Every finding on record at Bladen East Health and Rehab

Based on record review and staff interviews, the facility failed to employ a director of food and nutrition services that met the minimum qualifications. This had the potential to affect 58 of 62 residents who consumed food. Findings included: During an interview on 6/15/26 at 10:36 AM with the Dietary Manager she revealed that she did not have any of the following: certification as a dietary manager or food manager, national certification for food service management and safety, an associate's or higher degree in food service management or in hospitality, 2 or more years of experience in the position of Director of Food and Nutrition Services in a nursing facility setting. The Dietary Manager stated that she was not Serv Safe certified and that she was waiting for the Administrator to enroll her for the dietary/food manager training. She stated that she started in her current position on 12/8/25 after the former Dietary Manager left abruptly and that she had been a cook for around 10 years. The Dietary manager reported that the Corporate Registered Dietitian (RD) came to the facility weekly and she was also available over the phone if the Dietary Manager needed to call the RD.An interview was conducted with the RD on 6/17/26 at 9:30 AM. She reported that she was the Corporate RD and oversaw another building and came to the facility once a week every Thursday. The RD stated that she had been training the Dietary Manager on what was needed, such as hour of sleep snack and that she had not wanted to overwhelm her with the dietary/food manager course initially, and she would be registered for the food manager training soon.During an interview with the Administrator on 6/18/26 at 8:55 AM she stated that she thought the Dietary Manager had a grace period to be certified and that she had since enrolled the Dietary Manager in the food manager course since she became aware on 6/17/26 that the Dietary Manager did not meet the minimum qualifications.

Based on observation and staff interviews, the facility failed to ensure the Skilled Unit Medication Cart #1 was secured while unattended for 1 of 4 medication carts observed for medication storage (Skilled Unit Medication Cart #1).The findings included: On 06/16/2026 at 4:29 PM, Nurse #1 was observed walking on an adjacent hall away from the Skilled Unit Medication cart. The cart was not in her line of sight because we had to turn the corner from another hall to get back to her cart. When the Nurse and this surveyor walked back to her cart at 4:31 PM, due to a question about a medication she administered, the lock button was not pushed in to secure the cart. The Nurse pushed the lock button in when it was bought to her attention. During an interview on 06/16/2026 at 4:31 PM, Nurse #1 stated she usually locked her cart, but she forgot to lock her cart when she walked away. An interview with the Director of Nursing (DON) was conducted on 06/16/2026 at 4:33 PM. The DON stated she expected all nurses to make sure all carts were locked prior to walking away. An interview with the Administrator was conducted on 6/17/2026 at 11:09 AM. The Administrator stated she expected the nurses to lock their carts prior to leaving their carts.

Based on observations, record review, and resident, staff and Medical Director interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #2 hit Resident #1 with a grabber-reacher tool (a tool that assists people reach something to pick it up) multiple times on the right hand, injuring his right 4th digit fingernail. This affected 1 of 4 residents reviewed for abuse (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included multiple sclerosis, psychosis, anxiety disorder and mood disorder due to known physiological condition. Resident #1's Minimum Data Set (MDS), dated [DATE], revealed he was cognitively intact and had no behaviors. He had impairment on both sides of his upper and lower extremities and was dependent on staff for his activities of daily living and independently operated his manual wheelchair. Resident #1's care plan, last revised 01/02/25, indicated Resident #1 had been care planned for manipulative behaviors and physical and verbal aggression towards staff and other residents related to his anger and poor impulse control. Interventions included education to the resident on the importance of avoiding known triggers that could lead to the escalation of retaliatory physical aggression towards other residents, or by other residents to himself. Resident #2 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and dementia without behavioral disturbance. Resident #2's quarterly MDS, dated [DATE], revealed he was cognitively intact and had no behaviors. He had impairment on one side of his lower extremities, was dependent on staff for bed to chair transfers, and independently operated a manual wheelchair. Resident #2's care plan, last revised 02/18/25, revealed Resident #2 had been care planned for his potential to be physically and verbally aggressive with staff and other residents and making false statements/accusations related to anger and poor impulse control. Interventions included de-escalation of the resident's physical and verbal aggression towards staff and other residents to ensure safety. An Initial Allegation Report for resident-to-resident abuse was completed on 03/11/25 after Resident #2 struck Resident #1 with a grabber-reacher tool and resulted in Resident #1 sustaining an injury to his right 4th digit fingernail. Notifications were made to the local law enforcement agency and to the State Agency on 03/11/25. A Progress Notes note written by Nurse #1 on 03/11/25 at 5:45 PM. in Resident #1's medical record detailed the altercation on 03/11/25 (no time noted) between Resident #1 and Resident #2. The nurse wrote that Resident #2 had been observed by another resident (Resident #6) striking Resident #1 with his reacher-grabber tool which caused injury to Resident #1's right 4th digit fingernail. The nurse indicated that wound care had been provided to Resident #1's finger and stated that a local law enforcement officer came to the facility and took statements from residents involved in the altercation as well as statements from witnesses of the incident. A Progress Note written by Nurse #4 on 03/11/25 at 6:18 PM in Resident #2's Medical Record detailed the 03/11/25 altercation between Resident #2 and Resident #1. The nurse stated Resident #2 said he had been in his room, watching television, when Resident #1 went into his room and started talking s**t to him and told him (Resident #2) that he (Resident #1) was going to f**k him up and that Resident #1 had swung at him. The nurse wrote that Resident #2 told her he had defended himself by hitting Resident #1 with his reacher-grabber tool. The Investigation Report, submitted on 03/14/25 by the Administrator, indicated she substantiated the allegation of resident-to-resident abuse after the investigation concluded. A summary of the incident details included, .All witness statement support incident occurring in hallway outside of [Resident #2's] room. Blood was noted on the floor in the hallway. [Resident #2] continued to state throughout the investigation that [Resident #1] kicked open his door, busted into his room, and asked him if he wanted to fight. None of the witness statements support this. [Resident #1] was in sight of staff in the hallway where they witnessed [Resident #2] hitting him with the reacher . The local law enforcement officer's Incident/Investigation Report, dated 03/11/25, indicated he had been dispatched to the facility and once there, took statements from Resident #1, Resident #2 and witnesses to the altercation. The officer reported Resident #1 informed him he had approached Resident #2 and told him he had a big head and then Resident #2 told him that he had a big head and then Resident #2 began to swing a reacher-grabber tool, hitting him (Resident #1) in his knee and cut his finger with the tool. The officer then spoke with Resident #2 who informed him that Resident #1 always called him names and threatened him. Resident #2 told the officer that Resident #1 had entered his room and told him that he was going to mess him up so he began to hit Resident #1 because he had been scared for his safety. The report indicated the officer also took a statement from Resident #6 who had informed the officer he had observed both of the residents talking in the hallway before Resident #2 hit Resident #1 with his reacher-grabber tool. The officer acknowledged in his report that he had closed the report as closed by exception, victim refused to cooperate. An interview was conducted with Resident #6 on 04/02/25 at 12:58 PM. Resident #6 was coded as being cognitively intact on his 02/01/25 quarterly MDS. Resident #6 explained that on 03/11/25 he had observed Resident #1 in his wheelchair approach Resident #2 who had been sitting in his wheelchair outside of his room in the hall and in front of the doorway to Resident #2's room. As he continued to observe the two residents, Resident #6 described how Nurse #2 approached him as he sat in the hall and said he pointed to the two residents (Residents #1 and Resident #2) in the hall. He said Nurse #2 walked towards both of the residents and then the next thing he (Resident #6) knew, Resident #2 swung his reacher-grabber tool and struck Resident #1 with it and observed Resident #1 swinging his arms. Resident #6 indicated he thought Resident #1 had done that in self-defense from Resident #2. Resident #6 indicated that he did not hear any of the conversation between the two residents but could hear Resident #1 hollering. An interview was conducted with Nurse #2 on 04/02/25 at 2:55 PM. Nurse #2 confirmed she had worked from 3:00 PM until 11:00 PM on 03/11/25. Nurse #2 stated she had been walking down the Skilled A and B hall when Resident #6 stopped her and said, hey, they're fighting and pointed towards Resident #1 and Resident #2. She stated she looked in the direction of the two residents who were outside of Resident #2's doorway, in the hall. Nurse #2 explained Resident #1 was observed sitting in his wheelchair and facing Resident #2 who had been sitting in his wheelchair in the hallway, outside of his room's doorway. Nurse #2 further explained she immediately began walking towards the two residents and before she could get to them, Resident #2 began hitting Resident #1 with his reacher-grabber tool and that Resident #1 was observed trying to back up, holding his arms in a way to deflect the blows. Nurse #2 stated by the time she reached the residents, Resident #2 struck Resident #1 three to four more times with his reacher-grabber tool. She explained she pulled Resident #1's wheelchair away from Resident #2 and started to take him to his room when she noticed he was bleeding from his finger. Nurse #2 explained Resident #1's nurse provided treatment to his injured finger. Nurse #2 stated she did not know how the argument had started. Nurse #2 stated she provided a statement to the local law enforcement officer when he arrived at the facility. When asked about the residents' level of care required to perform their activities of daily living (ADL), the nurse stated Resident #1 was totally dependent on staff for his ADL and stated Resident #2 required extensive assistance with his ADL. She stated both of the residents were able to operate their wheelchairs independently after being placed in the wheelchairs using a mechanical lift. Nurse #2 confirmed both residents were alert, oriented and able to make their needs known. She stated both residents were known to be argumentative with each other, as well as with other residents and staff. An observation and interview were conducted with Resident #1 on 04/02/25 at 10:27 AM. Resident #1 explained that on 03/11/25, around 4:00 PM, he had started rolling down the hall in his wheelchair to visit another resident. Resident #1 further explained he rolled up to Resident #2 who had been sitting in his wheelchair in the hall, outside the door to his room, and told him, you have a big head. Resident #2 responded by saying to him, you have a big head. Resident #1 then asked Resident #2 if he wanted to fight and stated Resident #2 said no. Resident #1 stated Resident #2 then grabbed his reacher and started hitting him with it and he had tried to block Resident #2's blows with his arms. When asked about his relationship with Resident #2, Resident #1 declared that he did not like Resident #2 because he always starts trouble and that he had never liked him. When asked how he felt after being hit by Resident #2, Resident #1 said, I ain't scared of that boy. When asked about the injury he sustained during the incident, Resident #1 held up the fingers on his right hand and said they were fine and could not remember which finger had been injured. An observation of the fingers on his right hand revealed no outward signs of a healing/healed injury to any of the fingers on his right hand. An interview was conducted with Resident #2 on 04/01/25 at 3:10 PM. Resident #2 was observed sitting in his wheelchair in his room. Also present at this time was Nursing Assistant #2 who was providing a one-to-one observation. Resident #2 acknowledged he did not like Resident #1 and said that Resident #1 had told him that he hated white people. Resident #2 explained that on 03/11/25, at some time in the late afternoon, he had been napping while seated in his wheelchair in front of the TV in his room. He said Resident #1 kicked his door in, came into his room and began to fight with him. Resident #2 stated Resident #1 did not say anything to him and remained adamant he had struck Resident #1 with his grabber-reacher tool as a means of self-defense. When Resident #2 was informed that witness accounts of the incident placed both residents out in the hallway, Resident #2 maintained his story that Resident #1 kicked the door to his room open, entered the room and began to fight with him. Resident #2 stated he had witnesses that saw this and said to talk with Nursing Assistant (NA) #1. Resident #2 indicated that he was not afraid of Resident #1 and he had just been trying to protect himself after Resident #1 came into his room. An interview was conducted with NA #1 on 04/02/25 at 3:23 PM. NA #1 confirmed that she had worked from 3:00 PM until 11:00 PM on 03/11/25. NA #1 explained she had been walking towards the Nurses' Station on the Skilled A and B halls when she observed Resident #1 rolling down the hall in his wheelchair and headed towards where Resident #2 was seated in his wheelchair, outside of the doorway to his room. She thought Resident #1 would go on past Resident #2 but then she observed Resident #1 stop and begin to roll backwards, towards Resident #2. NA #1 stated she knew the two of these residents did not get along and started walking towards the two of them to prevent an altercation. Before she could get to them, she said she observed Resident #2 grab his reacher-grabber and swing at and strike Resident #1. NA #1 stated by the time she got to them, Nurse #2 had also arrived and explained that between the two of them, they got the two residents separated. As Nurse #2 pushed Resident #1 to his room, NA #1 said she told Resident #2 that he could not hit people and said he (Resident #2) told her that he could not help it because Resident #1 had told him he was going to beat his a**. She stated she then observed some blood on one of Resident #2's hand, assumed it had been from the altercation, and left him to inform a nurse. At the Nurses' Station, she spoke with the Unit Manager, Nurse #3. An interview was conducted with Nurse #3, on 04/02/25 at 1:45 PM. Nurse #3 confirmed that she was the Unit Manager for the Skilled A and B halls. Nurse #3 explained on 03/11/25 she became aware of the incident between Resident #1 and Resident #2 when she came out of her office located behind the Nurses' Station desk and heard yelling down the hall. Nurse #3 stated when she looked towards the commotion, she saw both residents in the hall, outside of Resident #2's room. She explained she observed Resident #2 swat Resident #1 repeatedly with his grabber-reacher as Resident #1 was trying to shield himself from the blows. She explained that Resident #1 did not have full control of his upper extremities because of his medical diagnosis. She described that Resident #1 sat in a semi-reclined position in his wheelchair and how he would not have been able to hit Resident #2 in retaliation if he wanted to. Nurse #3 described both residents as alert and oriented and stated how neither of them could get up out of their beds without the total assistance of staff using a mechanical lift to do so. She said that Resident #1 often rolled himself via wheelchair to other areas of the facility and enjoyed visiting with other residents and went to therapy and activities, all of which were located past Resident #2's room. Nurse #3 described Resident #2 as more stationary and said he often sat outside of the door to his room or outside in the smoking courtyard. Nurse #3 said Resident #2 had been known to make racist or disrespectful remarks to other residents and staff and would often not tell the truth when asked about incidents he may have been involved in. She also said that while Resident #2 hit Resident #1 during this incident, Resident #1 could be the instigator during arguments with residents and staff and stated that he sometimes feeds off being the victim as well and that he was not always truthful. Nurse #3 indicated that Resident #2's reacher-grabber tool had been removed from him by the Human Resources Director and he (Resident #2) had been placed on a one-to-one observation while out of his bed for his safety as well as the safety of other residents. An interview was conducted with the Human Resources Director on 04/02/25 at 2:39 PM. The Human Resources Director confirmed she had worked on 03/11/25 and stated the incident between Resident #1 and Resident #2 had occurred just prior to her clocking out for the day around 5:30 PM. The Human Resources Director stated after she clocked out and started walking back to her office, she heard Nurse #3 say, Oh my God, Resident #2 is hitting Resident #1. The Human Resources Director explained that she did not see the interaction between the two residents. She said she told Nurse #3 that someone needed to get Resident #2's reacher-grabber tool away from him. She stated she walked down to his (Resident #2's) room and asked him to let her have it. She stated that before he gave it to her, he told her, he started it. The Human Resources Director said she removed the grabber-reacher without incident and told him to stay in his room until everything got sorted out. An interview was conducted with the facility's Medical Director on 04/03/25 at 9:25 AM. The Medical Director explained he had been made aware of the 03/11/25 incident that involved Resident #1 and Resident #2. After talking with the residents, he felt that Resident #1 was the instigator of this incident, and Resident #2 the aggressor. He further explained that both residents lacked the appropriate coping mechanisms for handling a situation when anger and aggression were triggered. He stated Resident #2 had very little threshold for controlling his anger and impulsivity, and he believed Resident #2 was not a danger to himself or others provided he remain on the one-to-one observation. The Medical Director stated it was his expectation the facility provide a safe environment for all the residents who reside there and thought as long as Resident #2 remained on a one-to-one observation when he was out of his bed, that the facility was providing that safe environment. An interview with the Administrator was conducted on 04/03/25 at 10:54 AM. The Administrator stated that since the incident between Resident #1 and Resident #2 on 03/11/25, Resident #2 remained on a one-to-one observation until he went to bed at night. She explained that Resident #2 could not get out of bed by himself and therefore the one-to-one observation was not continued while he was in bed. She explained nursing staff did safety checks of him every 15 minutes. The Administrator further explained staff would continue to monitor Resident #1 and would assist him past Resident #2's room when he wanted to visit friends or attend therapy or activities, all of which were located past Resident #2's room. When asked how she thought this incident might have occurred, the Administrator stated no one could really say. She explained Resident #1 told her that he had planned on visiting his friend who resided across the hall from Resident #2, and she believed Resident #2 had been waiting in his doorway to confront Resident #1 because he thought he (Resident #1) was out to get him. The Administrator stated they tried to keep Resident #1 from any opportunity for him to antagonize Resident #2 as well as trying to keep him safe from Resident #2's aggression. The Administrator explained she put a Plan of Correction (POC) in place after meeting with her Interdisciplinary Team and provided a copy of it for consideration. She stated monitoring for this POC included keeping Resident #2 on a one-to-one observation for the duration of his stay at the facility and it would be reviewed in their monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Administrator explained she did not include a facility-wide in-service training on their Abuse policy as she felt strongly it did not occur because of staff error. She also felt the staff executed their Abuse policy and procedures as they should have after the incident occurred. The Administrator explained she had issued Resident #2 a 30-day notice of discharge on 03/14/25 and discussed the incident between the two residents at an Ad Hoc QAPI meeting on 03/11/25. She had plans to continue to bring the situation to their monthly QAPI meetings until a safe discharge location for Resident #2 could be arranged. The facility provided a corrective action plan that was not acceptable to the State Agency as it did not include the following required components: address how the facility will identify other residents having the potential to be affected by the same deficient practice; address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; and indicate how the facility plans to monitor its performance to make sure that solutions are sustained.

Based on observations and staff interviews, the facility failed to label and date resident's personal food items and discard expired food items stored in 1 of 1 nourishment refrigerator. This practice had the potential to cause foodborne illnesses. Findings included: An observation of the nourishment refrigerator with the facility's Dietary Manager on [DATE] at 1:28 PM revealed the following: a. 2 yogurt cups with the expiration date of [DATE] b. A Ranch dressing bottle with the expiration date of [DATE] c. Partially eaten chicken wings and corn on the cob in a disposable plate with no date or label d. A 2-liter soda bottle approximately two thirds full with no label or date e. A plastic bottle with orange colored liquid with no label or date The Dietary Manager, who was present during the observation, stated that nursing staff were supposed to ensure the food items were labeled and dated and that expired items were discarded. An interview was conducted on [DATE] at 1:30 PM with the Assistant Director of Nursing (ADON) when she came into the nourishment room and placed the food items in the trash can. The ADON stated that nursing staff should have labeled and dated the food items before placing them in the refrigerator and discarded any expired food items. An interview was conducted with the facility Administrator on [DATE] at 2:14 PM. The Administrator stated that if there were any expired food items they should have been thrown out and all foods should have been labeled and dated before being placed in the refrigerator.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed for restraints (Resident #15 and Resident #62). The findings included: 1. Resident #15 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #15 was cognitively intact, and a physical restraint of a bed rail was used daily. During an interview with Resident #15 on 03/03/2025 at 11:48 AM. The resident stated she did not have bedrails on her bed. An observation of Resident # 15's bed on 03/03/2025 at 11:48 AM did not reveal any bed rails. An interview with the MDS Coordinator was conducted on 03/04/2025 at 12:44 PM. She stated she was not at the facility at the time the screening was completed for Resident #15. She reported Resident # 15 did not have bedrails on her bed and the use of bedrails as a restraint was coded in an error on the MDS. An interview with the Director of Nursing (DON) was conducted on 03/04/2025 at 1:03 PM. The DON stated she completed Resident # 15's MDS assessment because the MDS Coordinator was on leave in December 2024. She reported the facility was restraint free and Resident #15 did not use bedrails on her bed. She stated the use of restraint coding on MDS was an error. An interview with the Administrator was conducted on 03/05/2025 at 3:00 PM. The Administrator explained she and the DON had completed MDS screenings while the MDS Coordinator was on leave in December 2024. She stated the use of restraint coding on MDS was an error and she expected the MDS to be coded correctly. 38702 2. Resident #62 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] noted Resident #62 was cognitively intact, and a physical restraint of a bed rail was used less than daily. The care plan dated 02/27/2025 had focus for activity of daily living (ADL) self-care performance deficit. The care plan did not include any interventions for physical restraint or bed rail use. An observation of Resident #62's bed on 03/03/2025 at 10:58 AM did not reveal any bed rails. An interview with Resident #62 was conducted on 03/03/2025 at 10:58 AM. The Resident stated he had never had rails on his bed. An interview with the MDS Coordinator was conducted on 03/04/2025 at 12:44 PM. She stated physical restraints should not be coded because the facility was restraint free. She was not at the facility at the time the screen was completed for Resident #62. She stated it was a coding error because Resident #62 has never had bedrails. An interview with the Director of Nursing (DON) was conducted on 03/04/2025 at 12:51 PM. The DON stated the facility was restraint free and it was a coding error because Resident #62 had not had rails on his bed. An interview with the Administrator was conducted on 03/04/2025 at 1:17 PM. The Administrator explained she and the DON had completed MDS screenings while the MDS Coordinator was on leave in December. The Administrator also explained the facility was restraint free and Resident #62 did not have bedrails. She stated she expected the MDS to be coded correctly.

Based on record review, interviews with the Responsible Party (RP) and staff, the facility failed to provide copies of the resident's medical records after a request for 1 of 3 sample resident reviewed for medical record access (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] Review of Resident #1's Admission Record completed on 01/25/2023 revealed a family member was listed as her RP and Power of Attorney. The discharge Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with severe impairment in cognition During a telephone interview on 10/08/2024 at 10:15 AM, the RP stated she spoke to the Business Office Manager about 2 months ago to request Resident #1's copies of the medical records and she had not received copies of the medical records. RP stated that she did not recall the Business Office Manager asking her to come to the facility to sign a release form to receive copies of the medical records.The RP added that she did not know the reason the facility had not sent her Resident #1's copies of the medical records. During an interview on 10/08/2024 at 11:50 AM, the Business Office Manager confirmed that the RP requested Resident #1's copies of the medical records 2 months ago verbally. The Business Office Manager stated that she had not sent the copies of medical records to the RP because she was waiting for the RP to come to the facility to sign a release form before she gave her the copies of the medical records. She did not notify the medical record staff that the RP had requested Resident # 1's copies of the medical records. The Business Office Manager stated she was not aware that a resident or the RP could request the copies of the medical records verbally and she was required to provide them within 2 working business days. The Business Office also stated that next time the RP requests copies of the medical records, she will refer to the request to the medical record staff, and she (medical records staff) will send copies of the medical records requested to the RP within 2 business working days. During an interview on 10/08/2024 at 12:20 PM, the Medical Records staff stated that she did not recall the Business Office Manager notifying her to send the copies of medical records to Resident #1's RP. She stated that if the Business Office Manager had notified her of Resident #1's RP request for the copies of the medical records she would have sent them within 2 working business days per the policy. During an interview on 10/08/2024 at 1:40 PM, the Administrator explained when copies of medical records were requested by the RP, the facility was required to send the copies of the records requested within 2 working business days. She stated the Medical Records staff should have sent copies of the medical records to the RP or asked the RP to come to the facility to pick copies of the medical records up within 2 working business days.

Based on record review and staff interviews, the facility failed to provide care in a safe manner resulting in a fall from a bed that was in the elevated position which resulted in a closed displaced fracture of left clavicle shaft, closed fracture of the left third, fourth and fifth ribs and hospitalization for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was initially admitted to the facility on [DATE] with the last readmission on 9/6/2024. Her diagnoses include diabetes, dementia and heart failure. Resident #1's significant change Minimum Data Set Assessment (MDS) dated [DATE] coded the resident as moderately cognitively impaired and dependent with bed mobility and toileting. Resident #1 was also coded for hospice care. Resident #1's care plan, last updated 6/10/24, revealed the staff identified the resident needing assistance with her activities of daily living due to heart failure. She required extensive assistance by 1 staff for toileting and incontinence care. The care plan also indicated Resident #1 was at risk for falls related to weakness and non-compliance with asking and waiting for assistance. Resident #1's medical records revealed physician order dated 8/2/24 that indicated to admit Resident #1 to hospice services for diagnoses of hypertensive heart and chronic kidney disease with heart failure. Resident #1 had an order dated 8/2/24 for morphine sulfate 0.25 milliliter by mouth every 2 hours as needed for end-of-life pain/discomfort and shortness of breath. Resident #1 was taking morphine for pain as needed prior to the fall injury on 9/4/24. An incident report dated 9/4/24 stated nursing assistant (NA) #1 was in the process of changing Resident #1 and turned away from the resident to get incontinent supplies from the chair. When NA #1 turned back Resident #1 had fallen off the bed to the floor landing on her left side. Resident #1 was assessed for injuries and Resident #1 was unable to rate her pain or describe what hurt. Resident #1 was grabbing her left shoulder stating, it is killing me, help me please. Vital signs were taken, and Resident #1 was sent to the hospital for further evaluation. During an interview on 9/17/24 at 11:42 AM with Nursing Assistant #1 (NA) #1, she indicated she went to provide incontinence care for Resident #1 on 9/4/24 at approximately 5:30 pm and she placed clean bed sheets on Resident #1's wheelchair which was inside the room by the door. She explained she raised Resident #1's bed to her waist level (NA #1 indicated she is 5 feet 8 inches tall), to provide incontinence care. She noticed the bed sheet and under pad were wet too and she tucked the sheet and under pad under Resident #1 who was turned away from her so that she could place a clean bed sheet on the bed. She then turned her back away from Resident #1 to grab the clean sheet which was on the wheelchair by the door and when she turned around Resident #1 had fallen to the floor on the opposite side of the bed. NA #1 went to the doorway and called Nurse #1 who was in the hallway and Nurse #1 came to the room to assess Resident #1. During an interview on 9/17/24 at 11:56 AM with Nurse #1, she revealed she was the primary nurse for Resident #1 when she fell off the bed on 9/4/24. She indicated she became aware of the fall after NA #1 called for assistance from Resident #1's doorway. When she walked into the room Resident #1 was on the floor close to the window and the bed was raised. Resident #1 was saying help me but could state where the pain was. Nurse #1 stated she called emergency services who came to transport Resident #1 to the hospital for further evaluation. Resident #1's pain level on the day of the fall on 9/4/24 during second shift (3 pm- 11pm) was documented as 9 out of 10 in the medication administration record (MAR). Hospital discharge summary dated 9/6/24 indicated Resident #1 was seen at the emergency department (ED) on 9/4/24 after a fall at a nursing home. Resident #1 was found to have fractures of the left third, fourth and fifth ribs as well as a left clavicle fracture. The left arm was placed in a sling at the ED. Computed tomography (CT) scan and X- rays completed at the ED revealed negative acute abnormality of the head, cervical spine, pelvis and left knee. Urinalysis showed leukocytes (sign of urinary tract infection) and Resident #1 was given a dose of intravenous Rocephin (antibiotic). Resident # 1 was hospitalized for 2 days and was discharged to the facility on [DATE] with instructions to continue adequate analgesia (pain management), sling to the left upper extremity, continue with incentive spirometer-respiratory therapy, and follow up with orthopedic outpatient in 1 - 2 weeks. Resident #1 was also prescribed oral antibiotics (cefdinir) for 5 days for urinary tract infection, and Breo Ellipta inhalation (breathing treatment) for shortness of breath as needed once a day. Review of Resident #1's MAR revealed Resident #1 had not required the breathing treatments since she was readmitted to the facility on [DATE] - 9/17/24. Resident #1 medication administration record (MAR) revealed Resident #1 received morphine 0.25 milliliter on 9/7/24 at 3:57 PM for 6/10 pain, and Percocet 1 tablet on 9/11/24 at 2:30 PM for 10/10 pain, 9/12/24 at 6:34 PM for 5/10 pain and on 9/16/24 at 6:23 AM for 4/10 pain. Documentation of Resident #1's pain assessment on all three shifts from 9/6/24 to 9/17/24 were documented as follows: 6/10 on 9/7/24, 10/10 on 9/11/24, 5/10 on 9/12/24, 4/10 on 9/16/24. All other pain assessments completed from 9/6/24 to 9/17/24 were 0 out of 10. During survey on 9/17/24 at 1:00 PM and 9/18/24 at 10:40 AM Resident #1 was observed in bed with a sling to the left upper extremity, her bed was noted in the lowest position and two fall mats were at bedside. Resident #1 did not appear to be in any pain or distress. She denied pain when asked if she was in any pain, but she was unable to describe what happened on the day she fell or why she had the sling on. During an interview on 9/18/24 at 11:36 AM with the Director of Nursing (DON), she indicated Resident #1 fell while being provided care by NA #1. The DON stated NA #1 should have placed all the items she needed at bedside before she started providing care for Resident #1 or she should have used the call light for another employee to come and get her the bed sheet from the wheelchair which was close to the door. The DON also stated NA #1 should not have left Resident #1 unattended while the bed was in an elevated position. An interview was conducted on 9/18/24 at 11:50 AM with the Administrator. She stated NA#1 should not have left Resident #1 unattended while the bed was in an elevated position. The Administrator verbalized NA #1 should have positioned Resident #1 midline in bed and lowered the bed to the lowest position before stepping away to grab the clean bed sheets.

Based on record review, observations, staff and physician interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 2 residents reviewed for respiratory care (Resident #15). The findings included: Resident #15 was initially admitted to the facility on [DATE] with the last readmission on 10/16/23. Her diagnoses included chronic obstructive pulmonary disease and heart failure. Resident #15's care plan initiated 2/25/23 indicated Resident #15 was on oxygen therapy related to congestive heart failure. Interventions included oxygen at 2 liters per minute via nasal cannula. A Physician's order dated 9/18/23 indicated administer oxygen at 2 liters/minute via nasal cannula for oxygen saturations less than 90%. Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively intact and received oxygen therapy. Diagnoses included heart failure and chronic obstructive pulmonary disease. During observation on 2/26/24 at 10:23 AM Resident #15 was observed with the oxygen nasal canula. Resident #15's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. During observation on 2/26/24 at 12:24 PM Resident #15 was observed with the oxygen nasal canula. Resident #15's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. During observation on 2/26/24 at 2:07 PM Resident #15 was observed with the oxygen nasal canula. Resident #15's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. Resident #15's oxygen regulator was verified with the Staff Development Coordinator (SDC) to be set at 3.5 liters/minute. During an interview on 2/26/24 at 2:07 PM with the SDC, she stated Resident #15 had a physician order for oxygen at 2 liters/minute via nasal cannula for oxygen saturations less than 90% and oxygen regulator should have been set at the physician ' s ordered rate. During an interview on 2/26/24 at 3:00 PM with Nurse #1, she stated Resident #15 had a physician order for oxygen at 2 liters/minute via nasal cannula for oxygen saturations less than 90%. Nurse #1 stated she had not checked Resident #15 ' s oxygen regulator since she started her shift at 7:00 AM. She verbalized she should have checked the regulator earlier when she went to check on Resident #15 and ensured it was set at the physician ' s ordered rate. During an interview on 2/28/24 at 2:34 PM with facility Administrator she stated nurses were supposed to check the oxygen concentrator to make sure it was set at the doctor's ordered rate. An interview was conducted on 2/28/24 at 2:49 PM with the Director of nursing (DON). The DON explained Nurse #1 Nurse should have checked the oxygen concentrator upon entering Resident #15's room during earlier medication administration and assessment to ensure it was set per the doctor's orders. She verbalized nurses were to follow physician ' s orders and obtain another order if they needed to titrate the oxygen rate. An interview was conducted on 2/29/24 at 11:10 AM with the facility Physician. He stated Resident #15 was a hospice patient and was receiving oxygen for comfort. The Physician stated nursing staff were to follow physician orders as given and to call the physician if they needed to titrate the oxygen rate.

Based on observations, record review, and staff interviews the facility failed to maintain dignity for a resident with an uncovered urinary drainage bag, with urine visible for public view from the hallway. The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want their urine visible to visitors, staff, and other residents, for 1 of 2 residents reviewed for dignity (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities, mental disorder. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #27 coded as moderately cognitively impaired was incontinent of bowel and bladder and had a foley catheter. The care plan dated 12/08/2023 had focus' of the residents impaired cognitive function or impaired thought processes and had a foley catheter in place. The interventions included to position catheter bag and tubing below the level of the bladder and away from the entrance room door. An observation of Resident #27 occurred on 02/26/2024 at 11:47 AM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An observation of Resident #27 occurred on 02/26/24 01:48 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An observation of Resident #27 occurred on 02/26/24 03:07 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An interview with Nursing Assistant (NA) #1 was conducted on 02/27/2024 at 3:02 PM. The NA stated she was the aide for Resident #27 that day and was aware he had a foley catheter. The Aide stated the foley bag should have been covered. The Aide stated she did not know why it wasn't covered but reported it to the nurse earlier that shift. The aide also stated she would get something to cover his foley drainage bag. An interview with Nurse #1 was conducted on 02/27/2024 at 3:07 PM. The Nurse stated the foley bag should have a cover over it or placed out of site to avoid dignity issues. The Nurse also stated she would get a new bag with a cover. An interview with the Director of Nursing (DON) was conducted on 02/27/2024 at 3:14 PM. The DON stated the residents' foley bags should be covered to avoid any dignity issues. The DON also stated the Residents foley bag is usually away from the door and out of site.

Based on observations, staff interviews and record review, the facility failed to keep a catheter drainage bag from touching the floor to reduce the risk of infection for 1 of 2 sampled resident reviewed for the use of a urinary catheter (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities, mental disorder. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #27 coded as moderately cognitively impaired was incontinent of bowel and bladder and had a foley catheter. The care plan dated 12/08/2023 had focus' of the residents impaired cognitive function or impaired thought processes and had a foley catheter in place. The interventions included to position catheter bag and tubing below the level of the bladder and away from the entrance room door. A review of the urology report dated 07/14/2022 revealed Resident #27 had a diagnosis of urinary retention with urinary tract infections (UTI) episodes and likely secondary to not completely emptying bladder. An observation of Resident #27 occurred on 02/26/2024 at 11:47 AM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag visible from the hallway. The catheter drainage bag was positioned on the floor. An observation of Resident #27 occurred on 02/26/24 01:48 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag visible from the hallway. The catheter drainage bag was positioned on the floor. An observation of Resident #27 occurred on 02/26/24 03:07 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag visible from the hallway. The catheter drainage bag was positioned on the floor. An interview with Nursing Assistant (NA) #1 was conducted on 02/27/2024 at 3:02 PM. The NA stated she was the aide for Resident #27 that day and was aware he had a foley catheter. The NA stated the foley bag should not have been touching the floor and she would adjust the drainage bag. An interview with Nurse #1 was conducted on 02/27/2024 at 3:07 PM. The Nurse stated the foley bag is usually on the side of the chair and off the floor and did not understand why it was on the floor. The Nurse also stated she had not noticed the bag on the floor that shift when she cared for the resident. An interview with the Director of Nursing (DON) was conducted on 02/27/2024 at 3:14 PM. The DON stated the residents' foley bags should be positioned off the floor to avoid any infection control issues. The DON also stated the Residents foley bag is usually away from the door, out of site and off the floor.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 10/28/2021 recertification survey. This was for a recited deficiency on the current recertification survey in accuracy of assessments. The continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F641: Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in Preadmission Screening and Resident Review (PASRR) Level II for 2 of 2 residents (Resident #19 and Resident # 38) reviewed for PASRR. During the recertification survey of 10/28/2021, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level II Preadmission Screening and Resident Review (PASRR). During an interview on 12/15/22 at 11:10 AM, the Administrator revealed the QAA committee meets monthly to discuss identified issues in the facility. She indicated PASRR level II was not discussed recently in the QAA meetings since she was not aware that the facility had concerns with coding PASRR level II accurately in the MDS.

Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Preadmission Screening and Resident Review (PASRR) Level II for 2 of 2 residents (Resident #19 and Resident # 38) reviewed for PASRR. Findings included: 1. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder, bipolar disorder, and major depressive disorder. Record review indicated Resident #19 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 11/10/2021. The Annual Minimum Data Set (MDS) assessment dated [DATE] was answered No to question A1500 which asked if Resident #19 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. The Minimum Data Set Nurse responsible for completion was not available for an interview during the survey. During an interview on 12/15/2022 at 11:32 AM, Administrator stated she was responsible for completing the PASRR for the residents at the facility. She indicated Resident#19 had PASRR level II since 11/10/2021 and the MDS should have been coded. The Administrator indicated the MDS nurse failed to code the Annual MDS dated [DATE] to reflect Resident#19 had PASRR level II. She stated she did not know the reason the MDS nurse failed to code the MDS. 36573 2. Resident #38 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder, bipolar disorder, and major depressive disorder. Record review indicated Resident #38 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 6/20/22. The significant change Minimum Data Set (MDS) assessment dated [DATE] was answered No to question A1500 which asked if Resident #38 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. The Minimum Data Set Nurse responsible for completion was not available for an interview during the survey. An interview was conducted on 12/13/22 at 12:24 PM with the Administrator. The Administrator explained she completed the PASRR for the residents at the facility; however, the MDS nurse had failed to complete the coding on the Significant Change MDS dated [DATE]. The Administrator stated the MDS coding should have been completed for Resident #38 PASRR Level II and she did not know why it was not done.

Based on staff and resident interviews and record review the facility failed to provide the assistance of two person staff with transfers which resulted in a fall without injury for 1 of 3 residents reviewed for falls. (Resident #1) Findings included: Resident #1 was admitted to the facility on [DATE] with the diagnoses that included [CONDITION(S)], [CONDITION(S)], heart failure, hypertension, [CONDITION(S)], diabetes, [CONDITION(S)] and anxiety disorder Review of Resident# 1's nurse's aide care guide (Kardex) dated 09/29/2021 revealed Resident#1 required extensive assistance with 2 person's assists. Review of Resident #1's most recent assessment of risk for falls dated 01/31/2022 revealed the resident was high risk for falls. The resident scored 55(45 and higher is high risk). Review of Resident #1's most recent minimum data set (MDS) assessment dated [DATE] revealed he was assessed as cognitively intact. The MDS dated [DATE] and 02/09/2022 revealed Resident #1 required extensive, two-person physical assistance with transfers. Review of Resident #1's care plan initiated 06/15/2021 revealed the resident had a care plan for history of falls and remains at risk for falls due to poor balance and unsteady gait. The goals were measurable, and the interventions were appropriate. Review of an incident report dated 02/02/2022 revealed Resident #1 sustained a fall without injury while transferring from bed A to bed B. The incident report revealed Nurse # 1 attempted to transfer Resident # 1. Upon the resident standing during the transfer, the resident was noted to be weak and unable to move to the next bed (bed B). The nurse lowered the resident to the floor by the bed. During an interview on 05/03/2022 at 2:29 PM, Resident #1 stated in February 2022 he was still weak after being readmitted back to the facility from the hospital. He indicated Nurse #1 attempted to transfer him from bed A to bed B without assistance from another staff. Resident # 1 informed Nurse # 1 that he was weak and was not able to walk and assist with the transfer. The resident reported he told Nurse # 1 to find another staff member to assist with his transfer. Resident # 1 indicated Nurse # 1 insisted in transferring him without assistance from another staff member. The resident indicated upon the transfer from bed A to bed B Nurse #1 dropped him down on the floor. He reported Nurse # 1 then asked for assistance from another staff member to get him off the floor. Resident # 1 indicated he did not suffer any injuries as a result of the fall. During the phone interview on 05/03/2022 at 2:24 PM, Nurse #1 stated she cared for Resident #1 and knew him well. She indicated when the resident was readmitted back to the facility in February 2022, his bed remote was not functioning and he needed to be transferred from bed A to bed B. Nurse # 1 indicated she attempted to transfer Resident # 1 from bed A to bed B by herself without another staff assistance. Upon the transfer, the resident became weak and she lowered the resident to the floor. Nurse # 1 reported Resident # 1 did not sustain any injuries from the fall. During an interview on 05/03/2022 at 3:43 PM the Assistant Director of Nursing stated it was her expectation that the staff would provide assistance with transfers according to the resident ' s assessments needs for transfers. She further stated that Resident #1 required two-person assistance during transfers and there should have been two staff present during his transfer on 02/01/2022 when he sustained his fall with no injuries. During an interview on 05/03/2022 at 3:45PM The Administrator stated Nurse #1 was expected to provide assistance with transfers according to the resident's assessment needs for two-persons during Resident # 1's transfers on 02/01/2022

Based on staff interview and record review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) for residents with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: Resident #54 was admitted to the facility on [DATE]. A review of the facility's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) dated [DATE] had resident #54 coded as cognitively intact with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The comprehensive care plan dated 10/03/2021 had focus' of uses antidepressant medication [MEDICATION(S)] r/t Depression and Anxiety, a mood problem r/t Disease Process Anxiety Disorder, has depression r/t facility placement. A review of the North Carolina Department of Health and Human Services PASRR level I determination notification dated 11/20/2017 revealed the level I screen and PASRR number already exists for the above named individual. You may use the existing PASRR number until it expires. There was no expiration date. A review of Resident #54's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one (1) capsule by mouth one time a day related to major depressive disorder, single episode, unspecified. An interview with the Administrator was conducted on 10/26/2021 at 1:49 PM. The Administrator stated when there is a new mental health diagnosis, the resident should be screened for a PASRR level II. The Administrator also stated they have a new Social Worker (SW) that just started and did not know why the screening had not been completed but would handle the PASRR screenings until the SW is fully trained. An interview with the SW was conducted on 10/26/2021 at 3:00 PM. The SW stated she had only been at the facility for a short while, was learning her role as SW and had not been trained on the PASRR filing for the facility. She also explained the Administrator would be completing the task until she learns the process and was as not aware of the PASRR needed to be completed when there is a new mental health diagnosis. 2.Resident #46 was admitted to the facility on [DATE] with last re-entry on 1/08/20 after hospitalization . Review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASRR Level I Determination Notification letter dated 9/20/11 revealed that no further PASRR screening is required unless a significant change occurs with the individual's status that suggest a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #46's medical record revealed mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Administrator was conducted on 10/26/21 at 1:49 PM. The Administrator stated when there is a new mental health diagnosis, the resident should be screened for a PASARR level II. The Administrator also stated they have a new Social Worker (SW) that just started her employment with the facility, and she would not know why the screening had not been completed. The last Social Worker was no longer employed by the facility and the Administrator did not know why the previous Social Worker did not submit the screening for Resident #46. The Administrator stated she would handle the PASARR screening process until the new SW is fully trained. An interview with the Social Worker (SW), was conducted on 10/26/21 at 3:00 PM. The SW stated she had only been at the facility for a short while, was learning her role as SW and had not been trained on the PASRR filing process for the facility. She also explained the Administrator would be completing the task until she learns the process. She also stated she was not aware of the PASRR needing to be completed when there is a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3.Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was not currently considered by the state Level II PASRR process to have a serious mental illness. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's diagnosis/history sheet dated 10/26/2021 indicated Resident #3 was diagnosed with delusional disorders on 7/9/2019, generalized anxiety disorder on 1/10/2020 and unspecified dementia without behavioral disturbance on 4/6/2020. An interview with the Administrator was conducted on 10/26/2021 at 1:49 PM. The Administrator stated when there was a new mental health diagnosis, the resident should be screened for a PASRR level II. The Administrator also stated they had a new Social Worker (SW) that just started and did not know why the screening had not been completed but would handle the PASRR screenings until the SW was fully trained. An interview with the SW was conducted on 10/26/2021 at 3:00 PM. The SW stated she had only been at the facility for a short while, was learning her role as SW and had not been trained on the PASRR filing for the facility. She also explained that the Administrator would be completing the task until she learned the process and was not aware of the PASRR needing to be completed when there was a new mental health diagnosis. 4.Review of Resident #2's PASRR Level I Determination Notification dated 8/20/13 indicated that No further PASARR screening is required unless a significant change occurs within the individual's status which suggests a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was admitted to the facility 8/29/13 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The questions Has the resident been evaluated by Level II PASRR? and PASRR conditions were unanswered. Resident #2's Comprehensive Care Plan (not dated) focused on mood problems related to [CONDITION(S)] and anxiety with goals to receive antipsychotic medications at lowest effective dose and improve mood state. Review of Resident #2's medical record indicated a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Administrator was conducted on 10/26/2021 at 1:49 PM. The Administrator stated when there was a new mental health diagnosis, the resident should be screened for a PASRR level II. The Administrator also stated they had a new Social Worker (SW) that just started and did not know why the screening had not been completed but would handle the PASRR screenings until the SW was fully trained. An interview with the SW was conducted on 10/26/2021 at 3:00 PM. The SW stated she had only been at the facility for a short while, was learning her role as SW and had not been trained on the PASRR filing for the facility. She also explained the Administrator would be completing the task until she learned the process and was as not aware of the PASRR needing to be completed when there is a new mental health diagnosis.

Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident (Resident # 12) identified as PASRR Level II. Findings included: Resident #12 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after hospitalization with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review indicated Resident #12 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 5/02/19. The annual MDS assessment dated [DATE] was left blank to question A1500 which asked if Resident #12 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. An interview was conducted on 10/26/21 at 2:50 PM with the Director of Nursing and the Administrator regarding PASRR II documentation. The Administrator provide a copy of the Level II PASRR Review for Resident #12. The Administrator explained it was not coded correctly due to the previous staff not being thorough in documentation. The Administrator stated until new staff is trained, PASRR reviews will be done by Administration. An interview was conducted with the Social Worker (SW) on 10/26/21 at 3:00 PM. She explained she has only been in her position a few weeks. She stated she is learning and had not been trained on the PASRR filing for the facility. She explained the Administrator was completing the task for PASRR until she completed her training. An interview was conducted with the MDS Nurse on 10/27/21 at 9:36 AM. The MDS Nurse was not aware of the Level II PASRR for Resident #12. The MDS Nurse stated she was new in her position and was not informed Resident #12 had a Level II PASRR.

Based on observations and staff interviews, the facility failed to remove expired medications from 1 of 2 medication rooms (Medication room [ROOM NUMBER]). The findings included: Accompanied by Nurse #1, an observation of Medication room [ROOM NUMBER] was conducted on 10/26/21 at 10:00 AM. The observation revealed two (2) boxes of [MEDICATION(S)] Ear Wax Removal Aid with an expiration date of 07/21/21. Nurse #1 confirmed the expiration date. During an interview with Nurse #1 on 10/26/21 at 10:05 AM, Nurse #1 stated night shift nurses check the stock medications usually, but all nurses check them if they pull from the stock supplies. During an interview with the Director of Nursing (DON) and the Administrator on 10/26/21 at 2:50 PM, the DON stated there should have been no expired medications in any medication room. She explained the room had been recently checked by pharmacy and nursing. She stated the expired medication got overlooked in some kind of way; but should not have been left in any medication room. She also stated it was her expectation that all expired medications be removed and disposed per the facility protocols.

Based on observations, record review, and staff interviews, the facility failed to implement and intervention in the current care plan to obtain weekly weights for 4 weeks for 1 of 3 residents (Resident #218) observed for weight loss. Findings included: Resident #218 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Cerebral infarction (stroke), [MEDICAL CONDITION] (impairment to one side), [MEDICAL CONDITIONS], coronary [MEDICAL CONDITION], and diabetes. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #218 was independent with set up only for meals and had impairment on one side to upper and lower extremity and used a wheelchair. Resident #218 ' s weight was coded as 199 lbs., had a 5% weight lost in the last month, and was not on a prescribed weight loss regimen. Resident #218 was coded for a therapeutic diet, did not have any swallowing issues, and received two days of a diuretic medication (a medication to remove excess fluid from the body). A review of Resident #218 ' s care plan revealed an updated plan of care dated 05/09/19. Resident #218 had a plan of care for potential nutritional problems related to current no concentrated sweet (NCS) diet that may affect intake. The goal was to maintain adequate nutritional status as evidenced by maintaining weight within 10% of current body weight, no signs or symptoms of malnutrition, and consuming at least 50% of at least 3 meals daily through review date. The interventions included, in part, to provide and serve diet as ordered, Registered Dietician (RD) to evaluate and make diet change recommendations and weekly weights X 4 weeks every Wednesday on day shift. A review of the physician orders [REDACTED]. A record review revealed there was an order on the MAR for weekly weights on Wednesdays at 6:00 PM, however, only one weight was documented on 05/10/19. There was no weight documented for Wednesday, 05/15/19 or Wednesday, 05/22/19. A record review of the weights recorded in the computer revealed the last weight obtained for Resident #218 was on 05/10/19 with a weight of 198.8 lbs. A review of the Dietician Nutritional risk note written on 05/20/19 revealed the resident was placed on NSA (no sugar added) mighty shakes three times daily for weight stability and to provide 18 gm (grams) supplemental protein to help [MEDICATION NAME] his visceral protein stores. The note indicated the Dietician would continue to monitor his oral intakes and would follow up as indicated. The note further indicated no current weight was available. An interview was conducted with NA #3 on 05/22/19 at 10:45 AM. NA #3 stated the process for obtaining weights was the nurse would let them know at the beginning of their shift who needed a weight for that day. NA #3 stated she would weigh the resident and report the weight to the nurse. If the nurse instructed NA #3 to get a reweigh, she would reweigh the resident and let the nurse know, again, what the weight was. An interview was conducted with Nurse #7 on 05/22/19 at 2:30 PM. Nurse #7 stated if there was an order for [REDACTED]. Nurse #7 stated the nursing assistants would weigh the resident and let the nurse know what the weight was so they could record it on the MAR or TAR and in the computer system under weights. A review of the MAR and the weight log in the computer system was done on 05/23/19 at 9:00 AM. The weight for 05/22/19 was not recorded on the MAR or in the weight section of the computer system. An interview was conducted with the RD via phone on 05/23/19 1:30 PM. The RD reported she would have expected the order of obtaining the weights to be carried out as written due to his [DIAGNOSES REDACTED]. An interview was conducted with the DON on 05/23/19 at 1:40 PM. The DON reported her expectation would be that the nurse ' s obtained the weekly weights as ordered.

Based on observation, nurse practitioner (NP) interview, staff interview, and record review the facility failed to follow a physician order [REDACTED].#35) reviewed for unnecessary medications and failed to obtain a physician order [REDACTED]. 1. Record review revealed Resident #35 was admitted on [DATE]. The resident's documented [DIAGNOSES REDACTED]. 10/02/18 lab results documented Resident #35's hemoglobin was 11.7 grams per deciliter (g/dL), with normal being 12 - 16 g/dL), and Resident #35's hematocrit was 34.8%, with normal being 37 - 47%. The resident's 03/31/19 quarterly minimum data set (MDS) documented her cognition was intact, she exhibited no behaviors including resistance to care, she was independent with her activities of daily living, she was always continent of bowel and bladder, and she had no wounds. 04/04/19 lab results documented Resident #35's hemoglobin was 7.5 g/dL, with normal being 12 - 16 g/dL), and Resident #35's hematocrit was 24.2%, with normal being 37 - 47%. 04/09/19 lab results documented Resident #35's hemoglobin was 7.5 g/dL, with normal being 12 - 16 g/dL), and Resident #35's hematocrit was 24.4%, with normal being 37 - 47%. A 04/10/19 3:53 PM progress note documented, Seen by ____ (name of primary physician) today with new orders noted 3) Obtain H & H (hemoglobin and hematocrit) weekly starting on 04/16/19 .Lab requisition done for labs. The primary physician wrote the order to draw weekly H & H labs on 04/10/19, and the order was present in the resident's medical record. Review of Resident #35's medical record revealed there were no H & H values obtained for the resident between 04/10/19 and 05/15/19. A 04/17/19 physician progress notes [REDACTED]. I requested for her to have H & H weekly x 3. Results from yesterday are not available for review. Requested for resident to have iron studies. She was found to have [MEDICAL CONDITION] and significant B-12 deficiency with normal folate level Assessment: [MEDICAL CONDITION]: unclear etiology. status [REDACTED]. Despite her comorbidities I am going to continue to hold her antiplatelet therapy given her significant drop in hemoglobin of unclear etiology and reassess in the near future. A 04/17/19 3:54 PM progress note documented, Resident seen by ____ (name of primary physician) today with new order to follow up with him on 05/15/19 A 05/15/19 physician progress notes [REDACTED]. Unfortunately her weekly laboratories do not appear to have been drawn A 05/15/19 12:46 PM progress note documented, ____ (name of primary physician) in today to see resident and verbal order received to obtain H and H on 05/16/19 and follow-up with Nurse Practitioner (NP) next week. 05/16/19 lab results documented Resident #35's hemoglobin was 6.8 g/dL, with normal being 12 - 16 g/dL), and Resident #35's hematocrit was 22.8%, with normal being 37 - 47%. A 05/16/19 12:20 PM progress noted documented, Nurse called (NP) regarding H & H results. New order to send to hospital as outpatient for type and cross and 2 units of blood for transfusion, due to (hemoglobin) of 6.8. A 05/16/19 2:30 PM progress note documented a hospital nurse called the nursing home to inform staff that Resident #35's hemoglobin was 8.7 g/dL (and hematocrit was 24.8%) when drawn in the emergency room (ER). Resident will be transferred back to facility. During an interview with the NP on 05/21/19 at 2:40 PM she stated if she or the physician wrote an order to draw labs then she expected the facility to follow through and obtain the labs so the information could be used in making healthcare decisions for residents. During an interview with Nurse #7 on 05/22/19 at 2:10 PM she stated she could write telephone lab orders or the physicians sometimes wrote their own lab orders, the Assistant Director of Nursing (ADON) put the orders into the electronic system, staff drew STAT labs and lab technicians drew other labs, lab results were faxed to the facility's main fax machine, and the unit manager distributed the faxes. She reported if she had not received lab results in about 2 - 3 days she would call the lab to see what the problem was. During an interview with Nurse #2, an Unit Manager, on 5/22/19 at 2:27 PM she stated the nurse who took the lab order put them into the electronic system under the lab tab. She reported the ADON kept a lab notebook, and Tuesday and Thursday were the facility's lab days. She commented the ADON checked each morning for new lab orders. She explained lab techs drew labs on lab days, and direct care staff drew STAT labs. According to Nurse #2, lists of labs to be drawn each day were kept in three places: at the fax machine and each of the two nursing stations. She remarked sometimes as a unit manager she would distribute lab results. The Unit Manager reported by the next morning if no lab results were obtained then a staff member should make contact with the lab to find out why no results had been received (unless the facility was waiting on C & S results which would take longer to obtain). She stated she was not sure what caused the problem with collecting weekly H & H labs for Resident #35. During an interview with the ADON on 5/22/19 at 4:02 PM she stated she could not explain how the weekly H & H lab draws for Resident #35 got missed. However, she reported the physician realized that the labs were missed, and the resident exhibited no side effects. She explained Resident #35 was sent out to the ER for transfusion based on the hemoglobin value the facility obtained on 05/16/19. However, she commented when the resident got to the ER the ER drew its own lab which found the resident's hemoglobin to be 8.7. According to the ADON, she did not think the hospital transfused unless the hemoglobin was below 7. During an interview with the Director of Nursing (DON) on 05/23/19 at 2:07 PM she stated she expected labs to be drawn per physician orders. 2) Resident #217 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. The MDS 5-day assessment dated [DATE] revealed the resident was moderately cognitively impaired with no moods or behaviors indicated. Resident #217 required total dependence with two staff physical assistance with bed mobility, transfers and dressing, total dependence with one staff physical assistance with locomotion on the unit, independent with set up only with meals, total dependence with two staff physical assistance with toileting, and extensive assistance with one staff physical assistance with personal hygiene. Resident #217 had an impairment to one side to the lower extremity, used a walker and a wheel chair, had an indwelling urinary catheter and was always incontinent of bowel. He was coded as having a surgical wound. A review of all of the physician orders, Medication Administration Record [REDACTED]. An interview was conducted with Nurse #1 on 05/20/19 at 3:30 PM. Nurse #1 worked on 05/12/19 and 05/13/19. Nurse #1 reported she was familiar with Resident #217 and recalled the day she identified the resident ' s deep tissue injury to his heel. Nurse #1 reported she was informed by the nursing assistant (NA) that there was blood on his bed and it looked like he was bleeding from his heel. Nurse #1 reported she noted the resident had on ted stockings and blood was oozing from the ted stocking. She removed the teds stocking and noted there was a large dark purplish area that was not raised, noted to be bleeding and the resident complained of pain. She stated she cleaned it up and put skin prep on it and reapplied the ted stocking. Nurse #1 reported there was no order for the stockings and stated the resident was admitted with the ted hose on. Nurse #1 stated she noted they were on the resident when she did her initial head to toe assessment upon admission. Nurse #1 stated she did not do the admitting orders, the Unit Manager did them, and she assumed there was an order for [REDACTED].#1 stated the NAs would usually apply the teds and the nurse ' s check to see if they are on and then document in the MAR indicated [REDACTED]. An interview was conducted with the Assistant Director of Nursing (ADON) on 05/21/19 at 4:45 PM. The ADON reported she recalled Resident #217 wearing ted stockings. An interview was conducted with NA #3 on 05/22/19 at 10:45 AM who worked on 05/09/10, 05/12/19, and 05/13/19. NA #3 reported she recalled Resident #217 and she assisted him to the shower on 05/09/19 via a wheelchair. NA #3 reported Resident #217 had his ted stockings on and she removed them prior to the shower. NA #3 stated on Saturday 05/12/19 she went to see the resident to get him up for his shower and she noted there was blood on the bed under his right heel. She stated she told Nurse #1 and the nurse removed his ted stocking and cleaned up the wound on his heel. NA #3 reported she noted the resident had his ted stockings on when she came in in the morning on 05/12/19 and 05/13/19. An interview was conducted with the Director of Therapy (DOT) on 05/22/19 at 3:20 PM. The DOT confirmed Resident #217 was on therapy caseload and recalled that he wore ted stockings to his bilateral feet as she remembered placing nonskid socks over the ted stockings to assist with transfers safely. An interview was conducted with the Unit Manager (UM) on 05/23/19 at 10:20 AM. The UM reported she did the admission orders [REDACTED]. The UM stated the process of implementing orders from the hospital discharge records was to call the physician to verify the discharge orders. Once the orders were verified, the orders were then put into the computer system which would generate a MAR based on the orders that were put in the system. The UM reported there were no orders for the ted stockings and if the resident came in with them applied, the nurse should have called the physician to verify if the physician wanted the resident to continue to use the ted stockings and then put an order in place. An interview was conducted with the Director of Nursing (DON) on 05/23/19 at 11:00 AM. The DON reported her expectation for the nurses were to call and verify if the resident should continue to wear the ted stockings he was admitted with and obtain an order if the physician felt the resident should continue to be wearing them. The DON reported the ted stockings application should have been on the MAR indicated [REDACTED].

Based on record reviews, staff, Nurse Practitioner (NP), and Emergency Medical Service (EMS) interviews, the facility transferred a resident with a visible injury from the floor to the bed prior to the arrival of Emergency Medical Services (EMS) following a fall in the facility for 1 of 3 sampled residents reviewed for falls (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE] and re-admitted [DATE] and discharged to the hospital 05/15/19 with a cumulative [DIAGNOSES REDACTED]. Resident #19 ' s Minimum Data Set ((MDS) dated [DATE] documented that the resident had severe cognitive impairments. The resident needed total assistance for personal hygiene, and one person physical assistance for all her other activities for daily living (ADLs). Resident #19 ' s care plan goals dated 03/07/19 documented: Resident had an ADL self-care performance deficit related to dementia. Resident was totally dependent on 1 staff assist to provide bath/shower, personal hygiene, and transferring. Resident #19 was at risk for falls related to cognitive impairment. A nursing note dated 05/08/19 at 9:55 PM revealed Nurse #3 was called into Resident #19 ' s room at 9:15 PM by Nurse Aide (NA) #1. Resident was observed lying on her right side on the floor. The NA #1 stated that she was cleaning resident and reached for wipes and quickly heard a thump and resident had fallen off of the bed; but, she did not see it happen, it was so quick. Resident ' s right leg was noted to have [MEDICAL CONDITION] and she had an area in the middle of her forehead, noted to be slightly swollen. The resident stated, her leg and her head was hurting. The resident also had an episode of vomiting. Nurse #3, called 911 at 9:20 PM and then immediately notified Nurse Practitioner (NP) #1, who was in agreement to send resident to the hospital. An interview conducted with NA #1 on 05/21/19 at 3:28 PM revealed that on 05/08/18 around 9:15 PM Resident #19 fell out of bed while she was doing her incontinent care. NA #1 said Resident #19 was laying on her left side in bed, and she was holding the resident ' s hand with her left hand. She said with her right hand she was trying to pull the wipes out of the pack when 3 or 4 got stuck together in the pack. The NA said when she let go of the resident ' s hand with her left hand in order to get the stuck wipes out of the container, the resident pushed herself off the wall with her foot and flipped quickly out of the bed onto the floor. NA #1 said she immediately went to the nursing station to get a nurse. She commented Nurse # 3, was the first to show up, assessed the resident on the floor, and then left to call the MD and Responsible Party (RP), leaving her and two other nurses with the resident. She stated the second nurse, Nurse #4 helped to calm the resident, and then left to take care of her own patients. She reported the third nurse, Nurse #5 told me to clean up the resident before EMS showed up, and left to get a draw sheet to put under the resident for transport. The NA said, she alone picked up the resident from behind her arms and put her in the bed. She said, she moved the resident to the bed, because there was stool/urine on the floor, and that the bed would be a better place than the floor to clean up the resident. The NA said, if she could do it all over again, she would not have moved the resident, and would have just left her on the floor until EMS arrived. An interview on 05/21/19 at 4:23 PM with Nurse #3 revealed that on 05/08/19 around 9:15 PM, NA #1 called her into Resident #19 ' s private room and found the resident on her right side on the floor by her bed. The nurse said while she was assessing the resident, the resident was trying to get back into her bed from the floor. She said, she tried to make the resident comfortable, and put a pillow under her head. The nurse said she left to call 911 and the MD, leaving NA #1 with the resident on the floor. She said she told staff who were present in the resident ' s room, you cannot move a resident with a head and leg injury, and not to move the resident until EMS showed up. An interview on 05/22/19 at 5:00 PM with Nurse #5 revealed on 05/08/19 she observed Resident #19 laying on her right side on the floor, next to her bed. She said when she when she first observed the resident it was obviously apparent her leg was broken, and she told NA #1 not to move the resident, and to leave her on the floor. She said she then went to get a draw-sheet to put under the resident. She said when she returned with the draw-sheet, she found the resident in her bed. The nurse said NA #1 should not have moved the resident. An Emergency Medical Services (EMS) Report dated 05/08/19 revealed EMS arrived on scene at 9:39 PM to find NA #1 and nursing staff in Resident #19 ' s room. Patient was laying semi-fowlers in nursing home bed. Patient ' s right leg was bent towards her and her thigh, on the right side was deformed. Patient ' s skin was warm and dry. Patient was wearing only an adult brief. Nursing home bed was up at its highest position. They found the patient laying on the floor with her right leg folded up behind her. EMS staff were told that staff picked the patient up and placed her back on the bed, where EMS crew found the patient. Patient was moved via draw-sheet, secured. An interview on 05/22/19 at 12:20 PM with EMS #1 revealed when she first saw Resident #19 in room on 08/05/19 at 9:39 PM Resident #19 was lying in bed, with a blanket pulled up to her chin. She said when she ask what happened, she was told that the resident fell out of bed while NA #1 was changing her. She said the resident ' s right leg showed extensive deformity. The resident was in pain, vomited, and had a hematoma to the head. She was told that the resident ' s bed was up, while the NA was changing her, and that she rolled out of bed, folding her leg. She said the facility staff should not have moved the resident from the floor to the bed. The NA told her that she moved the resident to the bed. The NA told her that she freaked out, when she saw the resident on the hard cold floor. A Hospital History and Physical (H&P) dated 05/09/19 at 3:47 AM revealed per Emergency Medical Services (EMS), for evaluation of right leg pain following a fall. Per EMS the facility staff report documented Resident #19 was on the bed at the high setting getting her adult brief changed. Subsequently she was found on the floor. The patient was placed back on the bed prior to EMS arrival. A Cartography Scan (CT) of Resident #19 ' s head without contrast was negative for acute changes other than the scalp hematoma/contusion. An x-ray of her right femur showed acute [MEDICAL CONDITION] right femoral shaft. A facility Nurse Practitioner (NP) #1 interviewed dated 05/21/19 at 2:30 PM revealed on 05/08/19 NA #1 should not have moved Resident #19 from the floor to the bed before an assessment by EMS was conducted. NP #1 said NA #1 should have kept the resident still until EMS showed up. An interview conducted with the Director of Nursing (DON) on 05/22/19 at 12:10 PM revealed it was her expectation, if a resident fell with an apparent body or head injury, the nursing staff would not move the resident until an EMS assessment was done on the resident. Staff would then keep the resident comfortable on the floor, encourage the resident to wait where they were, and wait for EMS assistance. An interview on 05/22/19 at 2:30 PM with the Therapy Director revealed if any resident was found on the floor, no one should put the resident back to bed if there is a visible injury. She said nursing staff should assess the resident, keep them comfortable on the floor, keep the resident comfortable, and stay with the resident until EMS arrived.

Based on observations, record review, and staff interviews, the facility failed to; 1) transcribe an ordered supplement for 1 of 3 residents (Resident #218) observed for weight loss and; 2) failed to follow an order that was in place to obtain weekly weights for 4 weeks for 1 of 3 residents (Resident #218) observed for weight loss. Findings included: Resident #218 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Cerebral infarction (stroke), [MEDICAL CONDITION] (impairment to one side), [MEDICAL CONDITIONS], coronary [MEDICAL CONDITION], and diabetes. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #218 was independent with set up only for meals and had impairment on one side to upper and lower extremity and used a wheelchair. Resident #218 ' s weight was coded as 199 lbs., had a 5% weight lost in the last month, and was not on a prescribed weight loss regimen. Resident #218 was coded for a therapeutic diet, did not have any swallowing issues, and received two days of a diuretic medication (a medication to remove excess fluid from the body). A review of Resident #218 ' s care plan revealed an updated plan of care dated 05/09/19. Resident #218 had a plan of care for potential nutritional problems related to current no concentrated sweet (NCS) diet that may affect intake. The goal was to maintain adequate nutritional status as evidenced by maintaining weight within 10% of current body weight, no signs or symptoms of malnutrition, and consuming at least 50% of at least 3 meals daily through review date. The interventions included, in part, to provide and serve diet as ordered, Registered Dietician (RD) to evaluate and make diet change recommendations and weekly weights X 4 weeks every Wednesday on day shift. 1) A review of the physician orders [REDACTED]. A record review revealed there was a written diet order and communication slip for mighty shakes with all meals dated 05/07/19 signed by the Unit Manager (UM). A record review of the (MONTH) Medication Administration Record (MAR) revealed there was no order for mighty shakes with all meals on the MAR. A review of the Dietician Nutritional risk note written on 05/20/19 revealed the resident was placed on NSA (no sugar added) mighty shakes three times daily for weight stability and to provide 18 gm (grams) supplemental protein to help [MEDICATION NAME] his visceral protein stores. The note indicated the Dietician would continue to monitor his oral intakes and would follow up as indicated. The note further indicated no current weight was available. A lunch observation was conducted for Resident #218 in the dining room on 05/21/19 at 12:50 PM. The lunch tray was placed in front of the resident and there was no mighty shake on the lunch tray. The resident was observed until 1:15 PM and at no time was a mighty shake placed on his tray. The resident was observed not eating and when asked if he was going to eat he shook his head, no. When asked if he liked what was being served, he shook his head, no. A staff member then asked if he would like something else and he shook his head, no. The resident was noted to have consumed about 120 milliliters (mls) of his beverage which was recorded on his dietary ticket as tea. A review of the resident ' s dietary ticket on his meal tray revealed there was no order for mighty shakes with each meal displayed on the ticket. A lunch observation was conducted for Resident #218 in the dining room on 05/22/19 at 12:53 PM. The lunch tray was placed in front of the Resident and there was no mighty shake on his lunch tray. The lunch tray was noted to have the main entrée and two cups of ice cream on it. A staff member was observed standing beside him and encouraging him to eat. The resident was observed eating one of the ice cream cups. A review of the resident ' s dietary ticket on his meal tray revealed there was no order for mighty shakes with each meal displayed on the ticket. An interview was conducted with Nurse #7 on 05/22/19 at 2:30 PM. Nurse #7 reported if there was an order for [REDACTED]. Nurse #7 stated Resident #218 did not have a very good appetite and would need a lot of encouraging to eat but he would do better with his beverages than he did with his solid food intake. A dinner observation was conducted for Resident #218 in his room on 05/22/19 at 6:20 PM. The dinner tray was observed being placed in front of the resident on his bed side table. There was no mighty shake on the tray. The resident was observed consuming his beverage, however he was not eating his entrée. A review of the resident ' s dietary ticket on his meal tray revealed there was no order for mighty shakes with each meal displayed on the ticket. An observation of the tray was conducted with the Dietary Manager (DM) on 05/22/19 at 6:30 PM. The DM confirmed there was no mighty shake on the tray and further added he had not been receiving mighty shakes because there was no order. The DM reviewed the dietary ticket and stated if there had been an order, it would have been on the dietary ticket. The DM stated when there was an order for [REDACTED]. The DM stated at that time, she would in put the order in the computer and the order would appear on the dietary ticket for staff to know that a mighty shake should be on each meal tray. An interview was conducted with the UM on 05/23/19 at 9:45 AM. The UM reviewed the diet slip for Resident #218 and confirmed she had written the diet slip for mighty shakes three times daily for Resident #218. The UM reported when she had an order for [REDACTED]. She would then fill out the diet slip and bring to the DM. The UM stated once the order was in the computer it would generate to the MAR. The UM reviewed the MAR with Nurse #8 and found there to be no order for mighty shakes on the MAR. The UM was not sure why the order was not transcribed on to the MAR. An interview with Nurse #8 on 05/23/19 at 9:50 AM revealed she did not a recall an order for [REDACTED].#8 stated she has not given any mighty shakes to Resident #218. An interview was conducted with the RD via phone on 05/23/19 1:30 PM. The RD reported she had ordered mighty shakes three times daily since Resident #218 was not eating well and he was better with fluid intake. The RD stated the mighty shakes would give the resident 54 grams of protein total and if he consumed just 25% of the shakes, it would help with his health maintenance. The RD stated she would have expected the nurses to transcribe the order and administer the mighty shakes as ordered. An interview was conducted with the Director of Nursing (DON) on 05/23/19 at 1:40 PM. The DON reported her expectation would be that the nurse ' s transcribed the order for the mighty shakes as written so that they would be administered. 2) A review of the physician orders [REDACTED]. A record review revealed there was an order on the MAR for weekly weights on Wednesdays at 6:00 PM, however, only one weight was documented on 05/10/19. There was no weight documented for Wednesday, 05/15/19 or Wednesday, 05/22/19. A record review of the weights recorded in the computer revealed the last weight obtained for Resident #218 was on 05/10/19 with a weight of 198.8 lbs. A review of the Dietician Nutritional risk note written on 05/20/19 revealed the resident was placed on NSA (no sugar added) mighty shakes three times daily for weight stability and to provide 18 gm (grams) supplemental protein to help [MEDICATION NAME] his visceral protein stores. The note indicated the Dietician would continue to monitor his oral intakes and would follow up as indicated. The note further indicated no current weight was available. An interview was conducted with NA #3 on 05/22/19 at 10:45 AM. NA #3 stated the process for obtaining weights was the nurse would let them know at the beginning of their shift who needed a weight for that day. NA #3 stated she would weigh the resident and report the weight to the nurse. If the nurse instructed NA #3 to get a reweigh, she would reweigh the resident and let the nurse know, again, what the weight was. An interview was conducted with Nurse #7 on 05/22/19 at 2:30 PM. Nurse #7 stated if there was an order for [REDACTED]. Nurse #7 stated the nursing assistants would weigh the resident and let the nurse know what the weight was so they could record it on the MAR or TAR and in the computer system under weights. A review of the MAR and the weight log in the computer system was done on 05/23/19 at 9:00 AM. The weight for 05/22/19 was not recorded on the MAR or in the weight section of the computer system. An interview was conducted with the RD via phone on 05/23/19 1:30 PM. The RD reported she would have expected the order of obtaining the weights to be carried out as written due to his [DIAGNOSES REDACTED]. An interview was conducted with the DON on 05/23/19 at 1:40 PM. The DON reported her expectation would be that the nurse ' s obtained the weekly weights as ordered.

Based on observation, physician interview, resident interview, staff interview and record review the facility failed to protect residents from staff to resident physical abuse resulting in two bruises on the left wrist and two bruises on the left hip for 1 of 1 sampled residents (Resident #1). The immediate jeopardy (IJ) began on 10/25/17 when Nurse Aide #1 grabbed Resident #1 by both wrists causing her to fall to the floor resulting in bruising to her left wrist and left hip. The IJ was removed on 10/28/17 at 11:00 AM when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to all the facility to monitor and implement its plan of correction for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set for Resident #1 dated 08/03/17 revealed the resident had intact cognition. She was independent for: bed mobility, transfers, locomotion on and off the unit, dressing, eating, personal hygiene and bathing. She required supervision for walking in corridor and toilet use and limited assistance for walking in room. Balance was steady at all times and she used a walker while ambulating. She was receiving Physical Therapy and Occupational Therapy. She participated in the assessment. She weighed 108 pounds. Record review showed that Resident #1 had a guardian which was the State of North Carolina. Record review of the facility Transportation Log revealed that no residents were transported on 10/25/17. Review of the General Nurse's Note of 10/25/17 at 8:48 AM documented: Resident alert verbal oriented. Resident refused several times to go to the appointment several times. Transportation person was in to transport. Resident continuously refused to go. Transport was trying to get her out of bed, resident refusing, slipped to floor by bed. Resident denied hitting head or back. No apparent injury noted at present time. Denied pain at present. Will continue to monitor. Record review revealed that the facility filed a 24-Hour Initial Report to the Department of Health and Human Services on 10/25/17 for resident abuse. The allegation description was: Allegation of abuse reported concerning transport nursing assistant trying to force resident to go to a doctor's appointment. Report stated the transport nursing assistant grabbed the resident's wrists and shook her, then pushed her causing her to fall. Resident is alert, but confused. No physical injury identified and resident has no recollection of the incident when interviewed. Law Enforcement was not notified. Review of X-rays taken on 10/26/17 of Resident #1's right tibia/fibula, bilateral hips, and pelvis showed all structures grossly intact. In an interview conducted with Resident #1 on 10/26/17 at 7:45 AM she stated that she had resided at the facility for two months. She said that she had told the transporter (Nurse Aide #1) that she didn't feel good and was not going to the medical appointment that morning. She reported that Nurse Aide #1 then grabbed her by the left arm and right foot and twisted her off the bed causing her to fall to the floor hitting her left hip on the side of the bed as she fell . She said that her left hip and right foot were still hurting. She revealed that several staff members had seen the incident and had tried to convince Nursing Aide #1 that she did not have to go to the appointment. She stated she was hurting where she wasn't hurting before: shooting pain down her right leg, lower back pain, right calf pain, left arm above her elbow and left hip pain. She pointed to the bruises on her left wrist and said that was where Nurse Aide #1 had grabbed her. An observation of the left wrist and left hip of Resident #1 on 10/26/17 at 7:45 AM revealed two circular bruises on her left wrist and two bruises on her left hip. In an interview with Nurse #3 on 10/26/17 at 8:43 AM she stated that when she reported for work the morning of 10/25/17 she heard screaming and followed it to Resident #1's room. She said the resident was on the floor screaming. She said Nurse Aide #1 and Nurse Aide #2 were yelling at each other. She said the resident told her she had been abused. She revealed she told staff to leave the room and move away from the doorway. She said she and Nurse #1 put the resident back into bed. She stated she tried to de-escalate the situation and had told everyone present to write a statement of the incident before they left the shift. In an interview with the Administrator on 10/26/17 at 9:15 AM he stated that because Resident #1 had a guardian at the Department of Social Services (DSS) that she had no rights and could not refuse to go to an appointment scheduled by DSS. In an interview conducted on 10/26/17 at 9:31 AM with Housekeeper #1 she revealed that she had heard a lot of commotion on the hallway when she reported to work at 6:56 AM on 10/25/17. She said she went to Resident #1's doorway and saw the resident swinging her arms trying to hit Nurse Aide #1 in the face. She said she saw Nurse Aide #1 grab both the resident's arms. She stated she saw the resident trying to get loose and when she jerked away she fell against the bed and hit the floor. She said Nurse Aide #2 was standing with her at the doorway and said to Nurse Aide #1, you pushed her down and that's abuse. I ought to call the police on you myself. In an interview conducted with Nurse Aide #1 on 10/26/17 at 10:30 AM she stated that she had arrived to work at 6:10 AM on 10/25/17 to transport Resident #1 to an appointment. She revealed that she asked Nurse #1 if Resident #1 was ready to go to the appointment and was told no. She said Nurse #1 told her that the resident said she was not going to go to the appointment. She revealed that she asked Nurse #1 to help her convince the resident to go to the appointment because it was important but that she did not. She said she also asked the resident's third shift aide (Nurse Aide #2) to help her but that she went down an opposite hall and did not help her. Nurse Aide #1 stated that she then called the Director of Nursing (DON) to ask her to tell Nurse #1 and Nurse Aide #2 to help her convince Resident #1 to go to the appointment. She said that Nurse #1 came to the room but that the resident refused to go. She reported that she took clothes out of the resident's closet and laid them on the bed. She reported that Resident #1 jumped out of the bed and ran toward her saying that she was going to whoop her --- (curse word). She said the resident had on slippery socks. She said she removed herself from the situation and went outside to move the van. She reported that when she returned to the room the resident rose up off the bed kicking, swinging and screaming. She said that she grabbed both of the resident's arms and when she let go the resident fell back on the bed and slid onto the floor. She said Nurse Aide #2 and Housekeeper #1 were standing in the doorway. She said that Nurse #3 told her to leave the room and that she went to her office, called the DON, and wrote a statement concerning the incident. In an interview conducted with Nurse Aide #3 ON 10/26/17 at 11:26 AM she revealed that when she reported to work on 10/25/17 she heard yelling coming from Resident #1'S room. She said Resident #1 was on the bed saying that she was not going to the appointment. She said that she told the resident that she needed to go to the appointment. She stated that Nurse Aide #1 asked her to help get the resident ready for the appointment and that she left the room to go and get gloves. She said that when she returned Nurse Aide #1 and Resident #1 were standing up and Nurse Aide #1 was holding the resident by both arms. She stated that she saw the resident rear back and fall to the floor. She said that she did not see the resident trying to strike Nurse Aide #1 as she had left the room to get gloves. In an interview with Nurse Aide #2 on 10/26/17 12:41 PM via the telephone she revealed she was the aide caring for the Resident #1 on third shift the morning of 10/25/17. Said she asked the resident twice during the shift to get ready for the appointment and the resident said she wasn't going. She said she refused to force the resident to get ready to go because she didn't want to go. She said she was at the nurse's station when she heard the resident yelling for help and she ran to the room. She said when she got to the doorway Nurse Aide #1 was holding the resident by both her wrists. The resident was sitting on the side of the bed. She said she heard Nurse Aide #1 say, You're going to get the ---- (curse word) up. She said she saw Resident #1 push Nurse Aide #1 and then Nurse Aide #1 push the resident to the floor. She said she told Nurse Aide #1 that she should call the police because it was abuse and that Nurse Aide #1 responded by telling her to mind her own business. She reported that Nurse #3 came to the room and told everyone to leave. She said that when the DON arrived she told her that she should have gotten the resident up for the appointment using any means necessary because she was DSS. She said she told the DON that she saw Nurse Aide #1 push the resident to the floor. She said the DON asked her if she had called the state and informed her that she was not allowed to call. In an interview with Nurse #1 on 10/26/17 at 2:43 PM she stated she was the nurse caring for Resident #1 on the morning of 10/25/17. She said the resident was alert, oriented and reliable. She said when she had passed medications earlier in the shift the resident had told her she was not going to the appointment the following morning. She said she gave the resident [MEDICATION NAME] at 5:00 AM (because of the appointment) and again the resident said she wasn't going. She said when Nurse Aide #1 asked her why the resident wasn't ready to go she said she told her the resident was refusing to go. She said Nurse Aide #1 told her the resident could not refuse because she was DSS. Nurse #1 said she told Nurse Aide #1 that she was not going to force anyone to go to an appointment. She said the DON called the facility and asked her to talk to the resident which she said she did and again the resident refused to go to the appointment. She said she left the room to care for another resident. She reported that all the sudden she heard screaming and yelling. She said she and the oncoming day shift nurse (Nurse #3) went to the resident's room. She said Nurse Aide #1 and Nurse Aide #2 where yelling at each other. She said Nurse #3 told everyone to leave the room and they assessed the resident. She reported that the resident told her that Nurse Aide #1 grabbed her arms and pulled her out of bed. She said the resident told her that her left leg was weak and that she slipped to the floor. She said the resident told her that her wrists had been twisted. Nurse #1 reported that she did not see any bruising at that time. She revealed when she went back to check on the resident the resident told her that her back was hurting. She stated that she told the resident that the day shift nurse would give her some medication for pain. She said she called the Nurse Practitioner (NP) on duty to report the incident. She reported that the NP asked her if she had given the resident the ordered [MEDICATION NAME] at 5:00 AM and told her that she should have called psychiatric services. In an interview conducted with the DSS Supervisor on 10/26/17 at 4:30 PM she stated that DSS was the guardian for Resident #1. She revealed that DSS makes the medical decisions for Resident #1. She said that the facility had contacted DSS on 10/24/17 and informed them that the resident did not want to go to the appointment scheduled for 10/25/17. She said that they requested that the facility try to convince the resident to go to the appointment so that DSS did not appear neglectful but that the resident had the right to refuse treatment. In an interview with the Medical Director on 10/27/17 at 12:47 PM he stated that he had assessed Resident #1 on 10/25/17. He said he had been told the resident had refused to go to her appointment that morning and he had gone to her room to talk to her about the appointment. He said that the resident told him someone had grabbed her calf and that it hurt. He reported that he looked at her calf and found nothing abnormal. He also stated that he saw no bruising on the resident at that time. He stated that he was not aware of an altercation between the resident and a member of the staff until the resident told him. He said that he had reviewed her current orders for pain medication and had not made any changes because she had not been taking all the medication that was available to her. On 10/27/17 at 2:45 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 10/27/17: Plan for correcting this deficiency: On 10/25/17 at approximately 6:15am, the transport aide arrived at the facility to take identified resident to a scheduled appointment. On 10/25/17 at approximately 7:00am, an allegation of abuse was made by a staff member alleging that the transport aide had grabbed the resident by the wrists, pulled her up off the bed and shook her after the resident refused to go to the appointment. She also stated that the resident had pushed the transport aide and the transport aide then pushed the resident, causing her to fall to the floor. The transport aide was suspended pending our investigation. The 24-hour report was submitted for identified resident on 10/25/17. Facility is still currently working on investigation of incident. The resident was assessed by the doctor on 10/25/17 at approximately 10:00am with no injury identified. Resident's guardian was notified of abuse allegation and 24-hour report on 10/25/17 as well. The identified resident did report pain to her left hip and right inner calf on 10/26/17 when interviewed by the state surveyor. This was reported to the doctor and x-rays were ordered and obtained on 10/26/17. All results were negative for injury. Police Department was called on 10/27/17 at 3:10pm and an officer was sent to the facility to receive report of incident. The facility did recognize the incident as abuse, but did not notify the police after the physical contact between the resident and the staff member. Procedure for implementing the acceptable plan of correction for the deficiency cited: 1. Facility will complete 24-hour reports for allegations of abuse as reported and notify police when physical contact is reported. 2. Alert and oriented residents were interviewed by the Social Worker on 10/27/17 and no further allegations of abuse were identified. 3. Police Department was called on 10/27/17 at 3:10pm and an officer was sent to the facility to receive report of incident. 4. Abuse training was completed for all active employees by the Staff Development Nurse on 10/26/17 and 10/27/17. 5. Staff training will be provided by the Staff Development Nurse on Management of Residents with Behaviors and Management of Residents Who Refuse Care. This training will include staff allowing residents to refuse care, allow residents to calm if agitated, and allowing residents to have choices honored. Monitoring procedure to ensure the plan of correction is effective and specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 1. The administrator will review all allegations of abuse and ensure police are notified for allegations where physical contact has occurred. 2. The administrator and/or designee will be notified of any resident refusing to attend a scheduled appointment. The administrator and/or designee will ensure resident's family member, POA, or guardian is notified of the refused appointment. The validation of the credible allegation was completed on 10/28/17 at 11:00 AM by doing the following: 1. Nine employees on duty were interviewed regarding identification of the different types of abuse and how to report abuse if identified. 2. The Social Worker was interviewed on 10/28/17 at 10:15 AM and she confirmed that she interviewed alert and oriented residents and no further allegations of abuse were identified. 3. A list of all alert and oriented residents in the facility was obtained and the residents were interviewed regarding allegations of abuse. No other allegations were identified. 4. The 24 hour report of abuse was reviewed. Police were at the facility to investigate on 10/27/17. The police report number of the ongoing investigation is 2017E-1061. 5. The abuse training sign sheets were reviewed for in-services held on 10/25 and 10/27/17. Some education was provided by phone for employees not on site. 6. The honoring of resident rights to refuse appointments in-service was reviewed for sign in sheets dated 10/27/17.

Based on observation, resident interview, staff interview and record review the facility failed to notify law enforcement concerning staff to resident physical abuse resulting in two bruises on the left wrist and two bruises on the left hip for 1 of 1 sampled residents (Resident #1). The immediate jeopardy (IJ) began on 10/25/17 when Nurse Aide #1 grabbed Resident #1 by both wrists causing her to fall to the floor resulting in bruising to her left wrist and left hip and law enforcement was not notified. The IJ was removed on 10/28/17 at 11:00 AM when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to all the facility to monitor and implement its plan of correction for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set for Resident #1 dated 08/03/17 revealed the resident had intact cognition. She was independent for: bed mobility, transfers, locomotion on and off the unit, dressing, eating, personal hygiene and bathing. She required supervision for walking in corridor and toilet use and limited assistance for walking in room. Balance was steady at all times and she used a walker while ambulating. She was receiving Physical Therapy and Occupational Therapy. She participated in the assessment. She weighed 108 pounds. Record review showed that Resident #1 had a guardian which was the State of North Carolina. Review of the General Nurse's Note of 10/25/17 at 8:48 AM documented: Resident alert verbal oriented. Resident refused several times to go to the appointment several times. Transportation person was in to transport. Resident continuously refused to go. Transport was trying to get her out of bed, resident refusing, slipped to floor by bed. Resident denied hitting head or back. No apparent injury noted at present time. Denied pain at present. Will continue to monitor. Record review revealed that the facility filed a 24-Hour Initial Report to the Department of Health and Human Services on 10/25/17 for resident abuse. The allegation description was: Allegation of abuse reported concerning transport nursing assistant trying to force resident to go to a doctor's appointment. Report stated the transport nursing assistant grabbed the resident's wrists and shook her, then pushed her causing her to fall. Resident is alert, but confused. No physical injury identified and resident has no recollection of the incident when interviewed. Law Enforcement was not notified. Review of the facility Abuse Prohibition Policy stated: Any outcomes resulting in the substantiation of abuse will be reported to the appropriate agencies as required by the law and professional ethical standards. The facility added the following addendum to the Abuse Prohibition Policy on 10/27/17: For all abuse allegations with reported physical contact involved will be reported to the local police department immediately. In an interview conducted with Resident #1 on 10/26/17 at 7:45 AM she stated that she had resided at the facility for two months. She said that she had told the transporter (Nurse Aide #1) that she didn't feel good and was not going to the medical appointment that morning. She reported that Nurse Aide #1 then grabbed her by the left arm and right foot and twisted her off the bed causing her to fall to the floor hitting her left hip on the side of the bed as she fell . She said that her left hip and right foot were still hurting. She revealed that several staff members had seen the incident and had tried to convince Nurse Aide #1 that she did not have to go to the appointment. She stated she was hurting where she wasn't hurting before: shooting pain down her right leg, lower back pain, right calf pain, left arm above her elbow and left hip pain. She pointed to the bruises on her left wrist and said that was where Nurse Aide #1 had grabbed her. An observation of the left wrist and left hip of Resident #1 on 10/26/17 at 7:45 AM revealed two circular bruises on her left wrist and two bruises on her left hip. Review of X-rays taken on 10/26/17 of Resident #1's right tibia/fibula, bilateral hips, and pelvis showed all structures grossly intact. In an interview with Nurse #3 on 10/26/17 at 8:43 AM she stated that when she reported for work the morning of 10/25/17 she heard screaming and followed it to Resident #1's room. She said the resident was on the floor screaming. She said Nurse Aide #1 and Nurse Aide #2 were yelling at each other. She said the resident told her she had been abused. She revealed she told staff to leave the room and move away from the doorway. She said she and Nurse #1 put the resident back into bed. She stated she tried to de-escalate the situation and had told everyone present to write a statement of the incident before they left the shift. In an interview conducted on 10/26/17 at 9:31 AM with Housekeeper #1 she revealed that she had heard a lot of commotion on the hallway when she reported to work at 6:56 AM on 10/25/17. She said she went to Resident #1's doorway and saw the resident swinging her arms trying to hit Nurse Aide #1 in the face. She said she saw Nurse Aide #1 grab both the resident's arms. She stated she saw the resident trying to get loose and when she jerked away she fell against the bed and hit the floor. She said Nurse Aide #2 was standing with her at the doorway and said to Nurse Aide #1, you pushed her down and that's abuse. I ought to call the police on you myself. In an interview conducted with Nurse Aide #1 on 10/26/17 at 10:30 AM she stated that she had arrived to work at 6:10 AM on 10/25/17 to transport Resident #1 to an appointment. She revealed that she asked Nurse #1 if Resident #1 was ready to go to the appointment and was told no. She said Nurse #1 told her that the resident said she was not going to go to the appointment. She revealed that she asked Nurse #1 to help her convince the resident to go to the appointment because it was important but that she did not. She said she also asked the resident's third shift aide (Nurse Aide #2) to help her but that she went down an opposite hall and did not help her. Nurse Aide #1 stated that she then called the Director of Nursing (DON) to ask her to tell Nurse #1 and Nurse Aide #2 to help her convince Resident #1 to go to the appointment. She said that Nurse #1 came to the room but that the resident refused to go. She reported that she took clothes out of the resident's closet and laid them on the bed. She reported that Resident #1 jumped out of the bed and ran toward her saying that she was going to whoop her --- (curse word). She said the resident had on slippery socks. She said she removed herself from the situation and went outside to move the van. She reported that when she returned to the room the resident rose up off the bed kicking, swinging and screaming. She said that she grabbed both of the resident's arms and when she let go the resident fell back on the bed and slid onto the floor. She said Nurse Aide #2 and Housekeeper #1 were standing in the doorway. She said that Nurse #3 told her to leave the room and that she went to her office, called the DON, and wrote a statement concerning the incident. In an interview conducted with Nurse Aide #3 ON 10/26/17 at 11:26 AM she revealed that when she reported to work on 10/25/17 she heard yelling coming from Resident #1'S room. She said Resident #1 was on the bed saying that she was not going to the appointment. She said that she told the resident that she needed to go to the appointment. She stated that Nurse Aide #1 asked her to help get the resident ready for the appointment and that she left the room to go and get gloves. She said that when she returned Nurse Aide #1 and Resident #1 were standing up and Nurse Aide #1 was holding the resident by both arms. She stated that she saw the resident rear back and fall to the floor. She said that she did not see the resident trying to strike Nurse Aide #1 as she had left the room to get gloves. In an interview with Nurse Aide #2 on 10/26/17 12:41 PM via the telephone she revealed she was the aide caring for the Resident #1 on third shift the morning of 10/25/17. Said she asked the resident twice during the shift to get ready for the appointment and the resident said she wasn't going. She said she refused to force the resident to get ready to go because she didn't want to go. She said she was at the nurse's station when she heard the resident yelling for help and she ran to the room. She said when she got to the doorway Nurse Aide #1 was holding the resident by both her wrists. The resident was sitting on the side of the bed. She said she heard Nurse Aide #1 say, You're going to get the ---- (curse word) up. She said she saw Resident #1 push Nurse Aide #1 and then Nurse Aide #1 push the resident to the floor. She said she told Nurse Aide #1 that she should call the police because it was abuse and that Nurse Aide #1 responded by telling her to mind her own business. She reported that Nurse #3 came to the room and told everyone to leave. She said that when the DON arrived she told her that she should have gotten the resident up for the appointment using any means necessary because she was DSS. She said she told the DON that she saw Nurse Aide #1 push the resident to the floor. She said the DON asked her if she had called the state and informed her that she was not allowed to call. In an interview with Nurse #1 on 10/26/17 at 2:43 PM she stated she was the nurse caring for Resident #1 on the morning of 10/25/17. She said the resident was alert, oriented and reliable. She said when she had passed medications earlier in the shift the resident had told her she was not going to the appointment the following morning. She said she gave the resident [MEDICATION NAME] at 5:00 AM (because of the appointment) and again the resident said she wasn't going. She said when Nurse Aide #1 asked her why the resident wasn't ready to go she said she told her the resident was refusing to go. She said Nurse Aide #1 told her the resident could not refuse because she was DSS. Nurse #1 said she told Nurse Aide #1 that she was not going to force anyone to go to an appointment. She said the DON called the facility and asked her to talk to the resident which she said she did and again the resident refused to go to the appointment. She said she left the room to care for another resident. She reported that all the sudden she heard screaming and yelling. She said she and the oncoming day shift nurse (Nurse #3) went to the resident's room. She said Nurse Aide #1 and Nurse Aide #2 where yelling at each other. She said Nurse #3 told everyone to leave the room and they assessed the resident. She reported that the resident told her that Nurse Aide #1 grabbed her arms and pulled her out of bed. She said the resident told her that her left leg was weak and that she slipped to the floor. She said the resident told her that her wrists had been twisted. Nurse #1 reported that she did not see any bruising at that time. She revealed when she went back to check on the resident the resident told her that her back was hurting. She stated that she told the resident that the day shift nurse would give her some medication for pain. She said she called the Nurse Practitioner (NP) on duty to report the incident. She reported that the NP asked her if she had given the resident the ordered [MEDICATION NAME] at 5:00 AM and told her that she should have called psychiatric services. In an interview conducted with the DSS Supervisor on 10/26/17 at 4:30 PM she stated that DSS was the guardian for Resident #1. She revealed that DSS makes the medical decisions for the resident. She said that the facility had contacted DSS on 10/24/17 and informed them that the resident did not want to go to the appointment scheduled for 10/25/17. She said that they requested that the facility try to convince the resident to go to the appointment so that DSS did not appear neglectful but that the resident had the right to refuse treatment. In an interview with the Medical Director on 10/27/17 at 12:47 PM he stated that he had assessed Resident #1 on 10/25/17. He said he had been told the resident had refused to go to her appointment that morning and he had gone to her room to talk to her about the appointment. He said that the resident told him someone had grabbed her calf and that it hurt. He reported that he looked at her calf and found nothing abnormal. He also stated that he saw no bruising on the resident at that time. He stated that he was not aware of an altercation between the resident and a member of the staff until the resident told him. He said that he had reviewed her current orders for pain medication and had not made any changes because she had not been taking all the medication that was available to her. On 10/27/17 at 2:45 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 10/27/17: Plan for correcting this deficiency: On 10/25/17 at approximately 7:00am, an allegation of abuse was made by a staff member alleging that the transport aide had grabbed the resident by the wrists, pulled her up off the bed and shook her after the resident refused to go to the appointment. She also stated that the resident had pushed the transport aide and the transport aide then pushed the resident, causing her to fall to the floor. The transport aide was suspended pending our investigation. The 24-hour report was submitted for identified resident on 10/25/17. Facility is still currently working on investigation of incident. The resident was assessed by Dr. on 10/25/17 at approximately 10:00am with no injury identified. Resident's guardian was notified of abuse allegation and 24-hour report on 10/25/17 as well. The identified resident did report pain to her left hip and right inner calf on 10/26/17 when interviewed by the state surveyor. This was reported to the doctor and x-rays were ordered and obtained on 10/26/17. All results were negative for injury. Police Department was called on 10/27/17 at 3:10pm and an officer was sent to the facility to receive report of incident. The facility did recognize the incident as abuse, but did not notify the police after the physical contact between the resident and the staff member. Abuse training completed with facility staff 10/26/17 and 10/27/17 which included identification of types of abuse and reporting incidents with physical contact to the police. Abuse policy was reviewed and updated to reflect the need for staff to remove themselves from the environment if resident behavior is escalating. Abuse policy was also revised to include police notification when physical contact occurs. Procedure for implementing the acceptable plan of correction for the deficiency cited: 1. Facility will complete 24-hour reports for allegations of abuse as reported. 2. Alert and oriented residents were interviewed by the Social Worker on 10/27/17 and no further allegations of abuse were identified. 3. Police Department was called on 10/27/17 at 3:10pm and an officer was sent to the facility to receive report of incident. 4. Abuse training was completed for all active employees by the Staff Development Nurse on 10/26/17 and 10/27/17 which included identification of types of abuse and reporting incidents with physical contact to the police. 5. Staff training will be provided by the Staff Development Nurse on Management of Residents with Behaviors and Management of Residents Who Refuse Care. This training will include staff allowing residents to refuse care, allow residents to calm if agitated, and allowing residents to have choices honored. Monitoring procedure to ensure the plan of correction is effective and specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 1. The administrator will review all allegations of abuse and ensure police are notified for allegations where physical contact has occurred. 2. The administrator and/or designee will be notified of any resident refusing to attend a scheduled appointment. The administrator and/or designee will ensure resident's family member, POA, or guardian is notified of the refused appointment. The validation of the credible allegation was completed on 10/28/17 at 11:00 AM by doing the following: 1. Nine employees on duty were interviewed regarding identification of the different types of abuse and how to report abuse if identified. 2. The Social Worker was interviewed on 10/28/17 at 10:15 AM and she confirmed that she interviewed alert and oriented residents and no further allegations of abuse were identified. 3. A list of all alert and oriented residents in the facility was obtained and the residents were interviewed regarding allegations of abuse. No other allegations were identified. 4. The 24 hour report of abuse was reviewed. Police were at the facility to investigate on 10/27/17. The police report number of the ongoing investigation is 2017E-1061. 5. The abuse training sign sheets were reviewed for in-services held on 10/25 and 10/27/17. Some education was provided by phone for employees not on site.

Based on observation, resident interview, staff interview and record review the facility failed to allow a resident the choice to refuse to attend a medical appointment resulting in a staff to resident physical abuse resulting in two bruises on the left wrist and two bruises on the left hip for 1 of 1 sampled residents (Resident #1). The immediate jeopardy (IJ) began on 10/25/17 when Resident #1 refused to go to an appointment and staff was insistent that she go. Nurse Aide #1 grabbed Resident #1 by both wrists causing her to fall to the floor resulting in bruising to her left wrist and left hip. The IJ was removed on 10/28/17 at 11:00 AM when the facility's acceptable credible allegation was verified. The facility remained out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to all the facility to monitor and implement its plan of correction for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set for Resident #1 dated 08/03/17 revealed the resident had intact cognition. She was independent for: bed mobility, transfers, locomotion on and off the unit, dressing, eating, personal hygiene and bathing. She required supervision for walking in corridor and toilet use and limited assistance for walking in room. Balance was steady at all times and she used a walker while ambulating. She was receiving Physical Therapy and Occupational Therapy. She participated in the assessment. She weighed 108 pounds. Record review showed that Resident #1 had a guardian which was the State of North Carolina. Review of the General Nurse's Note of 10/25/17 at 8:48 AM documented: Resident alert verbal oriented. Resident refused several times to go to the appointment several times. Transportation person was in to transport. Resident continuously refused to go. Transport was trying to get her out of bed, resident refusing, slipped to floor by bed. Resident denied hitting head or back. No apparent injury noted at present time. Denied pain at present. Will continue to monitor. Record review revealed that the facility filed a 24-Hour Initial Report to the Department of Health and Human Services on 10/25/17 for resident abuse. The allegation description was: Allegation of abuse reported concerning transport nursing assistant trying to force resident to go to a doctor's appointment. Report stated the transport nursing assistant grabbed the resident's wrists and shook her, then pushed her causing her to fall. Resident is alert, but confused. No physical injury identified and resident has no recollection of the incident when interviewed. Law Enforcement was not notified. In an interview conducted with Resident #1 on 10/26/17 at 7:45 AM she stated that she had resided at the facility for two months. She said that she had told the transporter (Nurse Aide #1) that she didn't feel good and was not going to the medical appointment that morning. She reported that Nurse Aide #1 then grabbed her by the left arm and right foot and twisted her off the bed causing her to fall to the floor hitting her left hip on the side of the bed as she fell . She said that her left hip and right foot were still hurting. She revealed that several staff members had seen the incident and had tried to convince Nurse Aide #1 that she did not have to go to the appointment. She stated she was hurting where she wasn't hurting before: shooting pain down her right leg, lower back pain, right calf pain, left arm above her elbow and left hip pain. She pointed to the bruises on her left wrist and said that was where Nurse Aide #1 had grabbed her. An observation of the left wrist and left hip of Resident #1 on 10/26/17 at 7:45 AM revealed two circular bruises on her left wrist and two bruises on her left hip. Review of X-rays taken on 10/26/17 of Resident #1's right tibia/fibula, bilateral hips, and pelvis showed all structures grossly intact. In an interview with Nurse #3 on 10/26/17 at 8:43 AM she stated that when she reported for work the morning of 10/25/17 she heard screaming and followed it to Resident #1's room. She said the resident was on the floor screaming. She said Nurse Aide #1 and Nurse Aide #2 were yelling at each other. She said the resident told her she had been abused. She revealed she told staff to leave the room and move away from the doorway. She said she and Nurse #1 put the resident back into bed. She stated she tried to de-escalate the situation and had told everyone present to write a statement of the incident before they left the shift. In an interview with the Administrator on 10/26/17 at 9:15 AM he stated that because Resident #1 had a guardian at the Department of Social Services (DSS) that she had no rights and could not refuse to go to an appointment scheduled by DSS. In an interview conducted on 10/26/17 at 9:31 AM with Housekeeper #1 she revealed that she had heard a lot of commotion on the hallway when she reported to work at 6:56 AM on 10/25/17. She said she went to Resident #1's doorway and saw the resident swinging her arms trying to hit Nurse Aide #1 in the face. She said she saw Nurse Aide #1 grab both the resident's arms. She stated she saw the resident trying to get loose and when she jerked away she fell against the bed and hit the floor. She said Nurse Aide #2 was standing with her at the doorway and said to Nurse Aide #1, you pushed her down and that's abuse. I ought to call the police on you myself. In an interview conducted with Nurse Aide #1 on 10/26/17 at 10:30 AM she stated that she had arrived to work at 6:10 AM on 10/25/17 to transport Resident #1 to an appointment. She revealed that she asked Nurse #1 if Resident #1 was ready to go to the appointment and was told no. She said Nurse #1 told her that the resident said she was not going to go to the appointment. She revealed that she asked Nurse #1 to help her convince the resident to go to the appointment because it was important but that she did not. She said she also asked the resident's third shift aide (Nurse Aide #2) to help her but that she went down an opposite hall and did not help her. Nurse Aide #1 stated that she then called the Director of Nursing (DON) to ask her to tell Nurse #1 and Nurse Aide #2 to help her convince Resident #1 to go to the appointment. She said that Nurse #1 came to the room but that the resident refused to go. She reported that she took clothes out of the resident's closet and laid them on the bed. She reported that Resident #1 jumped out of the bed and ran toward her saying that she was going to whoop her --- (curse word). She said the resident had on slippery socks. She said she removed herself from the situation and went outside to move the van. She reported that when she returned to the room the resident rose up off the bed kicking, swinging and screaming. She said that she grabbed both of the resident's arms and when she let go the resident fell back on the bed and slid onto the floor. She said Nurse Aide #2 and Housekeeper #1 were standing in the doorway. She said that Nurse #3 told her to leave the room and that she went to her office, called the DON, and wrote a statement concerning the incident. In an interview conducted with Nurse Aide #3 ON 10/26/17 at 11:26 AM she revealed that when she reported to work on 10/25/17 she heard yelling coming from Resident #1'S room. She said Resident #1 was on the bed saying that she was not going to the appointment. She said that she told the resident that she needed to go to the appointment. She stated that Nurse Aide #1 asked her to help get the resident ready for the appointment and that she left the room to go and get gloves. She said that when she returned Nurse Aide #1 and Resident #1 were standing up and Nurse Aide #1 was holding the resident by both arms. She stated that she saw the resident rear back and fall to the floor. She said that she did not see the resident trying to strike Nurse Aide #1 as she had left the room to get gloves. In an interview with Nurse Aide #2 on 10/26/17 12:41 PM via the telephone she revealed she was the aide caring for the Resident #1 on third shift the morning of 10/25/17. Said she asked the resident twice during the shift to get ready for the appointment and the resident said she wasn't going. She said she refused to force the resident to get ready to go because she didn't want to go. She said she was at the nurse's station when she heard the resident yelling for help and she ran to the room. She said when she got to the doorway Nurse Aide #1 was holding the resident by both her wrists. The resident was sitting on the side of the bed. She said she heard Nurse Aide #1 say, You're going to get the ---- (curse word) up. She said she saw Resident #1 push Nurse Aide #1 and then Nurse Aide #1 push the resident to the floor. She said she told Nurse Aide #1 that she should call the police because it was abuse and that Nurse Aide #1 responded by telling her to mind her own business. She reported that Nurse #3 came to the room and told everyone to leave. She said that when the DON arrived she told her that she should have gotten the resident up for the appointment using any means necessary because she was DSS. She said she told the DON that she saw Nurse Aide #1 push the resident to the floor. She said the DON asked her if she had called the state and informed her that she was not allowed to call. In an interview with Nurse #1 on 10/26/17 at 2:43 PM she stated she was the nurse caring for Resident #1 on the morning of 10/25/17. She said the resident was alert, oriented and reliable. She said when she had passed medications earlier in the shift the resident had told her she was not going to the appointment the following morning. She said she gave the resident [MEDICATION NAME] at 5:00 AM (because of the appointment) and again the resident said she wasn't going. She said when Nurse Aide #1 asked her why the resident wasn't ready to go she said she told her the resident was refusing to go. She said Nurse Aide #1 told her the resident could not refuse because she was DSS. Nurse #1 said she told Nurse Aide #1 that she was not going to force anyone to go to an appointment. She said the DON called the facility and asked her to talk to the resident which she said she did and again the resident refused to go to the appointment. She said she left the room to care for another resident. She reported that all the sudden she heard screaming and yelling. She said she and the oncoming day shift nurse (Nurse #3) went to the resident's room. She said Nurse Aide #1 and Nurse Aide #2 where yelling at each other. She said Nurse #3 told everyone to leave the room and they assessed the resident. She reported that the resident told her that Nurse Aide #1 grabbed her arms and pulled her out of bed. She said the resident told her that her left leg was weak and that she slipped to the floor. She said the resident told her that her wrists had been twisted. Nurse #1 reported that she did not see any bruising at that time. She revealed when she went back to check on the resident the resident told her that her back was hurting. She stated that she told the resident that the day shift nurse would give her some medication for pain. She said she called the Nurse Practitioner (NP) on duty to report the incident. She reported that the NP asked her if she had given the resident the ordered [MEDICATION NAME] at 5:00 AM and told her that she should have called psychiatric services. In an interview conducted with the DSS Supervisor on 10/26/17 at 4:30 PM she stated that DSS was the guardian for Resident #1. She revealed that DSS makes the medical decisions for Resident #1. She said that the facility had contacted DSS on 10/24/17 and informed them that the resident did not want to go to the appointment scheduled for 10/25/17. She said that they requested that the facility try to convince the resident to go to the appointment so that DSS did not appear neglectful but that the resident had the right to refuse treatment. In an interview with the Medical Director on 10/27/17 at 12:47 PM he stated that he had assessed Resident #1 on 10/25/17. He said he had been told the resident had refused to go to her appointment that morning and he had gone to her room to talk to her about the appointment. He said that the resident told him someone had grabbed her calf and that it hurt. He reported that he looked at her calf and found nothing abnormal. He also stated that he saw no bruising on the resident at that time. He stated that he was not aware of an altercation between the resident and a member of the staff until the resident told him. He said that he had reviewed her current orders for pain medication and had not made any changes because she had not been taking all the medication that was available to her. On 10/27/17 at 2:45 PM the facility was notified of IJ. The facility provided the following credible allegation of compliance on 10/27/17: Plan for correcting this deficiency: On 10/25/17 at approximately 6:15am, the transport aide arrived at the facility to take identified resident to a scheduled appointment. On 10/25/17 at approximately 7:00am, an allegation of abuse was made by a staff member alleging that the transport aide had grabbed the resident by the wrists, pulled her up off the bed and shook her after the resident refused to go to the appointment. She also stated that the resident had pushed the transport aide and the transport aide then pushed the resident, causing her to fall to the floor. The transport aide was suspended pending our investigation. The 24-hour report was submitted for identified resident on 10/25/17. Facility is still currently working on investigation of incident. The resident was assessed by the doctor on 10/25/17 at approximately 10:00am with no injury identified. Resident's guardian was notified of abuse allegation and 24-hour report on 10/25/17 as well. The identified resident did report pain to her left hip and right inner calf on 10/26/17 when interviewed by the state surveyor. This was reported and x-rays were ordered and obtained on 10/26/17. All results were negative for injury. Police Department was called on 10/27/17 at 3:10pm and an officer was sent to the facility to receive report of incident. The facility did recognize the incident as abuse, but did not notify the police after the physical contact between the resident and the staff member. Procedure for implementing the acceptable plan of correction for the deficiency cited: 1. Staff training for honoring resident choice to attend appointments was completed for all active employees by the Staff Development Nurse on 10/27/17. 2. Staff training will be provided by the Staff Development Nurse on Management of Residents with Behaviors and Management of Residents Who Refuse Care. This training will include staff allowing residents to refuse care, allow residents to calm if agitated, and allowing residents to have choices honored. Monitoring procedure to ensure the plan of correction is effective and specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: 1. The administrator and/or designee will be notified of any resident refusing to attend a scheduled appointment. The administrator and/or designee will ensure resident's family member, POA, or guardian is notified of the refused appointment. The validation of the credible allegation was completed on 10/28/17 at 11:00 AM by doing the following: 1. Nine employees on duty were interviewed regarding identification of the different types of abuse and how to report abuse if identified. 2. The Social Worker was interviewed on 10/28/17 at 10:15 AM and she confirmed that she interviewed alert and oriented residents and no further allegations of abuse were identified. 3. A list of all alert and oriented residents in the facility was obtained and the residents were interviewed regarding allegations of abuse. No other allegations were identified. 4. The 24 hour report of abuse was reviewed. Police were at the facility to investigate on 10/27/17. The police report number of the ongoing investigation is 2017E-1061. 5. The abuse training sign sheets were reviewed for in-services held on 10/25 and 10/27/17. Some education was provided by phone for employees not on site. 6. The honoring of resident rights to refuse appointments in-service was reviewed for sign in sheets dated 10/27/17.

Based on staff interview, and record review, the facility failed to prevent significant medication errors by administering the wrong medications to 1 of 2 residents (Resident #1) resulting in the resident's hospitalization and need for medical treatment for [REDACTED]. Findings included: Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. In an interview with the Director of Nursing (DON) on 05/21/13 at 9:15 AM, she stated that she was aware of a medication error which occurred on 05/17/13. Review of the facility investigation notes (time line of events) written by the DON on 5/17/13, revealed that Nurse #1 poured Resident #1's morning medications ([MEDICATION NAME], [MEDICATION NAME] and Aspirin are heart medication). When she entered the room the resident was not in the room. Resident #1 had gone outside with the activities department to watch flower planting. Nurse #1 covered the medication cup with another cup and placed both cups in the top drawer of the medication cart. Nurse #1 then proceeded to pass medications on her assigned hall. Nurse #1 had poured Resident #2's medications when Resident #1 rolled up to the medication cart and requested her medications. Nurse #1 then retrieved Resident #1's medication cup from the top drawer of the medication cart. She asked Resident #1 if she wanted juice or water. When Nurse #1 turned from pouring the water, she picked up Resident #2's medication cup and handed it to Resident #1 to take. Resident #1 took the cup and swallowed the medications. Review of the Interdisciplinary note of 5/17/13 revealed Resident #1 received the following medications; [MEDICATION NAME] 10 milligram (mg), [MEDICATION NAME] 10 mg, [MEDICATION NAME] 0.2 mg, [MEDICATION NAME] XL 50 mg, (all blood pressure medications); [MEDICATION NAME] 7.5/325 mg (Opiate), [MEDICATION NAME] 100 mg (pain killer), [MEDICATION NAME] 10 mg (antianxiety medication), [MEDICATION NAME] 30 mg (antidepressant medication), [MEDICATION NAME] 5 mg (bladder spasms), multivitamin, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 100 mg, Mag-Oxide 400 mg and Aspirin 81 mg. Resident received 15 medications in error. In an interview on 05/21/13 at 11:29 AM, Nurse #1 revealed that she realized that she gave Resident #1 the wrong medications as soon as the resident swallowed the medications. She told Resident #1 to spit the medications out and the Resident replied, "They're gone" meaning she had swallowed them. Nurse #1 stated she locked the medication cart and called for the RN supervisor, as noted on the facility timeline written by the DON at 11AM. Nurse #1 surrendered her keys to the medication cart to the RN supervisor and was sent to the Director of Nursing office. Review of the timeline of events of 5/17/13 revealed on 11:15 AM the DON ordered that the resident be placed on 1:1 monitoring by a CNA and to take vital signs every 15 minutes. The RN supervisor called the doctor at 11:25 AM who ordered vital signs every 15 minutes and to call him back if there was any change in condition. A family member of Resident #1 came to visit at 11:45 AM and was notified of the error and measures ordered by the attending physician. Review of a Nurses note written by the DON on 5/17/13 (untimed) revealed that from 11:00 AM (when the error occurred) until 12:45 PM, the resident's pulses (60-72), respirations (20) and blood pressures (120/70 -140/80) remained stable. The resident's family members returned to the facility at 1:10 PM and noted the resident with shallow breathing. Vital signs reading decreased to pulse (54), respirations (14) blood pressure of 100/50. The family member was quoted in the note "She looks like she is not breathing". The nurses responded to assess the resident. The resident had shallow breathing but was aroused by sternal rub. Once the resident became awake, the resident was verbally responsive but drowsy. The staff called 911 at 1:15 PM and EMS (Emergency Medical Services) arrived 1:20 PM. Review of the time line of event of 5/17/13 revealed the RN supervisor called the local hospital ED (emergency department) at 1:33 PM, while the resident was en route, to review with the hospital nurse what medications had been given in error. Nurse #1 was counseled, reeducated and suspended. Resident #1 was admitted to the local hospital on [DATE] at 1:45 PM with working [DIAGNOSES REDACTED]." The resident's hospital admission records revealed her vital signs were BP of 123/47 (normal 130-80), pulse 52 and irregular (normal 60-100). She was placed on cardiac monitoring which indicated "[MEDICAL CONDITION] with pulse rates of 40-70)." "In the Emergency Department the patient was slightly lethargic and her blood pressure was labile (unsteady). She had an episode of transient [MEDICAL CONDITION] (pulse rate dropped to 40 beats per minute) and we are placing her in the ICU (intensive care unit) under observation for further monitoring, evaluation and treatment." [MEDICATION NAME] (reverses the lethargy and decreases respirations exhibited with opiate overdose) was administered at 4:29 PM to reverse the effects of the [MEDICATION NAME] (opiate) that the resident had received as part of the 15 medication given at 11 AM. A note dictated by the hospitalist on 05/17/13 at 6:29 PM indicated creatinine (measure of kidney function) was 2.5 (normal for this patient is 2.0 from nursing home records) and EKD (electrocardiogram) "showed [MEDICAL CONDITION] with a variable rate between 41-61 beats per minute (normal=60-100) and left bundle branch block (delay or obstruction along the pathway that electrical impulses travel to make your heart beat)." An ICU nurses note on 05/17/13 at 7:45 PM revealed [MEDICAL CONDITION] of 50-70 with both lungs clear. At 8:30 PM her blood pressure dipped to 80s/40s. The medical doctor (MD) was notified and started the resident on a [MEDICATION NAME] drip. Lexi-comps Geriatric Dosage Handbook, 17th edition stated that [MEDICATION NAME] is used as an adjunct treatment in shock ([MEDICAL CONDITION] and cardiac decompensation (functionality)). At 10 PM her heart rate and BP were back up (136/60, HR=65) but she was not urinating. The MD was notified and increased her intravenous fluid rate to 75 cc per hour. On 05/18/13 laboratory assay revealed that the resident ' s creatinine has risen to 3.0 indicating worsening kidney function. IVF (intravenous fluids) were reduced to 35 mg/ hour at 6 PM. On 05/19/13 at 8:50 AM ICU nurses notes indicated resident complained of shortness of breath. Her oxygen saturations were dropping to 89-90% (normal =100%) and her heart rate was 120 and irregular. At 9:10 AM, MD notes indicated the MD ordered for the resident to have an EKG for shortness of breath, a portable chest x-ray now, a beta-natriuretic (BNP) to assess for worsening [MEDICAL CONDITION], cardiac tropins to rule out [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]), and [MEDICATION NAME] to regulate heart beat. Both BNP (indicative of congestive hearth failure) and tropin levels returned as significantly elevated. Chest x-ray results indicated "There has been slight interval of congestive cardiac failure and bilateral (both lungs) pleural effusions are present (fluid in both lungs)." On 05/19/13 at 8:15 PM the resident again complained of shortness of breath and the attending physician's notes indicated [MEDICAL CONDITION](fast heart rate) of 135 (abnormal range of 127-140s), decreased oxygen saturation of 87, definitive [MEDICAL CONDITION] and the necessity to start IV diuretic (Push [MEDICATION NAME] IV 40 mg). The resident's blood pressure at this note was 167/110. On 05/20/13 at 8:15 AM the attending physician noted acute [MEDICAL CONDITIONS]. The resident remained at the hospital as of 05/24/13.

Based on record review and interviews, the facility failed to provide the necessary care to maintain a resident ' s well being for one (1) of three (3) sampled residents (Resident #1) reviewed for skin breakdown by failing to obtain treatment orders for a resident with an immobilizer, failing to assess the skin under an immobilizer, failing to make a follow-up appointment and failing to report a change in skin condition to the physician. The findings include: Resident # 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 wore an immobilizer to her left leg. Review of the Admission Minimum Data Set Assessment, dated 11/11/11, documented that Resident #1 had short term memory impairment and was moderately impaired in making daily decisions. Resident #1 needed extensive assistance using two persons with bed mobility, was totally dependent on two persons for transferring and totally dependent on staff for bathing. Resident #1 was incontinent of bowel and bladder. Resident #1 was assessed as having two (2) Stage II pressure ulcers and one (1) unstageable pressure ulcer upon admission. Review of the Care Area Assessments, dated 11/11/11, triggered in the area Pressure Ulcers triggered related to Resident #1 needing assistance with bed mobility, urinary incontinence, bowel incontinence and the resident had one or more unhealed pressure ulcers at Stage 2 or higher, or one or more likely pressure ulcers that were unstageable. Review of the Care Plan for Alteration of Skin Integrity dated 11/8/11 and revised on 11/17/11 read in part, " Focus: Alteration in skin integrity related to: necrotic foot ulcer to right heel, two stage II to buttock, deep tissue injury to left heel. " Review of the Care Plan for " Self care deficit due to fracture " dated 11/17/11 read in part: " goals: will participate in ADL ' s (Activities of Daily Living) and have a neat, clean, well groomed appearance during the next 90 days. Listed interventions for meeting the goal included " baths and showers per schedule and as needed. Skin check. " Review of the Care Plans related to Falls, Pain, ADL ' s and Skin Integrity did not include mention of the leg immobilizer worn by Resident #1. Review of the Hospital Discharge Summary, dated 11/3/11 read in part, " Hospital Course: initially admitted to (name of Orthopedic physician) service secondary to her orthopedic problems. Special Instructions: Patient is to follow up with (name of Orthopedic physician) next week status [REDACTED]. " Review of the Admitting physician's order [REDACTED].#1 was to have a follow-up appointment with (name of Orthopedist), Date: next week. Nursing Admission Assessments, dated 11/04/11, indicated Resident # 1 had two " excoriated " areas to the right and left buttocks, " white spot " to the left buttocks, " deep tissue injury " to the left heel and a " necrotic area " to the right heel. Review of the Norton Plus Pressure Ulcer Scale documentation, dated 11/4/11, revealed that Resident #1 was at high risk for developing pressure ulcers. Resident #1 had an [MEDICATION NAME] level of 2.9 (A serum [MEDICATION NAME] level measures that amount of protein in the blood. The normal range is 3.4-5.4) Review of the November 2011 Treatment Record indicated Resident #1 received weekly skin checks on 11/12/11 and 11/18/11. No new skin issues were noted. During an interview with NA #1 on 1/31/11 at 11:55am she stated that Resident #1 had an immobilizer splint on her leg from the thigh to her ankle. She stated that the immobilizer was kept on at all times and she had never bathed under the immobilizer. She stated that no one had ever told her to remove the immobilizer and she did not, except on one occasion with the Nurse #1. When we removed the immobilizer " I was like, whoa. " NA #1 stated she didn ' t remember exactly why they took off the immobilizer; it may have had a smell. NA #1 stated there was a sore on the back of her calf when we checked under the brace and drainage on the immobilizer. I remember the nurse cleaned it and put a bandage on it and then put the brace back on. She stated that she does not remember there being any kind of protective material, stocking, or anything between the brace and the skin. It was just a padded brace. During an interview with the Director of Nursing (DON) on 1/31/12 at 1:30pm she stated that the floor nurses do the weekly skin assessments and if there is a negative finding then that is documented in the nursing notes. Review of the nursing note did not show any documentation of any skin changes to the left lower extremity (calf area). During an interview with Occupational Therapy on 1/31/12 at 2:00PM she stated that the immobilizer had not been removed by the therapy department. During an interview with Nurse #1, by telephone, on 1/31/12 at 2:00pm she stated that the resident had an immobilizer on her left lower extremity and it had never been removed since her admission. She stated that on 11/20/11 before lunch she and NA #1 were curious about the splint. They removed it and took it off. While washing her leg, an open area was observed about mid calf. Nurse #1 stated she cleaned it with normal saline and applied a dry piece of gauze and a little pad and then put the immobilizer back on. She stated the she did not recall a smell or drainage. She stated that she did not document any of this because she had placed a call to the on-call weekend nurse and I left the message and included her cell phone number because she wanted instructions on what to do. She stated that no one ever returned my call. She said this was on a Sunday and when she came in on Monday, 11/21/11 the resident had been sent to the hospital and never returned to the facility. During an interview with Nurse #2 on 1/31/12 at 2:10pm she stated that she had done the skin assessment on 11/18/11 and she did not remove the immobilizer to check the skin underneath because she was never instructed as to whether nursing or therapy could remove. During a follow up interview with Nurse #1 on 1/31/12 at 2:45pm she stated that she did the initial nursing assessment on 11/4/11 and did not remove the immobilizer during that assessment and check the resident ' s skin. She stated she probably should have but there was no order to remove it. She stated that she spoke with the physician and went over the admission medications and mentioned that the resident had an immobilizer but the physician never gave any orders regarding the immobilizer. She also stated that she did the skin assessment on 11/11/11 but had not removed the immobilizer during the skin assessment. During an interview on 1/31/12 at 3:45pm with the DON she stated that she was not here during this timeframe, but she would have expected the nursing staff to clarify the physician's order [REDACTED]. During an interview on 1/31/12 at 3:5pm with the resident ' s physician, she stated that she would expect the facility to follow orders given by the Orthopedist and she would have expected that the integrity of the skin be inspected on admission and during the resident ' s stay, the immobilizer be removed to clean the resident ' s leg and to inspect any surgical incision that the resident may have had. She also stated that when the facility found an open sore on the resident ' s left she would have liked to have been notified of this. During an interview on 2/1/12 at 11:00am with the Administration she stated that she would have expected that at the time of admission the follow up appointment with the Orthopedist have been made, that the nursing staff would have clarified how to care for a resident with an immobilizer, that the staff would have assessed the resident ' s skin on admission under the immobilizer and on weekly skin assessments and that when the ulcer was discovered the 24 hour report would have been completed and the physician notified. Further review of the physician's order [REDACTED]. Temperatures were documented on the Medication Administration Record and/or the Nursing notes. Review of a Physician order [REDACTED]. The results were negative. Review of the Hospital Admission records on 11/21/11 revealed that the " chief complaint was decreased appetite. " During an interview with the facility staff it was stated that the resident had not been eating well and the family wanted her sent to the emergency room for an evaluation. Review of the Nursing Notes on the date of discharge revealed that the resident ' s appetite was decreased and the family wanted her sent to the hospital. Review of the hospital history and physical record, dated 11/21/11, read in part, " Physical Examination: SKIN: Several [MEDICAL CONDITION] are seen - a 12cm (centimeter) vertical x 5 cm in diameter un-stageable ulceration over the posterior left lower extremity midway up the calf, poor skin turgor. " Review of the hospital consultation, dated 11/21/11, read in part, " REASON FOR EVALUATION: ulcer of both lower extremities. PHYSICIAL EXAMINATION: Extremities: Immobilized involving left knee. There was extensive necrosis with dry eschar involving the posterior calf. " Review of the hospital Infectious Disease consultation, dictation date of 11/24/11, read in part, " patient has multiple chronic health conditions and recently stopped eating; PHYSICAL EXAM: Extremities: the patient ' s straight leg brace was removed to reveal dryness of lower extremity, no swelling around her knee, Eschar lesion noted on the posterior distal tibia that does not appear to be related to the brace itself. LAB/DIAGNOSTIC Studies: X-ray of tib-fib from 11/21/11 reports no osteo[DIAGNOSES REDACTED], blood cultures negative, urine studies from 11/21/11 report 3+ bacteria, 3+leukocytes and greater than 180 white blood cells per high power field. IMPRESSION and PLAN: 1. Altered mental status, systemic [MEDICAL CONDITION] response syndrome, 2. urinary tract infection with [MEDICAL CONDITION], 3. failure to thrive with decreased appetite for over a week. PLAN: antimicrobial therapy noting the unstageable [MEDICAL CONDITION] of the patient ' s legs, no [DIAGNOSES REDACTED], no inflammation, possible the patient is having ischemic changes. " During a telephone interview on 2/8/12 at 7:45am with the Infectious disease physician he stated that the immobilizer did play a role in development of the ulcer, which was pressure. He further stated that there was a possibility that a pressure ulcer could develop at some point, but the immobilizer accelerated that development. He stated that the resident does not have a [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary, dated 12/4/11, read in part, " Diagnoses: [REDACTED]. End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], 3. [MEDICAL CONDITION], 4. Debility, 5. Spinal stenosis, 6. Left heel ulcer. " The Hospital course documented that Resident #1 was seen in the emergency room related to a fever and [MEDICAL CONDITION]. The resident was septic with blood cultures being negative and urinalysis showing presence of white blood cells. The physician documented that " this is probably related to etiology [MEDICAL CONDITION]. " In summary, Resident #1 was admitted with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility with three pressure ulcers. Resident #1 was receiving daily antibiotic coverage for a Urinary tract infection since admission. She wore an immobilizer to her left leg. Resident #1 had no skin assessments to the skin under her immobilizer during her stay until her 17th day in the facility, one day before she was sent to the hospital. At that time, an open area was observed to the back of the left calf. The physician was not notified at this time and there was no documentation in the medical record relating to the open area on the back of the left calf. Follow up appointments with the Orthopedic surgeon were not made by the facility and there was no clarification on the facility ' s part as to how to care for the resident with the immobilizer. The resident was transferred to the hospital on [DATE] and there she was found to have a 12cm x 5cm eschar ulcer to her left calf. The wound was negative for any growth, the X-ray showed no Osteomylitits. The resident was treated at the hospital and discharged to a different facility on 12/4/11.

Based on record reviews, staff interviews and hospital physician interview the facility failed to identify an eschar ulcer and for 1 of 3 sampled residents reviewed for risk of skin breakdown (Resident #1). The findings include: Resident # 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 wore an immobilizer to her left leg. Review of the Admission Minimum Data Set Assessment, dated 11/11/11, documented that Resident #1 had short term memory impairment and was moderately impaired in making daily decisions. Resident #1 needed extensive assistance using two persons with bed mobility, was totally dependent on two persons for transferring and totally dependent on staff for bathing. Resident #1 was incontinent of bowel and bladder. Resident #1 was assessed as having two (2) Stage II pressure ulcers and one (1) unstageable pressure ulcer upon admission. Review of the Care Area Assessments, dated 11/11/11, triggered in the area of Activities of Daily Living related to Resident #1 needing extensive assistance with bed mobility, moderate impairment in making daily decisions, totally dependent of transfers and being totally dependent in bathing. The area of Pressure Ulcers triggered related to Resident #1 needing assistance with bed mobility, urinary incontinence, bowel incontinence and the resident had one or more unhealed pressure ulcers at Stage 2 or higher, or one or more likely pressure ulcers that were unstageable. Review of the Care Plan for Alteration of Skin Integrity dated 11/8/11 and revised on 11/17/11 read in part, " Focus: Alteration in skin integrity related to: necrotic foot ulcer to right heel, two stage II to buttock, deep tissue injury to left heel. " Review of the Hospital Discharge Summary, dated 11/3/11 read in part, " Hospital Course: initially admitted to (name of orthopedic physician) service secondary to her orthopedic problems. Special Instructions: Patient is to follow up with (name of Orthopedic physician) next week status [REDACTED]. " Review of the Admitting physician's order [REDACTED].#1 was to have a follow-up appointment with (name of Orthopedist), Date: next week. Review of the Norton Plus Pressure Ulcer Scale documentation, dated 11/4/11, revealed that Resident #1 was at high risk for developing pressure ulcers. Resident #1 had an [MEDICATION NAME] level of 2.9 (A serum [MEDICATION NAME] level measures that amount of protein in the blood. The normal range is 3.4-5.4). Nursing Admission Assessments, dated 11/04/11, indicated Resident # 1 had two " excoriated " areas to the right and left buttocks, " white spot " to the left buttocks, " deep tissue injury " to the left heel and a " necrotic area " to the right heel. Review of the November 2011 Treatment Record indicated Resident #1 received weekly skin checks on 11/12/11 and 11/18/11. No new skin issues were noted. During an interview with NA #1 on 1/31/11 at 11:55am she stated that Resident #1 had an immobilizer splint on her leg from the thigh to her ankle. She stated that the immobilizer was kept on at all times and she had never bathed under the immobilizer. She stated that no one had ever told her to remove the immobilizer and she did not, except on one occasion with the Nurse #1. When we removed the immobilizer " I was like, whoa. " NA #1 stated she didn ' t remember exactly why they took off the immobilizer; it may have had a smell. NA #1 stated there was a sore on the back of her calf when we checked under the brace and drainage on the immobilizer. I remember the nurse cleaned it and put a bandage on it and then put the brace back on. She stated that she does not remember there being any kind of protective material, stocking, or anything between the brace and the skin. It was just a padded brace. During an interview with the Director of Nursing (DON) on 1/31/12 at 1:30pm she stated that the floor nurses do the weekly skin assessments and if there is a negative finding then that is documented in the nursing notes. During an interview with Occupational Therapy on 1/31/12 at 2:00PM she stated that the immobilizer had not been removed by the therapy department. During an interview with Nurse #1, by telephone, on 1/31/12 at 2:00pm she stated that the resident had an immobilizer on her left lower extremity and it had never been removed since her admission. She stated that on 11/20/11 before lunch she and NA #1 were curious about the splint. They removed it and took it off. While washing her leg, an open area was observed about mid calf. Nurse #1 stated she cleaned it with normal saline and applied a dry piece of gauze and a little pad and then put the immobilizer back on. She stated the she did not recall a smell or drainage. She stated that she did not document any of this because she had placed a call to the on-call weekend nurse and left a message and included her cell phone number because she wanted instructions on what to do. She stated that no one ever returned my call. She said this was on a Sunday and when she came in on Monday, 11/21/11 the resident had been sent to the hospital and never returned to the facility. During an interview with Nurse #2 on 1/31/12 at 2:10pm she stated that she had done the skin assessment on 11/18/11 and she did not remove the immobilizer to check the skin underneath because she was never instructed as to whether nursing or therapy could remove. During a follow up interview with Nurse #1 on 1/31/12 at 2:45pm she stated that she did the initial nursing assessment on 11/4/11 and did not remove the immobilizer during that assessment and check the resident ' s skin. She stated she probably should have but there was no order to remove it. She stated that she spoke with the physician and went over the admission medications and mentioned that the resident had an immobilizer but the physician never gave any orders regarding the immobilizer. She also stated that she did the skin assessment on 11/11/11 but had not removed the immobilizer during the skin assessment. During an interview on 1/31/12 at 3:45pm with the DON she stated that she was not here during this timeframe, but she would have expected the nursing staff to clarify the physician's order [REDACTED]. During an interview on 1/31/12 at 3:5pm with the resident ' s facility physician, she stated that she would expect the facility to follow orders given by the Orthopedist and she would have expected that the integrity of the skin be inspected on admission and during the resident ' s stay, the immobilizer be removed to clean the resident ' s leg and to inspect any surgical incision that the resident may have had. She also stated that when the facility found an open sore on the resident ' s left she would have liked to have been notified of this. During an interview on 2/1/12 at 11:00am with the Administration she stated that she would have expected that at the time of admission the follow up appointment with the Orthopedist have been made, that the nursing staff would have clarified how to care for a resident with an immobilizer, that the staff would have assessed the resident ' s skin on admission under the immobilizer and on weekly skin assessments and that when the ulcer was discovered the 24 hour report would have been completed and the physician notified. Review of the hospital history and physical record, dated 11/21/11, read in part, " Physical Examination: SKIN: Several [MEDICAL CONDITION] are seen - a 12cm (centimeter) vertical x 5 cm in diameter un-stageable ulceration over the posterior left lower extremity midway up the calf, poor skin turgor. " Review of the hospital consultation, dated 11/21/11, read in part, " REASON FOR EVALUATION: ulcer of both lower extremities. PHYSICIAL EXAMINATION: Extremities: Immobilized involving left knee. There was extensive necrosis with dry eschar involving the posterior calf. " Review of the hospital Infectious Disease consultation, dictation date of 11/24/11, read in part, " patient has multiple chronic health conditions; PHYSICAL EXAM: Extremities: the patient ' s straight leg brace was removed to reveal dryness of lower extremity, no swelling around her knee, Eschar lesion noted on the posterior distal tibia that does not appear to be related to the brace itself. PLAN: antimicrobial therapy noting the unstageable [MEDICAL CONDITION] of the patient ' s legs, no [DIAGNOSES REDACTED], no inflammation, possible the patient is having ischemic changes. " During a telephone interview on 2/8/12 at 7:45am with the Infectious disease physician he stated that the immobilizer did play a role in development of the ulcer, which was pressure. He further stated that there is always a possibility of a pressure ulcer developing at some point, but the immobilizer accelerated the development. He stated that the resident does not have a [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary, dated 12/4/11, read in part, " Diagnoses: [REDACTED]. End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], 3. [MEDICAL CONDITION], 4. Debility, 5. Spinal stenosis, 6. Left heel ulcer. " The Hospital course documented that Resident #1 was seen in the emergency room related to a fever and [MEDICAL CONDITION]. The resident was septic with blood cultures being negative and urinalysis showing presence of white blood cells. The physician documented that " this is probably related to etiology [MEDICAL CONDITION]. " In summary, Resident #1 was admitted with [DIAGNOSES REDACTED]. Resident #1 was receiving daily antibiotic coverage for a Urinary tract infection since admission. She wore an immobilizer to her left leg. Resident #1 was admitted to the facility with pressure ulcers to her buttock and heels. Resident #1 had no skin assessments to the skin under her immobilizer during her stay until her 17th day in the facility, one day before she was sent to the hospital. At that time, an open area was observed to the back of the left calf. The resident was transferred to the hospital on [DATE] and there she was found to have a 12cm x 5cm eschar ulcer to her left calf. The wound was negative for any growth, the X-ray showed no Osteomylitits. The resident was treated at the hospital and discharged to a different facility on 12/4/11.