Every finding on record at Cheraw Healthcare

Based on review of facility policy, record review, and interview, the facility failed to ensure and document annual performance evaluations were completed for 5 out of 5 Certified Nursing Assistants (CNAs) reviewed.Findings include:Review of the undated facility policy titled Skill Competency Evaluations, revealed, All Nurse's and CNA's will have competency evaluations performed during orientation, annually, and prn (as needed) by designated staff.Review of personnel records for 5 of 5 CNAs, revealed no documentation of an annual performance evaluation within the required timeframe.During an interview on 03/12/2026 at 11:21 AM, the Human Resource Director confirmed that annual competency evaluations have not been completed for the CNAs reviewed.During an interview on 03/12/2026 at 3:34 PM, the Administrator confirmed that although competency evaluations are required to be completed annually for nurses and CNAs, they have not been completed as required.

Based on review of facility policy, record review, observation and interview, the facility failed to ensure Resident (R)5 received the needed care and services related to activities of daily living. Specifically R5, was not provided routine hair and nail care, for 1 of 1 resident reviewed for activities of daily living.Findings include: Review of the facility policy titled, Activities of Daily Living (ADL) Supporting, with a revision date of March 2018, revealed as the policy statement, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy interpretation and implementation revealed, . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. 3. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 6. The resident's response to interventions will be monitored, evaluated and revised as appropriate. Review of R5's Face Sheet revealed the facility admitted R5 with diagnoses including, but not limited to, anxiety disorder, cerebral infarction, and history of urinary tract infections. Review of R5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/21/2026, a return after a hospital stay, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated R5 suffered from severe cognitive deficits. Review of R5's Care Plan dated 02/02/2025, revealed a focus area that states, The resident has an ADL self-care performance deficit related to fatigue, impaired balance and stroke. The goal states, The resident will improve current level of function in ADLS through the review date. The interventions include, Bathing/showering: The resident requires extensive assistance from staff to provide a bath and a shower. [R5] requires extensive assistance with bed mobility, dressing and transfer. Personal hygiene, The resident requires partial/moderate assistance by staff for personal hygiene and oral care.During an observation on 03/10/2026 at 11:22 AM, revealed R5 in bed, her fingernails were dirty and her hair was in need of a wash.During an observation on 03/11/2026 at 10:26 AM, revealed R5 resting in bed, her clothes were changed from 03/10/2026, but her fingernails and hair are still in need of cleaning.During an observation on 03/12/2026 at 8:04 AM, I entered R5's room and her Responsible Party (RP) was in the room feeding R5. R5's fingernails remained dirty and her hair was dirty and matted to her head.During an interview on 03/11/2026 at 12:50 PM, the Administrator stated, she would talk with the nurse and see why the resident was not bathed and clean daily. During an interview on 03/12/2026 at 3:41 PM, Licensed Practical Nurse (LPN)2, who was assigned to provide care for R5 on all 3 days, stated, if this resident refuses a bath or shower they will tell her and she will attempt to encourage the resident to bathe. LPN2 stated she was not aware that R5 had not received a bath on any of the three days mentioned. Upon entering R5's room LPN2 showed me her hands and fingernails which had been cleaned and her hair had been shampooed today, after this surveyor brought the concern to their attention.

Based on review of facility policy, record review and interview, the facility failed to attempt a gradual dose reduction (GDR) for Resident (R)10, who has a diagnoses of Alzheimer's Dementia and is receiving 200 milligrams of Quetiapine at bedtime, for 1 of 5 residents reviewed for unnecessary medications. Findings include:Review of the undated facility policy titled, Unnecessary Medications, revealed, Purpose: To ensure residents are free from unnecessary medications and that all medications are prescribed and administered only when clinically indicated. The policy states, The facility will ensure that each resident's medication regimen is free from unnecessary medications. An unnecessary medication is defined as any medication used in excessive dose, excessive duration, without adequate monitoring, without adequate clinical indication, in the presence of adverse consequences, or without adequate attempts at dose reduction when indicated. 4. Residents receiving medications such as psychotropic medications will receive gradual dose reductions when clinically appropriate unless contraindicated. Documentation must support when dose reductions are attempted or when clinical rational exists for not attempting a reduction. 5. Psychotropic medications will be used when necessary to treat a specific diagnosed condition. Non-pharmacological interventions will be attempted when appropriate and monitoring for effectiveness and side effects will be documented.Review of R10's Face Sheet revealed the facility admitted R10 with diagnoses including, but not limited to, cognitive communication deficit, anxiety and Alzheimer's dementia.Review of R10's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2026, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive deficit.Review of R10's Physician Order revealed an order for: Quetiapine 200 milligrams to be given at bedtime each night, which was ordered by the physician on 05/22/2025 on admission.Review of R10's Medical Record revealed a weight on 03/04/2026 of 86 pounds and according to the Care Plan Report dated 02/23/2026 states, resident has a history of significant weight changes. Review of R10's Care Plan Report dated 05/25/2025, revealed a fall with minor injuries. The Care Plan Report dated 06/03/2025 ,revealed a fall with a fracture of her left femur. The Care Plan revision dated 09/02/2025, revealed a fall with minor injuries and again on 01/16/2026, a fall with a minor injury and a complaint of right hip pain.Review of R10's Note To Attending Physician/Prescriber with a MRR (Medication Regimen Review) date of 11/21/2025, revealed, The resident has been taking the antipsychotic Quetiapine 200mg at bedtime since May 2025. please evaluate the current dose and consider a dose reduction. The physician indicated, Resident with good response, maintain the current dose. The next section of the document stated, IMPORTANT: Please add resident specific documentation to support the above action or check below if information was added to physician progress notes this section was left blank and did not include clinical rationale nor physician progress notes. During an interview on 03/12/2026 at 9:38 AM, the Pharmacist stated she had recommended a reduction in the Seroquel on 11/21/2025 and the physician declined. She stated that the physician makes the decision whether to reduce the medications or not. I informed her that the physician has checked the area that stated, Resident with good response. there was no documentation on the dose reduction recommendation as to specific rationale for no dose reduction.During an interview on 03/12/2026 at 10:35 AM, the attending physician for R10, she stated that 200 milligrams of Seroquel was a large dose for an [AGE] year old weighing 86 pounds. I brought to her attention the weight loss and the falls. She also agreed that the weight loss and the falls could have been attributed to the Quetiapine. She stated she look at the chart and make a decision.

Based on review of facility policy, observation and interview, the facility failed to ensure expired medications were removed from, and not in use with in-date medications for residents, in 1 of 4 medication carts.Review of the facility policy titled, Medication Labeling and Storage, states, . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. During an observation on 03/12/2026 at approximately 4:00 PM, of the South Hall medication cart #1, revealed one bottle of Aspirin, 325 milligram tablets, with Lot #921X06 was expired on 01/26/2026. During an interview on 03/12/2026 at 4:06 PM, Licensed Practical Nurse (LPN)1 confirmed the expired medication and removed the bottle of Aspirin from the medication cart.

Based on observation, interview, and record review, the facility failed to ensure temperatures were in range for safe food storage to prevent foodborne illness, in 1 of 2 nourishment room refrigerators.Findings include:Review of the undated facility policy titled, Policy: Resident Nourishment Refrigerator Temperature Monitoring, revealed, Purpose: To ensure all nourishment room refrigerators maintain safe temperature to prevent foodborne illness. Policy: All refrigerators used for resident nourishment storage will be maintained at 41 degrees F (5 degrees C) or below. Monitoring: Refrigerator temperature will be checked and documented daily by designated staff. Thermometers: Each refrigerator must contain a visible thermometer. Corrective Action: If temperature exceeds 41 degrees F, staff will recheck with 30 minutes and notify dietary or maintenance. Audits: Dietary manager or designee will conduct monthly audits to ensure compliance.During an observation on 03/12/26 at 8:40 AM, of the North Unit Hall-100 nourishment room refrigerator revealed the temperature gauge reading at 46 degrees Fahrenheit, which was verified by the kitchen manager. The refrigerator contained the following: nine (9) Mighty Shakes (strawberry and chocolate) 4FL oz., two (2) Medpass supplements drinks 32 FL oz., five (5) Glucerna Shake 10 FL oz., and eight (8) Ardmore 100% Orange Juice 4FL oz. The refrigerator also contained residents' personal food items. Review of the Daily Refrigerator/Freezer Temperature Checks Month February 2026-North Nourishment dated 02/24 revealed refrigerator temperature was 52 degrees Fahrenheit on 02/25 refrigerator temperature 52 degrees Fahrenheit, on 02/26 refrigerator temperature 50 degrees Fahrenheit, on 02/27 refrigerator 50 degrees Fahrenheit, on 02/28 refrigerator temperature 50 degrees Fahrenheit. Review of the Daily Refrigerator/Freezer Temperature Checks Month March 2026-North Nutrition dated 03/01 revealed refrigerator temperature 44 degrees Fahrenheit, on 03/02 refrigerator temperature 42 degrees Fahrenheit, on 03/04 refrigerator temperature 42 degrees Fahrenheit, on 03/09 refrigerator temperature 42 degrees Fahrenheit, on 03/10 refrigerator temperature 48 degrees Fahrenheit, on 03/11 refrigerator temperature 46 degrees Fahrenheit, on 03/12 refrigerator temperature 44 degrees Fahrenheit. During an interview on 03/12/26 at 9:12 AM, the Kitchen Manager (KM) revealed the unit nourishment rooms are maintained by the nursing staff. The refrigerator was recently replaced because the previous refrigerator was too small and was not big enough for nourishments and the residents' personal food. The refrigerator temperatures are normally checked before she gets into work. The nourishments are refilled by the kitchen staff, and they are expected to monitor the temperature readings and report to maintenance when the temperature is out of range. During an interview on 03/12/26 at 9:46 AM, the Maintenance Director revealed it was reported to him last week that the refrigerator temperature gauge was reading out of range. The temperature control was reset. The current refrigerator is new and was replaced on 02/19/26. The Maintenance Director believed it was the thermometer, so he changed it out, however, the temperature remained out of range. The Maintenance Director still didn't believe the thermometer is accurate and proceeded to switched out the thermometer again. During an interview on 03/12/26 at 10:00 AM, the Administrator revealed she was not aware the refrigerator temperatures were out of range. The Administrator stated they just found out and she asked maintenance to replace the thermometer and place it in the back of the refrigerator. The Administrator stated her expectation is for the temperature to be checked and when it is out of range to notify maintenance. The regulated temperature range is on the bottom of the temperature log and when to notify maintenance.

Based on review of the facility policy, record review, and interview, the facility failed to ensure a significant medication error did not occur when Resident (R)1 received medications intended for her roommate, resulting in R1 suffering from a low heart rate, low blood pressure, and becoming diaphoretic (excessive sweating), which required a hospital stay in intensive care from 08/23/25 until 08/26/25, for 1 of 1 resident reviewed for significant medication errors.On 11/06/25 at 1:35 PM, the survey team provided the DON with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/23/25. The IJ was related to 483.45-Pharmacy Services.On 11/06/25 at 6:45 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined that the facility put forth due diligence in addressing the non-compliance. The SA is considering this IJ at Past Non-Compliance as of 08/25/25.An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Findings include:Review of the facility policy titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection states under the Guidelines and Definitions: 1. Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident or consumer.Review of R1's medical record on 11/06/25 revealed R1 was admitted to the facility with diagnoses including, but not limited to, stroke, aortic valve stenosis, seizure disorder, hypertension, depression, heart failure with atrial fibrillation and cognitive communication deficit.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating R1 had severe cognitive deficits. Review of the Progress Notes for R1 dated 08/23/25 (2 notes) revealed, At around 09:30 PM, I heard [R1] calling for help. I, the RN on duty, went to the resident's bedside. She was found laying in the bed and asking for help to get up. She stated she felt sick. I adjusted the resident in bed and fanned her. While assessing her I found her pulse to be weak. I took the resident's blood pressure and she was found to be hypotensive. The Nurse Practitioner was notified of the resident's status, and she advised to call EMS for transport to send [R1] to the ER. EMS was called and the resident was picked up around 10:30 PM by EMS and transported to the hospital. The resident's family was contacted and informed of the transfer to the ER.Review of R1's Emergency Department (ED) Provider Notes with a Date of Service on 08/23/25 revealed the following: Chief Complaint: Drug Overdose (Pt form CHC after being given 15mg morphine among some other meds that was not hers). History of Present IlIness: Patient brought to the emergency room from Cheraw health care after receiving multiple medications from another patient's medication list. She received a single dose of morphine sulfate extended release 15 mg a single dose of quetiapine fumarate 300 mg a single dose of Eliquis 5 mg a single dose of clonidine 0.1 mg a single dose of docusate sodium 100 mg a single dose of carvedilol 25 mg a single dose of atorvastatin 40 mg a single dose of hydralazine 100 mg and a single dose of gabapentin 100 mg. Patient's blood pressure is low and mental status is somewhat subdued. The patient received Narcan and 1 L of LR by EMS and 1 mg of Narcan by EMS.During an interview on 11/03/25 at 10:03 AM, Registered Nurse (RN)1 stated it all started when R1 was in the restroom yelling for help. I had already pulled the medications for her roommate, and they were in a cup. I carried the cup of medication into the room and helped R1 get up from the toilet and then gave her the medications that were for her roommate. When I realized it was a mistake, I started monitoring her. She became diaphoretic and her heart rate decreased. So, I notified my Unit Manager and she called the Nurse Practitioner and got an order to transport the resident to the ER.During an interview on 11/06/25 at 12:03 PM the DON stated she could not find in the medical record where the vital signs were monitored. She stated that she would expect the nurse to monitor the vital signs so that she could report them to the physician.During an interview on 11/06/25 at 12:10 PM, the Unit Manager stated that she knew the nurse was monitoring the vital signs. RN1 had come to her and told her she thought she gave the wrong medications to the resident and I told her to call the physician and give him the information and go from there. The Unit Manager confirmed that the vital signs were not in the medical record and stated that she would expect the nurse to document them in the medical record. On 11/06/25 at 6:45 PM, the facility provided an acceptable IJ Removal Plan, which included the following:1. MD notified, and Resident was sent to the hospital on [DATE]. Returned to facility on 08/26/2025. Resident returned with no adverse effects.2. All residents were assessed by the Director of Nursing on 08/24/2025 with all residents without distress. VItal signs obtained and reviewed for abnormalities, none noted. All residents assessed by Director of Staff Developement on 11/06/2025. Roommate MAR (Medication Administration Record) reviewed for medication administration on 08/23/2025. Resident received medications as ordered.3. Resident's names placed outside doors and pictures placed on EMR on every resident. Identification bracelets placed on all residents on 11/06/2025. Inservice on Medication Administration, Medication Errors Policy & Procedures was completed on 08/25/2025. Director of Staff Development and/or designee to provide skills competency to each nurse before next scheduled shift.4. DON to monitor medication administrations skills competencies weekly x4, monthly x3, then quarterly until compliance has been met.5. Compliance date 08/24/2025.

Based on observations, review of facility policy, and interviews, the facility failed to remove expired medications and biologicals from 2 of 2 medication storage rooms. Findings include: Review of the undated facility policy titled, Medication Storage In The Facility documented, Policy: Medications and biologicals are stored safely, securely and properly following manufacturers' recommendations or those of the supplier. During an observation and interview on 11/14/24 at 7:21 AM, the medication storage room on the South Unit revealed, One (1) BD Vacutainer Red Top with lot number 2258780 and expiration date 09/30/24. Licensed Practical Nurse (LPN)2 verified the item was expired and removed it from the medication room. During an observation and interview on 11/14/24 at 7:53 AM, the medication storage room on the North Unit revealed the following: -One (1) BD Vacutainer Gel and Lithium Heparin [NAME] Top with lot number 3290681 and expiration date 10/31/24. The Director of Nursing (DON) verified the item was expired and removed it from the medication storage room. -Two (2) boxes of Covidien Filac Probe Covers with lot number 930156X and expiration date 08/31/24, containing 20 probe covers in each box. -One (1) box of Covidien Filac Probe Covers with lot number 930156X and expiration date 08/31/24, containing 19 probe covers. The DON verified the items were expired and removed them from the storage. During an observation and interview on 11/14/24 at 8:42 AM, the medication storage, in the hallway, on the North Unit revealed the following: -Three (3) Covidien Kangaroo Epump Sets with Flush 1000 ml with lot number 201110107 and expiration date 03/31/23. -One (1) Covidien Kangaroo Epump Set with Flush 1000 ml with lot number 2123613664 and expiration date 07/31/24. The DON verified the items were expired and removed them from storage.

Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)11, R62, R73, R96, and R100, had the right to formulate accurate Advance Directives for 5 of 8 residents reviewed for Advance Directives. Findings include: Review of the undated facility policy titled, Advance Directives Policy documented, It is the desire of Cheraw Healthcare Inc. to inform each resident of his/her right to make an informed decision concerning their medical care including: Their right to refuse or accept medical and surgical treatment and the right to formulate advance directives . Each record will be marked to signify that Advance Directives have been made . Review of the undated facility policy titled, Procedures for Advance Directives (DNR, Living Wills, Durable/Health Care Power of Attorney) documented, Information with respect to Advance Directives (Living Wills and Health Care Power of Attorney) in the form of pamphlets Medical Treatment and Your Living Will and Your Right to make Decisions about Your Health Care will be made available upon request. The Resident/Family member or representative will be responsible to make decisions concerning: B. The right to formulate advance directives . Copies of Advance Directives will be kept in the Social Services Coordinator's office and on the medical record. To alert physicians and staff, each record will be coded with A. D. for Advanced Directives. For No Code, the initials DNR will be placed on resident's record . 1. Review of R62's Face Sheet revealed R62 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease and unspecified dementia. Review of R62's Physician Order with a start date of 11/13/24 documented, DNR (Do Not Resuscitate). Review of R62's Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/18/24, did not reveal a Brief Interview for Mental Status (BIMS) score related to section C question 0100 being coded as no (rarely/never understood). Review of R62's Electronic Medical Record (EMR) on 11/13/24 at 12:13 PM, revealed there was no code status, however a Do Not Resuscitate (DNR) written order was discovered in R62's hard chart (paper chart). During an interview on 11/13/24 at 12:09 PM, Licensed Practical Nurse (LPN)2 confirmed that there was no code status order in R62's EMR. LPN2 verified a written DNR order in the hard chart. LPN2 stated she would get an order put into R62's EMR. During an interview on 11/13/24 at 2:15 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), stated that their expectations would be that the nurses would enter the residents code status into the EMAR when the resident is admitted . 46934 Findings include: 2. Review of R96's Face Sheet revealed R96 was admitted to the facility on [DATE], with diagnoses including but not limited to: anxiety disorder, dementia, atrial fibrillation, hypertension, and osteoarthritis. Review of R96's Physician Order on 11/12/24, did not reveal an order for R96's Code Status. Review of R96's Care Plan with a problem onset date of 05/09/24, revealed family has chosen R96 to be DNR. 3. Review of R11's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic kidney disease, retention of urine, muscle weakness, restless leg syndrome, and type 2 diabetes mellitus without complications. Review of R11's Physician Order on 11/12/2024, did not reveal an order for R11's Code Status. Review of R11's Care Plan revealed R11 has chosen to be DNR status. During an interview on 11/14/24 at 3:38 PM, LPN2 revealed the facility transitioned systems back in September 2024. LPN2 confirmed R96 and R11 did not have an active order for code status in the EMR and an audit was done once department entered the building to ensure those residents who did not have an order, to have one put in the system to match the code status in the residents' hard chart. 49818 4. Review of R100's Face Sheet revealed that the facility admitted R100 on 01/29/24, with diagnoses including but not limited to: fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, Alzheimer's disease, and type 2 diabetes mellitus without complications. Review of R100's quarterly MDS with an ARD of 08/02/24, revealed R100 had a BIMS of 4 out of 15, indicating R100 had severe cognitive impairment. Review of R100's Hard Chart revealed a Do Not Resuscitate Order (DNR) notice to EMS (Emergency Medical Services) Personnel dated 04/27/24. Review of R100's Physician Orders with an active date of 08/31/24, revealed a Full Code status. Review of R100's Care Plan revealed, family has chosen R100 to be DNR Status. Interventions directed staff to; Resident's Advanced Directives Wishes Will Be Known, Review Advanced Directives on file, if applicable. During an interview on 11/13/24 at 2:05 PM, LPN2 revealed R100's hard/paper chart showed that their code status is Do Not Resuscitate (DNR) and that there was no order in the chart to support the status. LPN2 reviewed R100's EMR and revealed that their code status was listed as Full Code. LPN2 stated that R100 is on Hospice and that if they were in distress Hospice would be notified for a Registered Nurse (RN) to come in and assess, however if there was an RN on shift they would have them to come and assess and they would provide comfort measures for the resident. LPN2 stated that they personally would go by what's on the resident's hard/paper chart, but stated some nurses look in the computer. LPN2 explained that the advanced directives are updated by Social Services. LPN2 retrieved a written order from Social Services and revealed that the order listed R100 as full code. During an interview on 11/13/24 at 2:15 PM, Social Services revealed that Hospice has only given us the Do Not Resuscitate paperwork with the doctor's signature on it. During a follow up interview on 11/15/24 at 12:19 PM, Social Services revealed that they meet with residents and family representatives during admission to discuss code status, once a code status is chosen, a sticker is placed in the resident's hard chart and the status is put in the computer. Social Services stated that if a resident and/or their representative decides on a DNR status they sign the paperwork and then either the physician or the nurse practitioner signs it and writes an order for it. Social Services further explains that the resident and/or representative has 7 days to inform them if they want to change the status from DNR back to Full Code or vice versa, and once a change is made they would update the resident's hard chart as well as the electronic chart as soon as they have an signed order from the physician. During an interview on 11/15/24 at 11:49 AM, the DON and the ADON revealed that a resident's code status is established during admission between Social Services and the residents and their family. If the resident and their family opt for DNR, the DNR is signed by the resident or resident representative, the doctor writes an order, and the order and status would be placed in the hard chart and is also scanned and added to the resident's electronic chart. The DON states that it's their expectation that the EMR is updated in a timely manner and that any changes be communicated as soon as possible as soon as they are received. The DON and ADON further explains there is sometimes a question of the real code status when a resident goes on Hospice and they have had staff call Social Services on the weekend if there needs to be clarity of the status. The DON concluded that R100 is on Hospice and that there wasn't an order for the DNR documentation and Social Services had to call the Hospice agency for an order. During an interview on 11/15/24 at 12:56 PM, the Administrator revealed that a resident's code status is to be on their hard chart identified by a sticker. The Administrator explains that the resident's code status is determined at admission and is discussed at length with the resident and their family. The Administrator further reveals that the DNR paperwork in the resident's chart is signed by the resident or the resident representative and the physician and to their understanding that is the order for the DNR. The Administrator states that their expectation is that for a resident who is DNR, is for the resident's code status to be in the hard chart as well as scanned in. 50850 5. Review of R73's Face Sheet revealed R73 was admitted to the facility on [DATE], with diagnoses including but not limited to: Multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, repeated falls, myasthenia gravis without (acute) exacerbation, hypo-osmolality and hyponatremia, and parkinsonism. Further review of the Face Sheet revealed R73's code status was not documented on the Face Sheet. Review of R73's Quarterly MDS with an ARD of 10/16/24, revealed R73 had a BIMS score of 15 out of 15, indicating R73 was cognitively intact. Review of R73's Physician Orders revealed no orders for advanced directives. Review of R73's Hard Chart (binder containing paper copies of medical records) revealed a document titled Cheraw Healthcare Code Status Clarification and Competency Form dated 07/09/24, revealed a DNR code status for R73. Review of R73's Hard Chart revealed a document titled SC Emergency Medical Services dated 07/15/24, which indicated R73's code status was DNR. Review of R73's Hard Chart revealed a written order dated 07/15/24, which documented, Resident's DNR Status. Review of R73's Care Plan revealed, resident has chosen to be DNR status. The interventions directed staff to; resident's Advanced Directives Wishes Will Be Known, review advanced directives on file, if applicable. During an interview on 11/13/24 at 2:09 PM, LPN4 reviewed resident's code status on the EMAR and confirmed there was no indication of the resident's code status. LPN4 also looked in the MD orders in the EMR and there was no order for code status. LPN4 stated, the hard chart contained an order for the resident to be a DNR. LPN4 concluded that she would put the DNR order in the EMR. During an interview on 11/13/24 at 2:15 PM, the DON revealed ADON stated that their expectations would be that the nurses would enter the residents code status into the EMR when the resident is admitted . The ADON stated, We have already identified that we have a problem with some of the orders for code status being brought over when we changed to PCC (Point Click Care (Electronic system for medical records)).

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)107 received proper positioning during tube feeding, which had the potential for aspiration for 1 of 1 resident reviewed. Findings include: Review of the facility policy titled Gastrostomy Tube Feeding (Bolus or Continuous Feeding) with a revision date of 10/10/19, documented, Purpose: 1. To feed the resident that has obstruction or disease of the esophagus or throat. 2. To feed the residents' that are unconscious or debilitated for long periods of time. 3. To reduce the danger of aspiration. 4. To provide adequate nourishment. Procedure: 6. Place resident in fowler's position [a semi-sitting position where a patient lies on their back with their head and upper body raised at an angle of 45 to 90 ]. Review of R107's Face Sheet revealed R107 was admitted to the facility on [DATE], with diagnoses including but not limited to: peptic ulcer, gastroduodenitis, severe intellectual disabilities, congenital hiatus hernia, and oropharyngeal phase dysphagia. Review of R107's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/22/24, did not reveal a Brief Interview for Mental Status (BIMS) score related to section C question 0100 being coded as no (rarely/never understood). Review of R107's Care Plan documented, the focus . requires tube feeding. Further review of the Care Plan revealed the following goal, The resident will be free of aspiration through the review date. The interventions directed staff to: Monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. During an observation and interview on 11/13/24 at 11:13 AM , R107 was observed lying on their right side, with the bed flat and tube feed infusing at Jevity 1.5 cal at 40 ml/hr. Licensed Practical Nurse (LPN)1 stated the bed should be 30-45 degrees elevated. LPN1 proceeded to raise the HOB (head of bed). During an interview on 11/15/24 at 2:07 PM, the Director of Nursing (DON) stated the expectation for staff is to elevate the HOB when finished with care to a 45 to 90 degree angle.

Based on review of facility policy, record review, observation, and interviews, the facility failed to complete a restraint assessment, for the use of trunk restraint on wheelchair, for Resident (R)47, for 3 of 4 residents reviewed for the use of restraints. Findings include: Review of the facility policy titled Restraint Assessment Policy with a revision date of [DATE], documents, 4. Orders must be obtained for any chemical or physical restraints. 5. Physical restraint assessment will be initiated to evaluate the appropriateness restraint use. Review of R47's Face Sheet revealed R47 was admitted to the facility with diagnoses including, but not limited to: Dementia, major depressive disorder, anxiety disorder, cerebrovascular disease, and overactive bladder. During an observation on [DATE] at 11:15 AM and on [DATE] at 10:06 AM, revealed R47 was sitting in her non mechanical wheelchair near the nurses station in North Unit, self-propelling with a lap n lock padded lap desk over her lap. R47's arms were crossed and the resident was leaning forward on the lap desk. Review of R47's Physician Order dated [DATE], revealed, Lap-n-lock pillow while up in w/c to help define safe perimeter due to inability to comprehend physical limitations, check q 30 minutes and release q 2 hrs. every shift. Review of R47's Electronic Medical Record (EMR) and Hard Chart (contains paper copies of medical records) did not reveal documentation to indicate R47 was assessed for the use of the lap desk, which could potentially be considered a restraint. Review of R47's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R47 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R47 is severely cognitively impaired. Further review of the MDS revealed R47 is coded for Trunk restraint - Used daily During an interview on [DATE] at 11:25 AM, Registered Nurse (RN)1 confirmed R47 has a trunk restraint per order, Lap N Lock Pillow. RN1 stated R47 was constantly falling at one point, getting up unassisted, so an order was placed to minimize falls. RN1 further stated CNAs (certified nursing assistant) and nurses are responsible for taking it off every 2 hours, or if she wants to eat, lay down, and brief change. RN1 revealed the use of the trunk restraint started on [DATE], after a fall she had on [DATE], where she fell attempting to get up and ambulate from wheelchair. RN1 stated since the trunk restraint was in place, it has minimized the risk of further injury, since September, no injuries. RN1 confirmed she could not locate R47's restraint assessment and restraint consent in the current EMR and resident's hard chart. RN1 concluded she would follow up with the Director of Nursing (DON), to see if she could locate the documentation. On [DATE] at 12:06 PM, RN1 provided a wet ink copy of a document titled Positioning Device Assessment Form which was dated [DATE]. Review of this form indicated it was completed for another resident with a similar name, who had expired in March of 2024. RN1 confirmed she, the DON and ADON could not locate the restraint assessment for R47. Furthermore, confirmed the DON produced and signed the form on [DATE], for the incorrect resident. During a phone interview on [DATE] at 12:25 PM, R47's Resident Representative revealed R47 is a fall risk, drops things and will fall while bending over to attempt to grab them. R47's Resident Representative states R47 has been there for years and he doesn't remember signing a form, or consenting via phone to his mother having a restraint. On [DATE], the DON provided a document titled Positioning Device Assessment which was dated [DATE] for R47. The assessment indicated, Late Entry done on [DATE]. The DON also provided a handwritten copy for the consent for the positioning device with a date of [DATE]. Review of the consent form revealed there was no signature and handwritten on the form was, Tel consent. The DON revealed this documentation was produced today [DATE], due to not being able to locate the original due to switching systems. During an interview on [DATE] at 1:34 PM, the DON and ADON revealed after R47's fall, a new order for Lap N lock cushion was in place because of the fall on [DATE]. Prior to [DATE], R47 was a fall risk in general. The device was used to minimize the risk of falls. The DON and ADON stated the resident can remove the restraint herself in case of an emergency. The DON stated the order was effective [DATE] and the rationale for choosing the device, the resident prefers to be out of bed in her wheelchair and often leaning forward. The DON further stated to her knowledge there were no risks when the device is in use. The DON stated if the resident wanted the restraint removed, its typically honored, if there is a staff member available. The DON and ADON concluded their expectations are for all residents to have appropriate documentation in their chart.

Based on review of facility policy, record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure Resident (R)33 nebulizer machine, oxygen mask and medication chamber were clean and/or bagged when not in use for 1 of 1 resident reviewed for respiratory care. Findings include: On 11/15/24 at 10:00 AM, a request was made to review the facility policy on maintenance and storage of equipment associated with respiratory therapy tasks particularly nebulizer machines. On 11/15/24 at 10:30 AM, the Director of Nursing (DON) stated that there was no policy for the cleaning and storage of a nebulizer machine. Review R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. Review of R33's Physician Orders with a start date of 09/03/24 and a revision date of 09/20/24, revealed an order for Albuterol Sulfate Solution Nebulizer 0.083% (2.5 MG/3ML) 1 vial via mask every 8 hours as needed for Shortness of Breath and Oxygen at 2 liters per Minute (LPM) via nasal cannula. During an observation and interview on 11/12/24 at 12:32 PM, revealed a nebulizer machine was in the seat of a chair beside the resident's bed. The oxygen mask was propped against the nebulizer machine. The mask was attached to the medication chamber and the tubing. The mask was not bagged. There was a clear liquid in the medication chamber. The medication chamber was attached to the mask and the oxygen tubing. R33 stated she is on 2 liters of oxygen. Oxygen (O2) concentrator was set to 2.5 LPM. During an observation on 11/13/24 at 11:20 AM, revealed R33 was resting in bed with eyes closed. O2 concentrator was set at 2.5 LPM. The nebulizer was in the chair at resident's bedside. A piece of tape on the nebulizer tubing documented 11/12/24. There was a clear liquid noted in the medication chamber. The oxygen mask was propped against the nebulizer machine. The mask was attached to the medication chamber and the tubing. The mask was not bagged. The O2 concentrator was set to 2.5 LPM. During an observation 11/14/24 at 3:37 PM, revealed R33 was out of bed in wheelchair. The O2 concentrator was set to 2.0 LPM. The nebulizer was in the chair at resident's bedside. A piece of tape on the nebulizer tubing documented 11/12/24. There was a clear liquid noted in the medication chamber. The oxygen mask was propped against the nebulizer machine. The mask was attached to the medication chamber and the tubing. The mask was not bagged. During an interview on 11/15/24 at 1:22 PM, the Director of Nursing (DON) revealed the nebulizer mask and medication chamber should be cleaned with water. The DON stated the mask and the separated medication chamber should then be placed on a paper towel to air dry. The mask and the separated medication chamber should then be placed in a zip lock bag and dated.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to implement an appropriate fall intervention to prevent the wheelchair from rolling for 1 (Resident (R)1) of 3 sampled residents reviewed for falls. Findings included: A facility policy titled, Fall Policy and Procedures, revised 07/04/2019, indicated, Objective: To assure as safe of an environment as possible for our residents. R1's Face Sheet revealed the facility admitted the resident on 05/19/2021. According to the Face Sheet, the resident had a medical history that included diagnoses of abnormalities with gait and mobility, dementia, osteoporosis, osteoarthritis, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed R1 did not have any behaviors during the assessment period. The MDS revealed the resident had no range-of-motion impairment to the upper or lower extremities and the resident used a wheelchair. The MDS revealed the resident's ability to transfer, and walk was not assessed. According to the MDS, R1 was always incontinent of bowel and bladder. The MDS revealed the resident had sustained two or more falls without injury, two or more falls with minor injuries, and no falls with major injury since their prior assessment. R1's Care Plan included a problem statement with an onset date of 05/27/2021 that indicated the resident had the potential for falls resulting in injury related to limited mobility, poor endurance, poor judgement due to dysarthria, heart murmur, hypertension, osteoarthritis, history of prostate cancer, osteoporosis, anxiety, depression, dementia, syncope, transient ischemic attacks, and a history of urinary tract infections. Interventions directed staff to offer reminders not to arise unassisted as needed, transport to high visibility areas as needed, and to assist the resident to the bathroom every two hours and as needed. An Accident/Incident Report, dated 10/12/2023, revealed R1 was eating in the dining room in their wheelchair and slid down out of the wheelchair into a sitting position on the floor. The report revealed the resident was assessed for injuries and none were noted. The report revealed an intervention for a nonskid pad on the wheelchair was crossed out. The report revealed an intervention was listed to reposition the resident in their wheelchair as needed. R1's Departmental Notes, dated 11/21/2023 at 4:19 PM, revealed staff were completing a body audit and heard a loud boom in the bathroom. The note revealed when the staff opened the bathroom door, R1 was sitting on the floor on their buttocks, leaning back with their head up. The note revealed that the resident stated, I hit the back of my head. The note revealed R1 was examined and slight redness was noted at the back of their head near their neck. The note revealed that no other injuries were noted, and the resident's range-of-motion was within their normal limits. The note revealed R1 was assisted by staff to their wheelchair. The note revealed the resident's vital signs were taken and within their normal limits. The note revealed the physician and resident representative were notified. The note revealed that the probable cause was R1 had gone to the restroom unassisted and the wheelchair rolled from underneath the resident before they sat down. An Accident/Incident Report, dated 11/21/2023, revealed preventive actions taken were to assist R1 to the bathroom every two hours and as needed, and to keep the resident in a highly visible area. The report revealed there were no documented interventions put in place to ensure the wheelchair did not roll from under the resident. R1's Departmental Notes, dated 12/18/2023 at 10:33 PM, revealed that at 6:45 PM, R1 was observed sitting upright on the floor in the television area after hearing a banging noise. The note revealed the resident was observed several minutes prior to the incident watching television. The note revealed the resident stated they were trying to get into their wheelchair, and it slipped from under them. The note revealed lacerations were noted to the residents right lower leg and bruising on their knee. The note revealed the resident had range-of-motion in all extremities. The note revealed the resident complained of pain but refused pain medication when offered. The note revealed the resident also refused to have their vital signs taken. The note revealed the physician and resident representative were notified, and x-rays were ordered. An Accident/Incident Report, dated 12/18/2023 revealed interventions that included continuing to keep R1 in visible areas and reminding the resident to ask for assistance with transfers. The report revealed that an intervention for keeping the wheelchair brakes locked was crossed out. An Accident/Incident Report, dated 05/09/2024, revealed R1 was trying to get in their wheelchair from the bed and the wheels were not locked, causing the resident to fall. The report revealed the resident had two bruised sites with open skin tears on their right leg and had three small pea size abrasions to their forehead. The report revealed that the preventive action put in place was to not leave the wheelchair in the resident's room when the resident was placed in bed. The report revealed that there was no intervention put in place to prevent the wheelchair from rolling from under the resident. During an interview on 06/18/2024 at 12:40 PM, the Director of Nursing (DON) indicated that previously there was a supervisory report completed, which had many of the same questions as the incident report. The DON stated that on this report, the supervisor could document any new interventions put into place. The DON indicated staff would not have a meeting after each fall, but falls would be discussed in the monthly quality assurance and performance improvement (QAPI) meetings. During an interview on 06/18/2024 at 3:18 PM, the DON stated the goal would be for a resident to not have any falls, but that was not realistic. She sated she would like to see the number of falls decrease by at least 50 percent. The DON indicated she would like to find better interventions that would decrease the number of falls while still providing the best care possible. During an interview on 06/19/2024 at 9:45 AM, the MDS Nurse and the DON both indicated the wheelchair skid pad was not available at the time of the fall on 10/12/2023. The MDS Nurse stated staff had been told an intervention could not be listed on the incident report if they were not able to implement it at the time. The DON stated they were not allowed to lock R1's wheelchair so the resident was free to move about. The DON also stated the intervention for more frequent toileting referred to staff checking on the resident between the two-hour intervals for rounds to make sure the resident did not need to use the restroom or be changed. During an interview on 06/19/2024 at 9:54 AM, the Medical Doctor stated his expectation was that interventions were done to try and make the environment safer for the resident in case they did fall. During an interview on 06/19/2024 at 12:34 PM, the Physical Therapy Assistant (PTA) stated that when the physical therapist performs an assessment, the goals were listed under the short-term goals or long-term goals. The PTA stated the for wheelchair mobility, the resident would usually be educated during therapy to make sure they locked the wheelchair before standing up or sitting down. The PTA stated that for R1, he did not feel the resident had the cognition to remember outside of the therapy sessions to lock the wheelchair. The PTA stated R1 was able to move around freely in the wheelchair. During an interview on 06/19/2024 at 1:40 PM, the DON stated she would need to get with the maintenance department to see if R1 could get a wheelchair that had automatic brakes to prevent it from rolling backwards. During a follow-up interview on 06/19/2024 at 3:02 PM, the DON stated education was provided to R1 on the importance of locking the wheelchair, but she realized the facility should have thought of a new intervention. The DON stated, going forward, the facility would implement additional interventions.

Based on review of the facility policy, review of video evidence, interviews, and record review, the facility failed to protect Resident (R)1 from physical and mental abuse by Certified Nursing Assistant (CNA)2. Observation of video evidence from 01/09/23-02/01/23 revealed CNA2 intentionally wrapping R1's head and face with clothing to restrict movement, pushing R1's head into her bed, and pinning R1 down with her knees to restrict movement. On 04/24/23 at 12:57 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator via phone with the Business Office Manager present, notifying them that an IJ existed at F600 with an effective date of 01/09/23. On 4/25/23 at 10:45 AM, the facility provided an acceptable IJ Removal Plan indicating they identified their own deficient practice and implemented a plan prior to the start of the survey. Verification of the removal plan confirmed the facility put forth good faith attempts and implemented a plan to remove the immediacy including terminating CNA2 from the facility and in services to staff, effective 02/17/23. Implementation of the removal plan for F600 included R1 being assessed by the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) Coordinator on 02/01/23 to validate that there were no signs or symptoms of abuse such as skin tears, or reddened skin areas, none were identified. On 02/01/23 the ADON identified residents that were potentially impacted by completing skin and body audits first on the residents cared for directly by CNA2 and then on all current residents. This was completed on 02/01/23; no abuse signs and symptoms were noted. On 02/02/23 current residents that are interviewable were asked if they had been abused by any staff member. This was completed by the Social Services Coordinator on 02/16/23, no additional residents were identified. On 02/15/23 -02/16/23 the Nursing Managers (DON, ADON, MDS Coordinator) interviewed all staff members to determine if they had witnessed another staff member being rough, mistreating, or abusing a resident; no additional residents were identified. On 02/09/23 the Administrator in-serviced all nursing staff (including agency staff) on abuse policies and procedures. On 02/16/23 the Nursing Managers in serviced all staff on abuse policy and procedures; competency testing was completed. This training included all current staff including agency and contract staff. The training included: recognizing physical and non-physical signs of abuse; when and how to report abuse; how to minimize the risk of abuse; what to do if a resident resists care; and how to respond to aggression. As of 02/17/23, all staff have attended the in-service, the DON will ensure that any newly identified staff who has not completed the in-service training will not be allowed to work until the training is completed. In-service and competency testing will continue once a month for three months, and then quarterly after that for one year. Abuse drills will be performed in coordination with the monthly and quarterly abuse services. The Social Services Coordinator will monitor abuse processes such as identification of abuse, reporting abuse, and identification of how to respond to care refusals weekly for two weeks; monthly for three months; then quarterly for up to one year. Reports will be presented to the Quality Assurance (QA) committee by the Administrator or DON to ensure the auditing program is reviewed at the QA meetings. The QA meetings are attended by the Administrator, DON, ADON, MDS Coordinator, Health Care Services Director, Therapy Director, Medical Director, Dietary Manager, Business Office Manager, and other supervisors. Findings include: Review of facility policy titled, Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure last revised 9/23/19, revealed Residents are to be free from verbal, sexual physical, environmental/mental abuse; neglect; self-neglect; involuntary seclusion; at all times. Abuse: the willful infliction of injury; unreasonable confinement; intimidation; or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to; dementia without behavioral disturbances, type 2 diabetes, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/23 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 99, which indicates severe cognitive impairment. An observation and an attempted interview on 03/27/23 at 10:45 AM revealed R1 was non-interviewable. She showed no visual signs of injury or abuse. A phone interview on 03/27/23 at 11:37 AM with R1's Resident Representative (RR) revealed CNA2 was arrested on 02/14/23 and was charged with abuse and neglect related to R1. CNA2 is being prosecuted by the Attorney General's Office for abuse and the allegation was determined to be substantiated due to video evidence. I had concerns about R1 being abuse since back in January when they went to visit the resident and she was jumping (motioning as if she was afraid) when I tried to hug her, and she had never done that to me before. I told the Administrator and other staff about this incident and I was brushed aside and was told that R1 has dementia, so that might be the reason she is becoming fearful towards others, because she is confused and doesn't know who I am anymore. I knew this didn't sound right and I could tell something was wrong with R1. So I decided to put a camera in R1's room and I observed CNA2 put her knee on R1 to hold her down, pushing her arms into R1's chest and into the bed, spraying R1 with deodorant, and flushing R1's food over the course of a few days. When I showed the video to the local Ombudsman and Attorney General, she (CNA2) was arrested immediately. An observation of the video evidence on 03/27/23 at 11:45 AM revealed a video with a date of 01/09/23. In the video, CNA2 was observed to be intentionally wrapping R1's head and face with clothing to restrict movement. CNA2 was observed pushing R1's head into her bed and pinning R1 down with her knees to also restrict R1's movement. Additional observation of video evidence on 03/27/23 revealed additional videos dated 01/09/23 - 02/01/23. These videos revealed CNA2 spraying R1's head, face, and body with an aerosol deodorant, in order to control R1's movement. Further observation of the videos revealed R1's head being pushed into her bed and CNA2 holding R1 down to restrict movement. A phone interview on 03/27/23 at 12:43 PM with the Director of the Ombudsman Program for South Carolina revealed On 01/23/23, R1's RR contacted our office because they had concerns of R1 suddenly becoming fearful of family members when they attempted to hug her, which was a new behavior. R1's RR put cameras in R1's room and over the course of a few days, videos showed CNA2 abusing R1. We were in contact with R1's RR on the following dates beginning on 01/23/23 and continued contact regarding this incident on the following days: 01/25/23; 01/26/23; 01/27/23; 01/31/23; and 02/06/23. After R1's RR showed us the videos of CNA2 abusing R1, we immediately reported this incident to law enforcement and the Attorney General's Office, so criminal charges could be taken against CNA2 and both agencies went onsite to investigate this matter. During the on-site investigation, Administration revealed that R1's RR had spoken to the facility about concerns related to R1 suddenly becoming fearful of others on (01/16/23) and had conducted their own internal investigation, but could not substantiate any abuse allegations at the time. CNA2 was arrested on 02/14/23 and a press release to the public by law enforcement was on 02/22/23. Record review of an internal investigation by the facility dated 01/16/23 revealed R1's RR was visiting the resident and she had concerns she addressed with the Administrator, which he spoke with other abuse coordinating staff about their concern. R1's RR stated that R1 was very jumpy today when she would move around her, when she went to hug R1 she jumped, almost as if she was afraid of being hit. R1's RR never accused anyone of any abuse, she was just concerned. A body audit was done and staff went to speak with R1. She was sitting in the hallway in her wheelchair with something in her hand that she was fidgeting with and was mumbling. When I spoke to her, she didn't acknowledge me, when I stooped down, she didn't look at me but she did rub my arm. I continued talking to her, she laughed as I talked to her, she continued mumbling something regarding smoking and a job. R1 didn't show any signs of distress, anxiousness or being nervous. R1 has been known to resist care (push staff away from her) and she will push off staff when they have tried to hug her in the past. She hasn't shown any signs of affection toward staff or her husband, that also resides at the facility since admission. Staff will continue to monitor for any changes in R1 and will address them accordingly. A phone interview on 03/27/23 at 4:06 PM with CNA2 revealed she denied all accusations of abusing R1. She further stated and denied being arrested and charged with elder abuse by law enforcement or the Attorney General's Office and denied any pending criminal charges as well. CNA2 stated that she retired from the facility by choice and was not terminated by the facility due to abusing R1. An interview with the Social Services Director (SSD) on 03/27/23 at 4:30 PM revealed that they had written the internal investigation concern related to this incident and interviewed R1 on 01/16/23 (date where RR had 1st concerns related to R1). The SSD further stated that she interviewed R1's roommate and other interviewable residents that were in the care of CNA2 and had no other concerns with abuse or neglect with other residents. An interview with the Administrator on 03/27/23 at 4:39 PM revealed that they were informed about CNA2's physical, mental, and involuntary seclusion of R1 by law enforcement/the Attorney General's Office on 02/01/23. When the facility was made aware of the abuse by law enforcement, they reported the abuse to the state agency in a timely manner. We spoke with R1's RR in mid-January (01/16/23), but were unable to substantiate abuse allegation at that time, due to no signs of harm in an interview and body audits. We were unaware that R1's RR had put a camera in R1's room after they reported their concerns until law enforcement and the Ombudsman Office arrived at the facility for their investigation. R1 and CNA2 previously worked together here at the facility before R1 was diagnosed with dementia and was admitted as a resident. We never suspected any abuse with CNA2 with other residents at the facility. When R1's RR spoke with us about her concerns she never alleged abuse against anyone at the facility, at the time. When law enforcement arrived at the facility for the investigation, CNA2 was still employed at the facility because we had no reason to believe that she harmed any residents, but after their investigation we terminated CNA2 on 02/05/23 and she was later charged by law enforcement on 2/14/23. Review on 03/27/23 at 4:45 PM of an Employee Termination Record dated 02/06/23 revealed CNA2 was terminated from the facility due to violations of resident rights and the care they provided was not in consistent expectations of the facility in a way that could have resulted in harm to the resident. A phone interview on 04/12/23 at 9:30 AM with the Attorney General Investigator revealed that CNA2 was still employed at the facility when they went onsite to complete their investigation. CNA2 was terminated from the facility after the completion of their investigation and has been charged with elder abuse. Under the terms of CNA2's bond, they are not allowed to be employed at any healthcare facility type.

Based on record review, observation, interview, and review of the facility policy titled Enteral Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse(LPN) #1 on 1/28/20 at 12:10 PM revealed s/he crushed [MEDICATION NAME]/[MEDICATION NAME] 25/100 milligrams(mgs) and [MEDICATION NAME] 60 mg and placed each in the same cup. After entering Resident #118B's room, LPN #1 placed 30 cubic centimeters(cc) of water into each of two 30cc medication cups. LPN #1 placed approximately 10 cc of water from one of the medication cups containing water into the medicine cup containing the crushed medications. After checking and confirming placement of the gastrostomy tube([DEVICE]), LPN #1 placed approximately 20 cc of water into the [DEVICE]. Medications were placed in the [DEVICE], residual medication was observed and LPN #1 placed water from the second medication cup twice trying to administer all of the medication. During this time, a small amount of spillage was noted dripping off of LPN #1's glove. S/he placed the remaining water into the tube. Observation of the medication cup which contained the medications revealed medication was still in the bottom of the cup. LPN #1 confirmed the medication in the cup. LPN #1 stated s/he should have probably let the medicine sit a little longer to help the medications dissolve. Review of the facility policy titled Enteral Tube Medication Administration revealed the policy did not address residual medication.

Based on observation, interview, clinical record review and review of facility policy, facility nursing staff failed to update 3 of 24 sampled residents' care plans (Residents #15, #16, and #17). The findings included: Review of the facility's Policy and Procedure for RAI (Resident Assessment Instrument)/Care Plans (not dated) revealed 3. Care plan team meets every Thursday to review care plan with family and residents who choose to attend unless arrangements are made for different time or date. Resident #15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #15 exhibited no behaviors (i.e. no physical behaviors and no self-injurious behaviors) and no signs/symptoms of depression, during the assessment periods. According to the MDS, Resident #15 required the extensive assistance of one staff person for bed mobility, transfers, toileting, dressing, walking in the room, and locomotion on and off the unit. The Annual MDS assessment, noted Resident #15 had impairment to one side of lower extremities and utilized a wheelchair for mobility. Resident #15 had no falls during either MDS assessment period. Continued review of the MDS revealed Resident #15 was administered no anti-coagulant medications; however, the resident did receive antipsychotic medication for seven (7) days during the assessment period. Review of Resident #15's Progress Notes revealed the following: 11/11/8 - While the CNA had the resident in the bathroom, she noticed bruises on resident's left arm, reddish purple in color. The resident was not able to state what might have happened. No complaint of pain or sign or symptom of pain noted to left arm when touched. Resident was able to move bilateral upper extremities on her own without difficulties or distress noted. No swelling noted to left arm. Resident observed by nurse using bilateral arms to push herself up out of w/c without difficulties or distress noted. MD made aware, no new orders noted at this time. RR (Resident Representative) made aware and stated, She had bruises on her arm when I was down there on Monday, but I didn't recognize them as bruises, I just thought they were smudges. Review of the facility's Investigation Report dated 11/13/18 confirmed Resident #15 sustained unexplained bruising. Review of Resident #15's Comprehensive Care Plan revealed the following care areas were addressed: 8/1/19 - Problem: Resident at times may resist care or make physical contact with staff or other residents due to Dementia and [MEDICAL CONDITION]. Goal: Talk to resident in a calm, reassuring tone of voice (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Talk to resident in a calm, reassuring tone of voice; explain all procedures to resident prior to assisting; If resident is resistant or combative with care, give her time to calm down and re-approach at a later time; Administer [MEDICATION NAME] per MD's (doctor's) orders; and family contacted/informed about drug use and possible side effects. 8/1/19 - Problem: Resident displays socially inappropriate/disruptive behaviors due to [MEDICAL CONDITION] Dementia. Goal: Decline in disruptive behaviors (through review date 11/1/19). Interventions (all initiated before 11/22/18): Place resident in area where constant observation when possible; Approach resident warmly and positively; Talk to resident in a calm voice when behaviors are recent; Remove resident from area when behaviors are unacceptable/disruptive; Offer food/drink when behaviors are present; Check to see if resident is soiled or cold; Administer [MEDICATION NAME] per MD orders. Monitor for effectiveness, for possible side effects or adverse reaction and report to MD as needed; and family informed/contacted about drug use and possible side effects. 8/1/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to left [MEDICAL CONDITION], Dementia, Urinary tract infection, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will not suffer injury related to falls (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Monitor for safety and maintain a safe environment; Assist as needed in all ADL (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to be clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for signs and symptoms of [DIAGNOSES REDACTED], such as tingling of extremities, muscle cramps, twitching, stooped posture and brittle bones; Provide diet per order, encourage consumption of calcium rich foods, such as eggs, milk, cheese and other dairy products served within diet; and monitor labs per order. Report to MD as needed. 8/1/19 - Problem: Potential for skin tears and bruising related to fragile condition of skin. Goal: Skin tears will heal without complication (through review date 11/1/19). Interventions (all initiated before 11/22/18): Monitor for safety and maintain a safe environment. Handle gently and protect from injury; Provide treatment to skin tears per order. Monitor effectiveness of treatment and progression of healing; Monitor for s/sx (signs/symptoms) of infection, such as redness, warmth, pain, tenderness, [MEDICAL CONDITION] and purulent drainage; Have resident wear long sleeves/pants/geri-sleeves as needed to protect extremities (2/24/19); Provide adequate lighting to reduce the risk of bumping into furniture or equipment; offer fluids with medication pass, at meals and as needed between meals in an effort to ensure hydration; Apply lotions and moisturizers to skin as needed; Use a lift sheet to move and turn resident when in bed as needed; Pad wheelchair arms and leg supports as needed; Support dangling arms and legs with pillows and blankets as needed; and perform skin tear risk assessment initially upon admission and quarterly thereafter, as needed. 8/1/19 - Problem: Resident requires extensive to total assistance from staff for ADLs related to limited mobility and poor endurance related to history left [MEDICAL CONDITION], Dementia, UTI, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will continue to participate in ADLs after set-up by staff (through review date 11/1/19). Interventions (all initiated before 11/22/18): Provide showers three times per week and sponge baths daily. Shampoo hair weekly with a shower unless other arrangements are made; Provide routine oral hygiene; Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide preventative skin care daily and as needed; Provide tray set up for meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Assist the resident to turn and reposition ever two hours and as needed while in bed; Assist to transfer from bed to wheelchair as tolerated; Transport to specific destinations once up; Provide Range of Motion (ROM) exercises to all extremities throughout nursing care as tolerated; and assist to dress/undress appropriately and groom hair daily and as needed. The comprehensive care plan was not updated after Resident #15 sustained unexplained bruising to her left arm on 11/11/18. 2. Review of Resident #16's clinical record revealed Resident #16 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored four (4) out of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired and exhibited no behavioral symptoms. Continued review of the assessment noted the resident required the total assistance of one staff person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and bathing. Resident #16 had no impairment to upper and lower bilateral extremities and did not utilize a mobility device. During the assessment period, Resident #16 had no falls and received no therapy services. Review of Resident #16's Annual MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and exhibited no behavioral symptoms during the assessment period. The Annual MDS noted Resident #16 required the total assistance of one staff person for bed mobility, transfers, locomotion off and on the unit, dressing, toileting, personal hygiene and bathing. Resident #16 had impairment of one side of lower extremity, and according to the MDS, the resident did not utilize a mobility device. During the assessment period, Resident #16 had no falls, was administered opioid medication for seven (7) days and received no therapy services. Review of Resident #16's Progress Notes revealed the following: 12/31/18 at 10:40 a.m. - Upon getting up this morning, resident complained (of) left leg pain. No swelling or bruise noted .when staff tries to push her to go to the activity she hollers and says that her leg is still hurt. When this nurse checked her leg once again, her leg just below the knee is swollen, tender to touch but not warm. No redness or bruise on the area. (MD) notified and made aware with no new order noted at this time. Continue monitoring resident condition. Review of Resident #16's Radiology report dated 12/31/18 revealed Resident #16 sustained an Acute proximal left lower leg fracture. Review of Resident #16's Care Plan revealed the following care areas were addressed: 9/12/19 - Problem: Requires extensive to total assistance from staff for ADLs (activities of daily living) related to limited mobility, poor endurance and intermittent episodes of confusion related to [MEDICAL CONDITIONS], Abnormality of Gait, Debility, [MEDICAL CONDITIONS], History of Pneumonia, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITIONS], Dysphasia, Hypertension, Obesity, Anxiety and Dementia. Goal: Resident will be cleaned and well-groomed by staff (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinent skin care after each incontinent episode; Provide preventative skin care daily and as needed; Provide tray set up for meals. Monitor self- feeding performance and meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Transport to specific destinations once up; Provide range of motion (ROM) exercises to all extremities throughout nursing care as tolerated; Provide showers three times weekly and sponge baths daily as tolerated. Shampoo hair weekly with a shower unless other arrangements are made. Encourage to wash face, hands and upper body after set-up and cueing from staff. Monitor performance and assist as needed; Dress/undress appropriately and groom hair daily and as needed; Turn and reposition every two hours and as needed while in bed; Side rails up x 2 when in bed to assist with turning and repositioning. Check every 30 minutes and release every two hours. Allow free time during meals, care and family/social visits; Perform positioning assessment quarterly; and transfer from bed to chair with Hoyer lift or sit-to-stand. 9/12/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Cardiovascular Accident ([MEDICAL CONDITION]), Debility, Abnormal Gait, [MEDICAL CONDITIONS], Anxiety, Age-related [MEDICAL CONDITION] without current pathological fracture and intermittent episodes of confusion related to Dementia. Goal: Resident #16 will not suffer injury related to fall (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for safety and maintain a safe environment; Assist as needed in all ADL areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to bathroom clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order. Encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; and administer medications and monitor labs per MD orders. Report to MD as needed. 9/12/19 - Problem: Potential for pain or discomfort related to limited mobility and [MEDICAL CONDITION] and history of proximal left lower leg fracture. Goal: Resident #16 will obtain relief from pain/discomfort 30-60 minutes after medications/measures taken (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for s/sx of pain/discomfort such as verbal complaints, moaning, crying, facial grimace, loss of appetite, withdrawal and resistance to care; Maintain calm and reassuring environment. Avoid stressors; Position for comfort with pillow supports as needed; Provide diversionary activities so resident does not focus only on pain; Encourage and assist with exercise to tolerance within physical limitations within. Allow resident to guide pacing of movements and provide frequent rest periods; and administer medications per MD orders. The comprehensive care plan was not updated to address Resident #16's potential to sustain pathological fractures related to the [DIAGNOSES REDACTED]. 3. Record review revealed Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off of the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA (Certified Nursing Assistant) was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed the following interventions were to be added to Resident #17's fall care plan: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fractures, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions: Monitor for safety and maintain safe environment; Assist as needed in all ADLs (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; Encourage to wear shoes with non-slip soles; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify Responsible Party and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions: Provide routine oral hygiene; Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinence skin care daily and as needed; Turn and reposition every two hours and as needed while in bed; Transport to specific destinations once up; Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; Provide showers three times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; Transfer from bed to geri-chair as tolerated; and perform treatments per MD orders. Resident #17's care plan was not updated to include the interventions to place floor pads on the floor and to make sure a chair was not right beside Resident #17's bed. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed a chair was placed next to the head of Resident #17's bed. Interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator revealed residents' care plans were maintained in the electronic health record, and a hard copy was also maintained in the resident's paper chart. The MDS Coordinator said that nursing staff can update residents' hard copy care plans when needed by writing in newly developed interventions. The MDS Coordinator said that updated information documented on the hard copy care plans was formally added to residents' electronic care plans on a quarterly basis when care plan meetings were held. The DON and MDS Coordinator acknowledged that care plans for Residents #15, #16, and #17 were not updated; however, they should have been.

Based on observation, interview, clinical record review and review of facility policy, facility staff failed to ensure 1 of 24 sampled residents (Resident #17) was free from possible neglect. On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 turned the resident onto her side but failed to ensure the resident was safe from falling. As a result, Resident #17 fell from the bed and struck her head on the corner of a chair that was sitting next to the bed. The resident sustained [REDACTED]. The findings included: Review of the facility's policy entitled Perineal Care (Peri-care) (undated) revealed the following: Purpose: 1. To cleanse the perineum; 2. To prevent infection and odors. Equipment: 1. Soap and water; 2. Bath basin; 3. Washcloths and towel. Procedure: 1. Explain procedure to the resident and bring equipment to the bedside; 2. Provide privacy for the resident; 3. Assist the resident to void first if they need to; 4. Do perineal care at least one time a day with bath and PRN (as needed); 5. Cleanse the area with warm water and soap. When washing the area, always wash from the front to back (sic). Be careful not to pull the washcloth from the anal area to the vaginal area; 6. Rinse the area; 7. Towel blot dry the area; 8. Assist the resident to a comfortable position; 9. Return equipment to its proper area; 10. Wash hands; 11. Chart care rendered. Notify the appropriate person of any abnormal findings. The policy did not address adjustment of residents' bed heights, or the use of side rails during peri-care. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one (1) staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one (1) staff person for transfers and had impairment to one (1) side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Monitor for safety and maintain safe environment; 2. Assist as needed in all ADLs (activities of daily living) areas; 3. Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; 4. Encourage to wear shoes with non-slip soles; 5. Maintain bed in low position while not rendering care. 6. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; 7. Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; 8. Notify Responsible Party and MD of all fall instances; 9. Monitor for s/sx (signs/symptoms) of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; 10. Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; 11. Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and 12. Administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Provide routine oral hygiene; 2. Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; 3. Offer toileting assistance every two hours and as needed in an effort to maintain some continence; 4. Provide incontinence skin care daily and as needed; 5. Turn and reposition every two (2) hours and as needed while in bed; 6. Transport to specific destinations once up; 7. Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; 8. Provide showers three (3) times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; 9. Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; 10. Transfer from bed to geri-chair as tolerated; and 11. Perform treatments per MD orders. Review of Resident #17's Progress Notes revealed the following: 7/7/19 - Resident #17 Quietly resting in bed with eyes closed. (No added distress) NAD noted. Resp(irations) even and nonlabored. Total dependent care by staff. Kept clean, dry and comfortable in bed. 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of Resident #17's Radiology report dated 7/13/19 revealed the resident's left shoulder was x-rayed and compared to an x-ray completed 12/12/17. According to the comparison there was no change in resident's status since prior x-ray. Results: Impacted fracture involving the humeral neck. The acromioclavicular and coracoclavicular joints are intact. Conclusion: Impacted humeral neck fracture (present prior to the fall from bed). The report also noted no fracture to the resident's left elbow. Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. According to the report, CNA #6 had Resident #17 facing her while the staff performed incontinent care, but when the aide moved to reach for the diaper located at the foot of the resident's bed, Resident #17 suddenly flipped over causing her to hit the left side of her face on the chair which was beside her bed then fell to the floor. Bed was in low position. Interventions by facility to prevent future injury/Alleged Abuse: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper, she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN (Registered Nurse) #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. Review of CNA #6's Employee file revealed the Aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence. The document noted the following: Negligence in assigned duties or overall resident care. CNA failed to follow proper turn and reposition. Not making sure resident is in the center of the bed before turning and repositioning. CNA was in-serviced 1:1 on turning and repositioning with charge aide. If it happens again - will terminate. The form was executed by both the Director of Nursing (DON) and the Assistant DON (ADON). The form noted that CNA #6 Refused to sign the document. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a Geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. The resident was able to nod yes or no to direct questions. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed that CNA #2 escorted Resident #17 to her room in order to transfer the resident from her Geri-chair to her bed. CNA #2 completed a one-person pivot transfer and placed the resident in the center of her bed, elevated the head of Resident #17's bed and then placed the bed in a low position. The transfer was completed safely without incident or injury. Interview on 10/15/19 at 10:47 a.m. with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor and positioned between the two (2) beds in the room. CNA #1 said that when she entered the room, she saw that Resident #17's bed was not in a low position and neither side rail was raised. CNA #1 explained that when providing resident care and moving residents from side to side, aides were to raise the side rail so that residents could hold onto the rails during care. CNA #1 said Resident #17 was not able to independently roll from side to side while in the bed. She said the resident was total assist and required assistance from staff to move in the bed. She said she did not understand how the resident could have rolled from bed. According to CNA #1, CNA #6 told her that while she (CNA #6) was providing care for Resident #17, she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. When asked about the position of residents' beds during peri-care, the ADON said the aides were to adjust residents' beds to a comfortable height in order to provide care. Upon completion of care, aides were to place the beds back in a lower position. The ADON said CNA #6 reported to her that Resident #17 was on her back and that when CNA #6 went to grab a diaper on the wheelchair, Resident #17 fell from the bed. The ADON said CNA #6 was written up because she performed peri-care incorrectly. The ADON said the resident's fall was not identified as a possible incident of neglect. Further interview revealed that CNA #1 told the ADON that she believed Resident #17 was too close to the edge of the bed, and that was the reason the resident fell . Telephone interview on 101/17/19 at 4:38 p.m. with RN #2 revealed the nurse did not recall well Resident #17's fall from bed during peri-care. RN #2 said the incident was so long ago. RN #2 said she did remember that CNA #6 told her that she (CNA #6) pulled Resident #17 towards her (CNA #6) and when she did this, Resident #17 slipped between her and the bed. RN #2 said she did not recall CNA #6 saying that she was reaching for a diaper (incontinent brief). RN #2 continued and said that she did not think CNA #6 could have done anything differently to prevent the incident from occurring. RN #2 said possible neglect was not considered because if CNA #6 had required more assistance to complete peri-care, then the aide would have asked her co-workers for help. The RN said it was possible for that type of thing to happen.

Based on observation, interview, clinical record review and review of facility policy, the facility failed to thoroughly investigate and prevent the possibility of further neglect from occurring for 1 of 24 sampled residents (Resident #17). On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 failed to ensure the resident was safe from falling and as a result, Resident #17 fell and sustained lacerations to the left eyebrow and left upper cheek. According to the facility's Investigation Report, only CNA #6 and the assessing Registered Nurse (RN) #2 were interviewed regarding the incident. In addition, CNA #6 was not suspended pending the outcome of the investigation. The findings included: Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. All reports of possible abuse are promptly and thoroughly investigated by facility management. Residents and staff are protected during incident investigation by ensuring reports are made without fear of retaliation and that anonymous reports are investigated. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence .Completion of the following interviews: i. Person(s) reporting the incident; ii. Any witnesses to the incident (a) The resident (if appropriate); (b) The resident's roommate, family members and visitors (if applicable); (c) Staff members who have had contact with the resident during the period of the alleged incident. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. In addition, there were no other witness statements documented in the Investigation Report. Review of CNA #6's Employee file revealed the aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence in reference to failing to follow proper turn and reposition technique. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. Interview at this time with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor. CNA #6 told CNA #1 that she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. CNA #1 was not sure if CNA #6 was suspended during the investigation of the incident. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. According to the DON, a thorough investigation included interviewing the resident involved in the allegation (if possible), other residents, all pertinent staff/family/visitors (as applicable). When reviewing the witness statements from CNA #6 and RN #2, the DON confirmed that components of their statements were contradictory. The DON said when contradictory statements were obtained during an investigation, it was expected for the assigned Investigator to conduct follow-up interviews to obtain clarification. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. The ADON said that all witness statements (2) were included in the Investigation Report. In addition, the ADON said the resident's fall was not identified as a possible incident of neglect and CNA #6 was written up because she performed peri-care incorrectly. Continued interview with the ADON confirmed that the aide's failure to properly perform peri-care could be possible neglect that required investigation. Further interview revealed that CNA #6 was not suspended pending the outcome of the facility's investigation.

Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident #22, #19, # 57, #47 and #100 as soon as practicable of a facility initiated transfer. 5 of 5 reviewed for transfer to the hospital. The findings included: The facility admitted Resident #22 on 7/12/2018 with dignoses including, but not limited to, Muscle weakness, Acute and Chronic [MEDICAL CONDITION], unspecified with [MEDICAL CONDITION] or hypercapnia, Athscl [MEDICAL CONDITION] of native coronary artery without [MEDICAL CONDITION] pectoris, Heart Failure, [MEDICAL CONDITION] (chronic) (peripheral), Essential Hypertension, [MEDICAL CONDITION], Type II Diabetes Mellitus, Spinal Stenosis-lumbar region without [MEDICAL CONDITION] claudication, allergic rhinitis, [MEDICAL CONDITION] Stage 3, [MEDICAL CONDITION] disease, [MEDICAL CONDITION], Major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION], unspecified hearing loss, nausea with vomiting, unspecified Dementia without behavioral disturbance, pressure ulcer right and left heel unstageable. Review of the medical record revealed that Resident #22 was transferred to the hospital on [DATE], 07/27/2018 and 08/22/2018, all were facility initiated with no documentation that written notice was provided to the resident and Resident Represenative (RR) of the transfer. During an interview on 10/09/2018 at approximately 12:30 PM, the Social Worker confirmed that the facility had not been providing written notification to the resident/ RR for hospital transfers. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Record review on 10/09/18 at 11:59 AM revealed that the resident had multiple recent hospitalization s: (1) From 7/26/18 to 7/30/18 for Acute Hypoxic [MEDICAL CONDITION] and Exacerbation of [MEDICAL CONDITION], (2) From 8/14/18 to 8/17/18 for Shortness of Breath, Oxygen Saturation of 64% [MEDICAL CONDITION] Facial and Bilateral Lower Extremity [MEDICAL CONDITION], and [MEDICATION NAME]. (3) From 8/28/18 to 8/29/18 for Acute Hypoxic [MEDICAL CONDITIONS], Hypertensive Emergency, [MEDICAL CONDITIONS], Mitral Stenosis, and [MEDICAL CONDITION] Fibrillation. (4) From 9/11/18 to 9/12/18 for Acute Hypoxic [MEDICAL CONDITIONS], Hypertensive Emergency, [MEDICAL CONDITIONS], Mitral Stenosis, and [MEDICAL CONDITION] Fibrillation. (5) From 10/2/18 to 10/4/18 for Acute Hypoxic [MEDICAL CONDITIONS], Malignant Hypertension, Fluid Overload, and [MEDICAL CONDITION]. There was no evidence in the medical record of written notices to the resident's representative of the facility-initiated hospital transfers, including the reasons for the moves. The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Review of Progress Notes on 10/10/18 at 8:40 AM revealed that the resident complained of hip pain after sustaining a fall on 6/14/18. Radiology reports showed no acute fractures at that time. The resident continued to complain of hip pain, and after an orthopedic consult, the facility was notified on 7/18/18 to send Resident #100 to the hospital for direct admission for treatment for [REDACTED]. There was no evidence in the medical record of written notices to the resident's representative of the facility-initiated hospital transfers, including the reasons for the moves. The facility admitted Resident #19 on 06/02/17 with [DIAGNOSES REDACTED]. On 10/08/18 at 03:01 PM, record review revealed the resident was hospitalized from [DATE] to 06/01/18 and from 06/22/18 to 6/29/18. Review of the general progress notes revealed no documentation that the facility provided a written notice of transfer to the resident or the resident representative. The facility admitted Resident #47 on 02/09/15 with [DIAGNOSES REDACTED]. On 10/08/18 at 01:13 PM, record review revealed the resident was hospitalized from [DATE] to 09/21/18. Review of the General Progress Notes on 10/10/18 revealed no documentation that the facility provided a written notice of transfer to the resident or the resident representative. During an interview on 10/10/18 04:09 PM, the Social Services Director confirmed the facility had not been providing written notices of transfer to the resident or resident representative when a resident was transferred to the hospital.

Based on review of personal funds and interview, the facility failed to ensure that written authorization was obtained prior to disbursing monies from the account of one of one sampled resident reviewed for personal funds (Resident #23). The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. During an interview and review of the personal funds account with the Resident Financial Coordinator on 10/11/18 at 2:27 PM, multiple deductions (7/12/18, 7/31/18, 8/9/18, 8/24/18, and 9/7/18) were noted for the Beauty Shop for Resident #23. The invoices for the services provided were reviewed but no written authorizations were obtained from the resident/resident representative to deduct monies from the personal funds account.

The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that CNA #1 was suspended during the investigation. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the RN Supervisor, and 4 of the 5 CNAs on duty on the 100 Hall, including the alleged perpetrator. There were no statements from the two nurses on duty on the 100 Hall. All statements were either unwitnessed or witnessed by one individual. During an interview on 10/11/18 at 12:45 PM, when asked to describe a thorough investigation, the DON stated, You should talk to the resident, nurses, CNAs on the unit, visitors, and other people on duty at the time. The facility's abuse policies and procedures regarding investigation state: D. 7. Develop a list of known and possible witnesses to the reportable incident. Interview staff, residents and/or visitors, or anyone who has or might have knowledge of the incident under investigation . 9. Obtain written signed, double witnessed or notarized statements from the reporter and all other identified witnesses . Statements taken from actual eyewitnesses should .contain the witness's name, address, and phone number. Based on record review and interview, the facility failed to thoroughly investigate an injury of unknown origin for Resident #37 and an allegation of abuse for Resident #42, 2 of 4 residents reviewed for reportable incidents. The findings included: The facility admitted Resdient #37 on 11/04/13 with [DIAGNOSES REDACTED]. On 10/09/18 at 11:27 AM, review of the reportable for a 07/14/18 incident revealed Resident #37 experienced a fall and sustained a Left Femoral Neck Fracture on 07/14/18. Further review revealed the resident was receiving a bath by the CNA (Certified Nursing Assistant) and when the CNA turned the resident on her/his side to wash the back, the resident slid out of bed to the floor on her/his knees. The Accident/Incident Report stated the CNA reported that s/he lost control of the resident and the resident slid to the floor. A statement was obtained from the CNA that was giving Resident #37 a bath but no other statements were obtained from any other staff on duty at the time. In addition, Resident #37 also sustained an incompletely characterized recent right proximal fracture with mild angular deformity on 09/01/18. Review of the reportable file revealed employee statements from the nurse on all 3 shifts on 08/31/18 and day shift on 09/01/18. Statements were also obtained from the CNA assigned to Mrs.(NAME)on the 3:00-11:00 PM and 11:00 PM-7:00 AM shift on 08/31/18 and the day and evening shift on 09/01/18. No statements were obtained from any other staff assigned to the unit during the 2 days. During an interview on 10/11/18 at 02:33 PM, the Director of Nursing (DON) stated Resident #37 did have side rails ordered at the time of the fall on 07/14/18. The DON confirmed there was no mention in the CNA's statement if the side rail was up and that s/he could not say for sure. The DON confirmed there was no documentation of an investigation and asked the Assistant Director of Nursing (ADON) if the side rail had been up when the resident fell . The ADON stated s/he did not recall asking and also confirmed the statement did not say if the side rails were in use. Both the DON and the ADON confirmed no statements had been obtained from any staff that had not been assigned to Resident #37 related to the 09/01/18 fracture and that a thorough investigation had not been done to rule out possible abuse.