25 AM with the Pharmacy Director about the manufacturer guidelines for Lumigan and Xalatan eye drops and how long they can be used after opening revealed they can be used for 6 weeks after opening. When asked if the nurses should be labeling the bottle when it was opened, he stated: "that would be a good idea." He stated the eye drops can't be guaranteed sterile beyond 6 weeks after opening. An interview on 05/21/15 at 9:08 AM with Nursing Supervisor #1 about the facility policy or expectation for dating insulin containers or eye drops when they are opened revealed the nurses are expected to date the containers when they are opened. NS #1 was asked about Xalatan & Lumigan eye drops and how long they could remain in use after being opened and she stated she thought it was 6 weeks but she would have to call Pharmacy to be sure. NS #1 was asked if the nurses had a reference guide with expiration dates for insulin and eye drops after they were opened and she stated she was not aware of a reference guide. NS #1 was asked about her expectation for discarding medications that were in use past their expiration date and she stated she expected the medications to be put in the tray and returned to Pharmacy. An interview on 05/21/15 at 9:32 AM with the Director of Nursing (DON) about her expectation for labeling and dating eye drops when they were opened revealed she expected the nurses to label the bottle with the date it was opened & their initials. The DON was asked if there was any reference tool for the nurses to use for expiration dates on how long medications could be used after opening and she stated there wasn't a reference guide but pharmacy staff monitored the dates monthly.

Based on record review and staff interviews facility staff failed to protect 1 of 3 residents from physical abuse (Resident #1) and 2 of 3 residents from emotional abuse (Resident #1 and #2) for residents sampled for abuse. The findings included: 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED].#1 was able to make himself understood, had short and long-term memory problems, and severely impaired cognitive skills for daily decision making. The quarterly MDS noted Resident #1 required extensive assistance for most activities of daily living. Review of a 24-Hour Initial Report faxed to the Health Care Personnel Registry (HCPR) on [DATE] alleged on [DATE] Nurse Aide (NA) #1 had referred to Resident #1 as a "p........" and stated he would like to suffocate the life out of him. It was also alleged he dragged Resident #1 across the bathroom floor. An interview with Advocate #2 on [DATE] at 2:00 PM revealed she contacted by the Senior Administrative Officer (SAO) on [DATE] regarding alleged emotional and physical abuse of Resident #1 by NA #1. Advocate #2 stated she and the SAO came in to the facility immediately on [DATE] to start the facility's investigation and interviewed NA #1, NA #2, and NA #3. Advocate #2 stated NA #1 had been removed from the resident care area by the Health Care Supervisor (HCS) on duty that weekend. The interview further revealed Advocate #2 substantiated the allegations of emotional and physical abuse based on interviews and the definition of abuse. Advocate #2 further stated she completed the 24-Hour Initial Report and the SAO faxed it to the HCPR. Advocate #2 further stated Resident #1 was assessed by a nurse again on [DATE] with no injuries noted to his lower back, buttocks, under his arms, or on his arms. The interview further revealed additional interviews were conducted after [DATE] and a summary of the advocacy report was given to the management team for review on [DATE]. An interview was conducted with NA #3 on [DATE] at 2:37 PM. NA #3 stated Resident #1 had indicated he needed to sit on the toilet during the 1:00 PM check and change rounds on [DATE] and he was assisted on the toilet in the central bath. NA #3 explained while she monitored Resident #1 NA #1 came into the central bath and started talking about Resident #1 and another resident. NA #1 told NA #3 he thought Resident #1 and the other resident were "p........." and he would like to choke the life out of them. NA #1 indicated he provided these residents with the care they needed but did not feel any love for them. NA #3 stated Resident #1 was on the other side of the privacy curtain in the central bath and she did not know if he heard what NA #1 said. NA #3 explained she told NA #1 to calm down and he stopped the discussion. NA #3 stated she had never heard NA #1 talk like this before and had not ever observed him mistreating a resident. NA #3 left for her break and NA #2 came in the central bath. The interview further revealed NA #3 informed Nurse #1 and the HCS what NA #1 told her in the central bath. During an interview on [DATE] at 3:01 PM the Assistant Director stated NA #1 was sent home on administrative leave with pay after the incident on [DATE]. The management team reviewed the summary of the advocacy report on the 5th working day ([DATE]) and determined substantiation of the allegations. The Assistant Director further stated NA #1 admitted to the verbal abuse or Resident #1 and while he did not admit to the physical abuse management determined NA #1's physical actions were not at the standard of care and felt he had other options while caring for Resident #1 on [DATE]. Management met with NA #1 on [DATE] for a disciplinary pre-conference and discussed grounds for dismissal related to his job performance and substantiated allegations of abuse. NA #1 was dismissed on [DATE]. A telephone interview with Nurse #1 on [DATE] at 3:14 PM revealed he was called in to the central bathroom by NA #1 on [DATE] and NA #1 asked him what he should do because Resident #1 had been sitting on the toilet for a long time. Nurse #1 instructed NA #1 to let Resident #1 stay on the toilet. Nurse #1 stated he was called back to the central bath approximately 10 minutes later and Resident #1 was sitting on the floor several feet from the toilet. NA #1 indicated to Nurse #1 he had eased Resident #1 to the floor. Nurse #1 and NA #1 assisted Resident #1 off the floor, cleaned him up, and assisted him into his wheel chair. Nurse #1 stated Resident #1 was agitated but he did not note any injuries when he assessed him in the central bath. The interview further revealed NA #2 and NA #3 came to him after the incident in the central bath and told him NA #1 had forced Resident #1 off the toilet and also called him a "p........". Nurse #1 recalled NA #2 and NA #3 went straight to their HCS to report their concerns. A telephone interview was conducted with NA #1 on [DATE] at 4:02 PM. NA #1 stated NA #3 was in the central bath with him at first and then NA #2 was there with him. NA #1 further stated when he assisted Resident #1 off the toilet on [DATE] he became unsteady and NA #1 eased him to the floor. NA #1 explained Resident #1 was near the bathroom door and he wanted to move him so he stood behind him and pulled him from under his arms approximately 4 feet to the center of the bathroom. Nurse #1 returned to the central bath and assisted NA #1 to get Resident #1 off the floor and cleaned up. NA #1 stated he did not think he was rough with the resident. When asked about referring to Resident #1 as a p........ and stating he would like to suffocate the life out of a p........ NA #1 stated he should not have said these things and regretted having done so. During an interview on [DATE] at 3:39 PM the SAO stated she was contacted by the HCS on [DATE] regarding alleged emotional and physical abuse of Resident #1 by NA #1. The SAO assisted with the interviews and at the conclusion gave NA #1 a letter informing him he was on administrative leave with pay. An interview was conducted with NA #2 on [DATE] at 9:58 AM. NA #2 stated she went to the central bath after her break on [DATE] at approximately 2:18 PM. NA #2 recalled Resident #1 was sitting on the toilet behind the privacy curtain and NA #1 was leaning against the sink. NA #1 indicated Resident #1 was not finished using the toilet. NA #2 stated she asked Resident #1 if he was ready to get off the toilet and Resident #1 told her he was ready to get up. NA #2 stated when she turned around after getting supplies she observed NA #1 pulling on Resident #1's arms and telling him to stand up. NA #2 further stated Resident #1 fell to the floor on his left side and the back of his head was in front of the central bath door. The interview further revealed NA #2 put her foot in front of the bathroom door to stop it from being opened completely. NA #1 then dragged Resident #1 several feet by his lower arms and moved him in to the middle of the bathroom floor. About that time NA #4 stuck her head in to the bathroom and went to get Nurse #1. NA #2 further explained when she and NA #3 wheeled Resident #1 out of the central bath he was kicking and hitting at them and told his family staff were beating him. NA #2 then reported her observations to Nurse #1 and the HCS. An interview with NA #4 on [DATE] at 10:35 AM revealed she took Resident #1 to the central bath because he indicated he needed to have a bowel movement. NA #4 stated Resident #1 was able to stand with assist and use the rail to pivot to the toilet. NA #4 explained it was time for her break and Resident #1 told her he was not ready to get off the toilet and NA #1 came in the bathroom and offered to watch Resident #1. NA #4 stated Resident #1 was standing by the time she got back in to the central bath and he seemed upset. NA #4 further stated she was assigned to monitor Resident #1's visit with his family immediately after the incident in the bathroom and when his family asked him what was wrong he did not answer them. The interview further revealed NA #4 observed the visit for approximately 30 minutes and stated Resident #1 seemed calm after a few minutes with his family. An interview was conducted with the Staff Development Coordinator (SDC) on [DATE] at 3:20 PM. The SDC stated all employees received training regarding abuse and neglect during their initial orientation to the facility presented by the advocacy department. The SDC reviewed facility documents and confirmed NA #1 attended a mandatory staff annual update on [DATE] which included a review of information regarding client's rights, abuse, neglect, exploitation, rights infringements, and reporting incidents. During an interview on [DATE] at 4:03 PM the Program Director stated physical and emotional abuse were substantiated for Resident #1 because the physical evidence from the investigation did not support all of NA #1's statement. 2. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 required extensive assistance with bed mobility, transfer, and locomotion on and off unit, dressing, toilet use and personal hygiene. Resident #2 was occasionally incontinent of bowel and bladder. The MDS further indicated Resident #2 had problems with short term and long term memory. During an interview on [DATE] at 2:09 PM, Advocate #2 stated an incident had occurred with Resident #2 on [DATE]. Advocate #2 continued by stating near the end of first shift on [DATE], NA #7 reported she had witnessed NA #9 in Resident #2's room purposefully withholding her doll and would not give it back to Resident #2 despite her repeated requests to have the doll back. Resident #2 became visibly upset using a whiny voice to indicate she was sad, upset and spitting. NA #7 then entered Resident #2's room and took the resident to the bathroom. During an interview on [DATE] at 11:05 AM, NA #7 discussed reporting an incident she had witnessed on [DATE]. NA #7 stated she saw NA #9 taunting and emotionally abusing Resident #2 and purposefully withholding her doll. NA #9 reportedly held Resident #2's doll and said, "I have your doll" and would not give it back to Resident #2 after the resident asked NA #9 several times. NA #9 was also reported to be laughing at the resident. During an interview on [DATE] at 11:23 AM, NA #8 stated she was walking in Resident #2's room on [DATE] when she saw NA#7 trying to take the resident to the bathroom. Resident #2 was being resistive because NA#9 would not give her doll back. Resident #2 said several times she wanted her doll back. NA#7 took Resident #2 to the bathroom. On [DATE] at 11:48 AM an attempt was made to contact NA#7 which was unsuccessful. During an interview on [DATE] at 3:32 PM, Program Director and Senior Advocate #1 stated the facility had conducted an investigation and determined this case to be substantiated as emotional abuse.

Based on staff, family member, nurse practitioner and medical director interviews, and record review, the facility failed to notify a family member of a significant change in condition which required antibiotic therapy for 1 of 3 sampled residents with a significant change in condition (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's Medical Orders for Scope of Treatment form dated 04/01/13 revealed the use or limitation of antibiotics would be determined when an infection occurred. This form was signed by Resident #36's family member who was also the Resident's legal guardian. Review of Resident #36's quarterly Minimum (MDS) data set [DATE] revealed an assessment of severely impaired decision making ability with a life expectancy of less than 6 months. Review of a nursing note dated 01/07/14 revealed Resident #36's temperature was 102 degrees Fahrenheit with agitated behavior. The physician received notification. Review of telephone physician's orders [REDACTED].) for one dose and obtain a chest x-ray. Review of Nurse Practitioner's orders dated 01/09/14 revealed direction to administer [MEDICATION NAME] 500 mg. daily for 7 days for possible pneumonia. Telephone interview with Resident #36's family member and legal guardian on 01/23/14 at 10:56 AM revealed the facility did not notify him of Resident#36's possible pneumonia and order for antibiotic therapy. The family member reported he did not know if he would have agreed to antibiotic therapy but wanted to be informed and consulted when Resident #36 became ill. Interview with Nurse #1 on 01/23/14 at 11:29 AM revealed the physician or nurse practitioner would notify family members when a resident condition changed. Nurse #1 did not know if Resident #36's family member received notification of the possible pneumonia and antibiotic therapy. Interview with the Nurse Practitioner (NP) on 01/23/14 at 12:34 PM revealed she did not notify Resident #36's family member. The NP explained she was not in the facility at the time the significant change or orders for treatment occurred. Interview with the acting Director of Nursing on 01/23/14 at 1:35 PM revealed Resident #36's family member should receive notification of the significant change in condition but did not know who was responsible for the notification. Interview with the Quality Assurance (QA) Director on 01/23/14 at 1:48 PM revealed the medical staff notified family members and legal representatives when a significant change occurred. The QA Director explained there was no written policy which designated responsibility of notification. Interview with the Medical Director on 01/23/14 at 2:03 PM revealed the facility's medical staff notified family members of significant changes unless the change occurred after work hours or on weekends. The Medical Director reported Resident #36's family member should have received notification of the condition change and order for antibiotics.