Every finding on record at Compass Healthcare and Rehab Hawfields, Inc.

Based on record review and interviews with resident, staff, pharmacy and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #2).The findings included:The facility's Abuse and Neglect Prohibition policy last revised 6/12/25 indicated that each resident had the right to be free from abuse which included misappropriation of property which was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Resident #2 was admitted to the facility on [DATE]. Review of her recent quarterly Minimum Data Set (MDS) assessment, dated 9/31/25, revealed the resident was cognitively intact. Record review of the physician's order for Resident #2, dated 1/20/25, revealed Oxycodone (narcotic medication) 5 mg (milligrams), to give 1 tablet by mouth, 4 times a day as needed for chronic pain syndrome.Record review of the physician's order for Resident #2, dated 6/6/25, revealed Oxycodone 5 mg, to give 1 tablet by mouth at bedtime for chronic pain syndrome. Review of the Medication Administration Record (MAR) for Resident #2 for October 2025, revealed that scheduled and as needed Oxycodone 5 mg tablets were administered as ordered, including 10/6/25 and 10/7/25.On 1/23/26 at 12:10 PM, during the phone interview, Nurse #2 indicated that she worked from 11:00 PM on 10/6/25 to 7:00 AM on 10/7/25. She counted the narcotics on the medication cart with Nurse #1 at the beginning of her shift on 10/6/26 and the count was correct. Nurse #2 stated she could not recall what the count was but there was no discrepancy. Nurse #2 explained during the shift, Resident #2 did not require as needed narcotic medications. On 10/7/25 at 7:00 AM, during the shift change report with Medication Aide #1, the narcotic count was correct. Nurse #2 confirmed that during her shift, she did not remove the narcotic medication card or narcotic count sheet for Resident #2. Nurse #2 indicated the staff and Staff Development Coordinator (SDC) started the investigation. On 1/22/26 at 9:30 AM, during an interview, Medication Aide #1 indicated that on 10/7/25 she worked 7:00 AM to 3:00 PM shift on medication cart utilized for the A-hall. At 7:00 AM she completed the shift change report, including narcotic count for the medication cart with Nurse #2. Medication Aide #1 stated that when they completed the narcotic count, the number of narcotic medication cards in the locked drawer of the medication cart matched the number of the narcotics noted on the controlled drug count record (used to monitor narcotics that were added and removed from the medication cart). At 7:15 AM, during the medication administration on A-Hall, Medication Aide #1 could not locate the narcotic medication card or controlled drug count record for Resident #2 in the medication cart. She reported it to SDC, who was at the facility at the time. The SDC began looking through the medication cart with Medication Aide #1 to determine if any narcotics were missing. It was found that Resident #2 had narcotic medication card and narcotic count sheet for this medication missing from the medication cart. Record review of the Initial Allegation Report, completed by the Administrator, revealed the facility became aware of misappropriation of Resident 2's property on 10/7/25 when the Staff Development Coordinator (SDC) and Director of Nursing (DON) notified the Administrator that Resident #2 had missing narcotics and the medications were unable to be located in the facility. All medication carts were audited to locate the missing card of oxycodone. All residents were assessed for pain and alert, and oriented residents were interviewed for concerns with pain medication administration. Record review of the Investigation Report, completed by the Administrator on 10/16/25, revealed that the allegation of misappropriation of resident property for Resident #2 was substantiated by the facility. The facility's investigation indicated that Resident #2 had one medication card, which contained 53 tablets of Oxycodone 5 mg, that was unable to be located in the facility. Nurse #1, named in the investigation report, was terminated on 10/10/25. The attempts to conduct a telephone interview with Nurse #1 on 1/21/26 at 1:45 PM and 1/22/26 at 9:30 AM were not successful. Nurse #1 was not available for interview. On 1/22/26 at 9:15 AM, during an interview, Resident #2 indicated that she received pain medications every day and had no concerns related to pain management. On 1/22/26 at 10:35 AM, during a phone interview, the Pharmacy Manager indicated that when narcotics were sent from the pharmacy to the facility, each narcotic medication pack was sent with an individual count down sheet. He confirmed that on 10/7/25, the facility notified the pharmacy about alleged drug diversion with Oxycodone 5 mg tablets. The facility submitted new prescription for Oxycodone 5 mg tablets. The Pharmacy Manager stated that according to the facility, the affected resident continued to receive her narcotics per order with no pain management interruption. On 1/23/26 at 12:30 PM, during an interview, the Director of Nursing (DON) indicated that a complete investigation was initiated when it was discovered that Resident 2's Oxycodone medication and substance control sheet were missing from the medication cart. She stated that on 10/7/25, Medication Aide #1 and SDC reported that Resident 2's narcotic and control sheets were missing. The investigation included reviewing the staff schedule of all person's working the A-hall medication cart from 10/6/25 to 10/7/25. The SDC reported that narcotic card for Resident #2 with 60 tablets of Oxycodone 5 mg was delivered to the facility on 1/3/26, which was verified with pharmacy. The DON, SDC and Unit Coordinator audited all the pertinent pharmacy packing slips, MARs, prescription order tracking records, controlled medication return sheets and comparing controlled medication in all the medication carts. It was found that a total of 53 tablets of Oxycodone 5 mg for Resident #2 were missing and Resident #2 was the only resident affected by this incident. All the staff members, who worked on A-hall medication cart on 10/6/25 to 10/7/25 indicated they did not remove the narcotic medication card or narcotic count sheet for Resident #2 from the medication cart. The facility could not contact Nurse #1 and she did not come to work her next shift on 10/8/25. The Administrator reported the incident to the Department of Health and Human Services (DHHS), Law Enforcement agency, North Carolina Board of Nursing, and Medical Director. The missing Oxycodone was reordered and paid for by the facility. All residents were assessed, and alert and oriented residents were interviewed for possible harm. In-service related to narcotic accountability and process was conducted to all the current employees and agency staff. The DON, SDC and Unit Coordinator completed the audit of all medication carts and the documentation for residents, who received controlled substance once weekly for 4 weeks and then monthly for 2 months. The audit report was presented to Quality Assurance Performance Improvement (QAPI) meeting for 3 months. After the incident, she did not recall having any additional incident related to controlled medication discrepancies or drug diversion. In result of investigation, Nurse #1 was terminated.On 1/22/26 at 1:00 PM, during the phone interview, the Medical Director indicated the facility notified her immediately about alleged drug diversion incident on 10/7/25. She confirmed the affected resident (Resident #2) was assessed immediately without any adverse consequences noted. The missing pain medication was obtained from the Pyxis backup system without delays. The Medical Director expected the nurses to use the Pyxis backup medication until the missing medications were replaced. The Medical Director continued that the new prescription for Oxycodone 5 mg tablets was submitted to the pharmacy on 10/7/25. The facility provided a plan of correction that was not acceptable to the State Agency as the facility did not present interventions to prevent misappropriation of resident's property (narcotic medications for Resident #2).

Based on records review, and staff interviews, the facility failed to implement the abuse policy and procedure in the area of reporting when the facility failed to report an abuse allegation to the State Agency within the specified timeframes, and failed to notify the Adult Protection Services (APS) for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #2).The findings included:The facility's Abuse and Neglect Prohibition policy last revised 6/12/25 indicated that each resident had the right to be free from abuse which included misappropriation of property which was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The allegations are reported immediately, but no later than 2 hours if the events that cause the allegation involve abuse or result in serious injury, or no later than 24 hours if the events that cause the allegations do not involve abuse or result in serious injury to the Administrator, and other officials (including to the State Survey Agency and Adult Protection Services were state law provides for jurisdictions in long-term care facilities). This included an allegation regarding any individual against whom an allegation was made. The Administrator or designee will ensure that a completed Initial Allegation Report is submitted to DHSR in the required timeframe. The Administrator or designee will ensure that a report of the investigation is submitted within 5 working days of the allegation using the DHSR Investigation Report. Record review of the Initial Allegation Report, completed by the Administrator, revealed the facility became aware of misappropriation of resident property on 10/7/25 when the Staff Development Coordinator (SDC) and Director of Nursing (DON) notified the Administrator that Resident #2 had missing narcotics and the medications were unable to be located in the facility. The Administrator submitted an Initial Allegation Report to the Division of Health Service Regulation for misappropriation of resident property for Resident #2 on 10/10/25. The police department was notified of suspicion of crime on 10/10/25 at 5:00 PM. The report did not indicate Adult Protective Services was notified. Record review of the Investigation Report, completed by the Administrator on 10/16/25, revealed that the allegation of misappropriation of resident property for Resident #2 was substantiated by the facility. The facility's investigation indicated that Resident #2 had one medication card, which contained 53 tablets of Oxycodone 5 mg, that was unable to be located in the facility. Nurse #1, named in the investigation report, was terminated. The Nursing Board and Law Enforcement were notified of the missing narcotics. On 1/23/26 at 1:10 PM, during an interview, the Administrator indicated that on 10/7/25, he was notified of the narcotic discrepancy with one of the medication carts at the facility, but it was not confirmed until 10/10/25. He continued the DON, SDC and nursing staff initiated the investigation to locate the missing medications and after pharmacy confirmation and full search of the facility, the missing narcotics were confirmed. The Administrator stated that the facility replaced the missing narcotics for the resident immediately to prevent medication treatment interruption. He did not report the allegation to the State until 10/10/25, because the facility was not sure if the narcotics were missing. The Administrator continued that the facility did not report the allegation to the Adult Protective Service (APS) because the resident was not affected by the situation. The facility reported the drug diversion to the Law Enforcement, North Carolina Board of Nursing, substantiated the allegation and terminated the accused employee Nurse #1. The facility was unable to speak with Nurse #1 about the missing narcotics. The Administrator confirmed that the facility was unable to locate Resident 2's missing narcotics, that the narcotics were removed from the facility, and that Nurse #1 was the named nurse in the allegation.

Based on observations, and staff interviews, the facility failed to store food in the walk-in freezer not open to air and without freezer burn. The facility failed to discard foods past their use-by date, failed to label and date food placed in the nourishment refrigerator in 1 of 2 nourishment refrigerator/freezers reviewed for food storage (E/F hallway). The facility also failed to hold cold foods in a safe temperature range during tray line observation. These practices had the potential to affect food being served to the residents. Findings included: An observation of the walk-in freezer on [DATE] from at 9:30 AM to 9:45 AM revealed the following were located on shelves below the compressor: 1 a. An opened brown cardboard box labeled Chicken -10 lbs. that had ice on top of the box. Inside the box was an opened plastic bag containing 7 pieces of breaded chicken tenders with ice on them. There was no label or date on the bag. 1b. An opened brown cardboard labeled Chicken -10 lbs. that had ice on it. Inside the box was an opened plastic bag containing 5 pieces of chicken patties with no label or date on the bag. 1c. An opened white cardboard that had ice on it. Inside the box was an opened plastic bag with no label or date containing 24 Manicotti (type of pasta) with freezer burn. 1d. An opened brown cardboard labeled beef steak fritters - 71 pieces that had ice on top of the box. Inside the box was an opened plastic bag containing approximately 50 portions of meat with ice on plastic bag. The plastic bag was not labeled or dated. 1e. An opened brown box with 2 unopened bags labeled Italian Sauage - 2 lbs. that had ice on the box. The sausages inside the bags had freezer burn with ice crystals on them. 1f. An opened white cardboard box labeled Breaded Cod -10 lbs. that had ice on the box. Inside the box was an opened plastic bag containing 9 pieces of breaded fish that had freezer burn. There was on label or date on the plastic bag. During an interview on [DATE] at 9:45 AM the Dietary Manager indicated the freezer's compressor was having some issues and was repaired recently by maintenance. He stated when the freezer defrosted, it over cooled causing ice on the food placed on the shelves under the compressor and causing food to have freezer burn. He stated the food placed in the freezer should be properly closed and labeled. The Dietary Manager stated that all dietary staff were responsible to check the walk-in freezer temperature and ensure food packages were properly closed, labeled after use and ensure food had no freezer burn. 2. An observation of the nourishment refrigerator/freezer on the E-F Hallway on [DATE] at 9:58 AM revealed a blue green thermal lunch bag with no name or date in the nourishment refrigerator. The freezer contained a 16-ounce (oz) Styrofoam cup with lid. Inside the cup was frozen pink colored liquid. There was no label or date on the Styrofoam cup. There were four (4) Nutritional supplement ice creams with a use by date of [DATE]. During an interview on [DATE] at 10:00 AM the Dietary Manager stated all food brought in by a resident's family should be labeled and dated by the nursing staff. Employees should not be placing their personal food in the nourishment refrigerator. The Dietary Manager stated he was unsure to whom the insulated lunch bag belonged. to. The Dietary Manager stated all food that had expired should be discarded by the dietary staff when stocking the nourishment refrigerator. The Dietary Manager indicated the Nutritional supplement ice cream were served on the residents' meal tray during meals. The nursing staff may have placed them in the nourishment refrigerator when these were not consumed. During an interview on [DATE] at 10:05 AM Unit Manager #1 stated all resident's food brought in the facility by their family should be labeled by nursing staff prior to be placed in the nourishment refrigerator. The label should have the resident's name and date when the food was placed in the nourishment refrigerator. 3. Tray line observation was made on [DATE] from 11:20 AM - 12:00 Noon. The temperatures of foods on the tray line were taken by the Dietary Cook. Coleslaw was the vegetable option on the menu for the lunch meal. The coleslaw was placed in individual cups and was in an insulated cart near the tray line. The temperature of the coleslaw was taken with a calibrated thermometer, and it read 44 degrees Fahrenheit (F). There were 7 individually wrapped plated containing salad with meat for residents who requested alternate option. The temperature of the salad plate with meat was 49 degrees Fahrenheit (F). The Dietary Manager removed the food from the tray line and placed them in the refrigerator until the internal temperature of these foods reached below 40 degrees F. The food was later placed on the tray line over ice and the Dietary Manager rechecked the temperature of the foods to ensure they were below 40 degrees F. During an interview on [DATE] at 11:50 AM, the Dietary Manager indicated the coleslaw and salads were prepared prior to lunch and were placed in the refrigerator until tray line started. While setting up for the tray line, the dietary aide had placed the individual cups of coleslaw and salad plates in the insulated cart instead of placing them on ice on the table beside the steam table. The insulated cart could not maintain the cold temperature, resulting in the temperature of the food going over the recommended level. The Dietary Manager stated the cook was responsible for checking temperature of food before the food was placed on the steam table for tray line and plated. If the cold foods temperature were not the recommended level of 41 degrees or below, then they should be placed back in the refrigerator until the required temperatures were reached. He stated the cold food should be placed in the cold side of the table with ice to maintain their internal temperatures. During an interview on [DATE] at 4:02 PM, the Administrator indicated he was unaware that kitchen freezer was having issue with the compressor. The Administrator stated all dietary staff should ensure all opened boxes and bags were properly closed and opened packages were labeled. He further stated that food served to the residents should be maintained at proper temperatures. The Administrator indicated the dietary staff were responsible for nourishment refrigerator/ freezer. The dietary staff should be checking for any expired food items and cleaning the refrigerator/ freezer when stocking it with snacks and food daily. Nursing staff should be labeling and dating food brought in by families, however the dietary staff should be cross checking to ensure the food was dated, labeled and discarded as needed.

Based on record review, resident and staff interviews, the facility failed to treat a resident with dignity and respect when a nurse aide was witnessed yelling at a resident during an interaction in the resident's room for 1 of 4 residents reviewed for dignity (Resident #75). A reasonable person expects to be treated with respect and dignity by their caregivers in their home environment. Findings included: Resident #75 was admitted on [DATE]. Review of Resident 75's quarterly Minimum Data Set 3/26/24 revealed Resident #75 was cognitively intact. Review of facility provided allegations of abuse, neglect, or misappropriation revealed Resident # 75 was involved in an altercation with Nurse Aide #1 on 3/27/24 in which Therapy Assistant #1 heard Nurse Aide #1 shouting at Resident #75 but unable to determine the exact words spoken at that time. Review of the facility provided schedules revealed Nurse #1 was assigned as the hall nurse the day of the incident and Nurse Aide #2 was assigned to Resident #75 on the day of the incident. Nurse Aide #2 was assigned to Resident #75's hall but on another assignment. An interview with Resident #75 was completed on 10/8/24 at 9:23 AM. Resident #75 had no recollection of the event and stated she felt safe at the facility. Resident #75 did not report any issues or concerns at that time An interview with Nurse Aide #1 was conducted on 10/9/24 at 12:21 PM revealed she worked on first shift on 3/27/24 but was not assigned to Resident #75. She further revealed that she recalled during first shift on 3/27/24 that she heard Resident #75 hollering, so she went in to see why Resident #75 was hollering and if she needed anything. Resident #75 voiced that she just wanted someone to sit with her and she tried to explain that she had other residents that needed care, but she would come back, and Resident #75 continued to holler out. An interview with Therapy Assistant #1 on 10/9/24 at 12:25 PM revealed she was working on the first shift on 3/27/24 with another resident across the hall from Resident #75's room when she overheard Nurse Aide #1 yelling at Resident #75. She further revealed that she was not able to determine the words that were spoken by Nurse Aide #1 but felt that the level of Nurse Aide #1's voice was not respectful. An attempt was made to reach Nurse # 1 by telephone however the facility was not able to provide a working telephone number. An interview with the Unit Manager #1 on 10/10/24 at 9:14am revealed she worked the day of the incident and Resident #75 reported to her around shift change that Nurse Aide #1 told Resident #75 to shut up. She further revealed that when she interviewed Therapy Assistant #1, she was informed that Nurse Aide #1 was yelling at Resident #75 who was working in a room across the hall. An interview with Nurse Aide #2 on 10/10/24 at 9:48 AM revealed she did recall this incident. An interview with the Administrator on 10/10/24 at 11:40 AM revealed that the investigation revealed Nurse Aide #1 spoke to Resident #75 in a tone that was not acceptable or respectful and therefore Nurse Aide #1 was terminated. He further revealed that all residents should be treated with dignity and respect.

Based on observations, staff interviews and record reviews, the facility failed to apply signage indicating the use of oxygen outside residents' rooms with supplemental oxygen for 1 of 2 residents reviewed for respiratory care (Resident # 79). The findings included: Resident # 79 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. A physician's order for Resident # 69 dated 9/20/24 read oxygen at 3 liters per minute via nasal canula continuously. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident # 79 was cognitively intact and coded for the use of oxygen. During an observation on 10/7/24 at 2:38 PM of Resident #79's room, there was no signage for oxygen use found anywhere near Resident # 79's room entrance. Resident #79 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 79's room. During an observation on 10/10/24 at 8:37 AM there was no signage for oxygen use found anywhere near the entrance of Resident # 79's room. Resident #79 was observed wearing oxygen via nasal cannula at 3 liters per minute (LPM). The oxygen concentrator was observed in Resident # 79's room. During an interview with Nurse #2 on 10/10/24 at 08:40 AM she stated that Resident #79 received oxygen continuously and nursing staff made sure oxygen was applied to Resident #79 and he was monitored. Nurse #2 further revealed that she did not know for sure why Resident #79 was missing the signage, but it should have been posted outside his door. An interview occurred on 10/10/24 at 08:44 with the Director of Nursing (DON). She stated it was the nursing staff's responsibility to put up the oxygen in use sign on the resident's door and if the signage is missing the nurse should have it replaced. An interview on 10/10/24 at 1:37 PM occurred with the Administrator. The Administrator indicated that Resident #79 should have had signage posted outside the room to indicate the use of oxygen.

Based on record review, Responsible Party and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 sampled resident (Residents #8) reviewed for grievances. This practice occurred for 6 grievances filed on behalf of Resident #8. Findings include: Resident #8 was readmitted to the facility on [DATE]. Review of the Grievance Policy (revised dated July 2023) read in part The resident or person filling the grievance and/or complaint on behalf of the resident will be informed (verbally and in writing) of the findings of the investigation and the action that will be taken to correct any identified problems. A written summary of the investigation will also be provided to the resident and a copy will be filed. Review of the grievance log from October 2022 to July 2023 revealed the following: On 11/8/22 there was grievance filed by Resident #8's responsible party (RP) regarding soiled clothes been placed in the resident's closet. Resolution indicated the staff were educated. There was no documentation that resident's RP was notified about the interventions and a written grievance summary was provided to the family. On 1/5/23 there was a grievance filled by the resident's RP regarding a small cup of water in the resident's room. The RP was upset because the resident was on thickened liquid. There was no documentation regarding interventions put in place. There was no documentation that resident's RP was notified about the interventions and a written grievance summary was provided to the family. On 2/24/23 there was a grievance filled by the resident's family members during the care plan meeting requesting agency Nurse Aides (NA), not be assigned to resident's care, and requesting all staff to wear a name badge. Resolution indicated only facility staff to be assigned to the resident. There was no documentation that resident's RP was notified about the interventions and a written grievance summary was provided to the family. There was a generic letter dated 2/24/23 attached to the grievance form that states the grievance was investigated and a course of action was determined. It does not include if what the course of action was. The letter further states if more information is needed to contact the Administrator. On 4/5/23 there were 3 grievances filled by resident's RP on the same day. 1) The first Grievance was regarding poor communication between the staff and the resident's family. 2) The second was regarding pork served on the menu for 3 days in a row and 3) The NA failed to change the bed linens after incontinent care was provided to the resident. Resolutions reached were- all staff were in-serviced about customer care; and Dietary manager provided the RP an always available menu to select from if the resident did not like what was served on the tray. There was no documentation that resident's RP was notified about the interventions or if a written grievance summary was provided to the family. On 4/10/23 the grievance was related to weekend NAs being loud and using profanity. This was filled by the resident's RP. Resolution was all NAs were in-serviced. There was no documentation that resident's RP was notified about the interventions or if a written grievance summary was provided to the family. On 5/14/23 there was a grievance filled by the resident's RP regarding an empty apple slice package/cover in the resident's thrash. The RP indicated that the resident's assigned NA had fed the resident apple slices. The resident was on soft diet. The investigation included written statements from NAs and Nurse and resolution was the resident was not given apple slices. An empty wrapper was put in the trash. There was no documentation that resident's RP was notified about the interventions or if a written grievance summary was provided to the family. During an interview on 07/25/23 10:02 AM, Resident #8's RP indicated since October 2022 she had placed multiple grievances with the facility and has not been provided with any resolutions for her grievances. Resident #8's RP stated the Social Worker (SW) did not contact her and provide her with any solutions to her issues and no written summary was provided. During an interview on 7/27/23 at 2:41 PM, Social Worker (SW) stated all the resident's grievance were investigated and resolved immediately. SW further stated the resident's RP was provided verbal communication about the resolutions by her or the nurse. SW indicated she did not give a written response regarding the resolutions. All concerns that were immediately resolved were communicated verbally. On occasions a generic letter was given to the family indicating her grievance was resolved and date when it was resolved. The letter did not contain the details of the resolution. During an interview on 7/28/23 at 7:53 AM, the Administrator stated the SW was the grievance officer. Residents/ family members/staff can submit a grievance either verbally or written. The grievance form was given to the SW for appropriate action. The SW or the concern department would conduct a thorough investigation. The Administrator also stated the concerns should be addressed with resident and/or representatives with appropriate documentation to support concerns and resolutions were satisfied and agreeable to the resident and/or resident's family with written documentation. The Administrator indicated the resident's RP visited the facility on daily basis and staff would often update the family member on the resolution for grievance, but not always. The letter was not always given/ sent to her.

Based on observations, and staff interviews the facility failed to maintain the walk-in refrigerator floor and racks in clean condition, label foods and discard foods that were spoiled. The facility failed to maintain the double stack oven clean and without grease build up. The facility failed maintain food in the walk-in freezer without freezer burn. The facility also failed to hold hot food (equal to or greater than 135 degrees Fahrenheit (F) on the steam table during tray line observation. The facility failed to ensure a male dietary staff had all facial hair contained in a face covering. These practices had the potential to affect food being served to residents. Findings included: 1. a) An observation of the walk-in refrigerator on 7/25/23 at 6:30 AM, revealed the walk-in refrigerator floor had onion peels, pieces of paper and dirt. The multiple racks of the shelf that were used to stock/ store milk had white colored stains on them. b) Observation of the tray containing packages of cheese revealed: an opened pack of cheese, one fourth filled, printed Mozzarella cheese - 5 pounds (lbs.) not closed properly and not labeled with use by date. An open pack of cheese, half-filled, printed Mild cheddar cheese - 5lbs. not closed and not labelled with use by date. An opened package of deli meat with no label or date. An opened package of deli meat printed Smoked Ham - 5 lbs. which was not closed properly and not labeled with use by date. A half-cut onion which was wrapped in cling wrap with no label or date. There was a strong onion smell in the tray. A half-cut tomato wrapped in cling wrap with no label or date. The tomato appeared to be rotting, juice leaking on the tray, and mushed. During an interview on 7/25/23 at 6:35 AM, the dietary cook indicated the opened pack of deli meat was left over ham. During an interview on 7/26/23 at 11:15 AM the Dietary Manager indicated the cheese tray was cleaned and the food was labeled. The vegetables were thrown out. He stated that the staff should close any opened packages of cheese and ensure that they were labeled and sealed. A second observation of the walk-in refrigerator on 7/26/23 at 11:15 AM revealed the racks that were used to store milk contained white stains on them. During an interview on 7/28/23 at 8:56 AM, the Dietary Manager stated the walk-in refrigerator was cleaned weekly before the truck arrived with food. The walk-in refrigerator was cleaned every Tuesday and Friday. All staff were accountable, but the cook has the prime responsibility to ensure that the refrigerator was clean. 2. An observation of the double stack oven on 7/25/23 at 6:35 AM, revealed large volume of grease buildup inside of the oven and on the door. The grease buildup was encrusted on doors and on shelves where food would be cooked. An observation of the double stack oven on 7/26/23 at 11:20AM, revealed large volume of grease buildup inside of the oven, on the racks and on the inside of the door. There was food cooking in the oven. An empty tray inside the oven had grease buildup. During an interview on 7/26/23 at 11:25 AM, the Dietary Manager indicated the staff were assigned to clean the double stack oven every week. The Dietary Manager stated that the oven was not cleaned the previous week as the facility was going to replace the equipment and install new equipment. 3. An observation of the walk-in freezer on 7/25/23 at 6:40 AM, revealed the following: A roll of brown colored food, wrapped in aluminum foiled was noted. The aluminum foil was not completely sealed/ wrapped. Pepperoni was written on the foil with no date. An unopened pack of meat with no label was observed on the shelf. The package had ice on the meat and had freezer burn. An opened brown colored cardboard box containing meat that appeared like chicken drumsticks revealed the meat was not covered and there was ice on the meat and the food had freezer burn A white colored food that was not properly wrapped in cling wrap. The food was exposed and had ice on it. A white colored food wrapped in cling wrap with no label or date on it. During an interview on 7/25/23 at 6:42 AM, the Dietary Cook indicated the white colored food wrapped in cling wrap was potatoes. She was unsure why the food was not properly wrapped or labeled. The Dietary Cook indicated the meat looked like beef. During an interview on 7/26/23 at 11:27 AM, the Dietary Manager indicated the freezer was repaired recently. The temperature in the freezer had dropped after repair, resulting in food having ice particles on them. He indicated the box containing chicken drumsticks were discarded due to freezer burn. He stated the food placed in the freezer should be properly closed and labeled. The white food in the cling wrap was diced potatoes. During an interview on 7/28/23 at 8:56 AM, the Dietary Manager stated that he and Chef Manager were responsible to check for the walk-in freezer temperature and ensure no food with freezer burns. The walk-in freezer had over cooled over the weekend resulting in ice on meat products. 4) Tray line observation was made on 7/26/23 from11:32 AM - 12:00 Noon. The temperatures of food on the tray line were taken by the Dietary Chef Manager. Salisbury steak was the alternate meat option and was on the steam table. Temperature of the alternate meat read 107 degrees F. Pureed chicken on the steam table read 120 degrees F and mashed potatoes read 124 degrees F. The cook removed the food from the tray line and reheated the food until the internal temperature of these foods reached 165 degrees F. The food was later placed on the steam tables and the the Dietary Chef Manager rechecked the temperature of the foods to ensure they were at or above 140 degress F. During an interview in 7/26/23 at 11:40 AM, the Dietary Chef Manager indicated the food temperatures on the tray line should be above 135 degrees. Review of the tray line temperature log dated 7/26/23 revealed the temperature for lunch alternate meat was not entered. The pureed meat was recorded as 121 degrees F. During an interview with the Dietary Cook on 7/26/23 at 12:10 PM, she indicated the temperatures of all foods that were placed on tray line were taken twice. Once when the food was cooked and once when the food was placed on the tray line, before been it is served to the residents. The cook stated she had taken the temperature of the alternate meat and it was at 150 degrees F when recorded. She had just forgot to write it on the log. She was unable to state why hot food was below 135degree F on the steam table. During an interview on 7/26/23 at 4:00 PM, the Dietary Manager stated the cook was responsible for checking temperature of food before the food was placed on the steam table for tray line. The Dietary Manager further stated all foods that were to be served should have the temperatures entered in the logbook. When temperatures were not up to the required level, the food was to be warmed again to 165 degrees F. Meat temperatures during cooking were checked to ensure food reach a temperature of 165 degrees F. The Dietary Manager indicated Salisbury Steak which was an alternate meat was cooked to the correct temperature of 165 degrees F, however, was not put over water on the steam table and was just placed in a pan on the steam table. The pureed chicken did not have the lid on it to ensure the temperature was maintained on the steam table. He stated the mashed potatoes also were not properly covered with a lid; hence the temperature was not maintained. 5) During an observations and interview on 7/25/23 at 6:30 AM the Dietary Aide helping with breakfast preparation had a beard but was not wearing beard guard. Interview with dietary aide revealed he was unsure where the beard guards were for staff use and that he had forgot to wear a beard guard. During an interview on 7/26/23 at 4:00 PM, the Dietary Manager stated hairnets and beard guards should be used appropriately by staff when working in the kitchen. During an interview on 7/28/23 at 7:53 AM, the Administrator stated the food items should be labeled and discarded appropriately. He added the walk-in refrigerator, and the equipment should be cleaned on scheduled days. All staff should wear appropriate hair nets and beard covers while working in the kitchen. The Administrator further stated all foods served to the residents should be within appropriate range related to temperatures. Staff should ensure food temperatures were recorded for each meal every day.

Based on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the 7/19/22 complaint investigation survey. This was for one recited deficiency of F812 Food Procurement, Store/Prepare/Serve - Sanitary. This deficiency was cited again during the annual recertification and complaint investigation survey of 7/28/23. This continued failure of the facility during two consecutive surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referred to: F812: Based on observations, and staff interviews the facility failed to maintain the walk-in refrigerator floor and racks in clean condition, label foods and discard foods that were spoiled. The facility failed to maintain the double stack oven clean and without grease build up. The facility failed maintain food in the walk-in freezer without freezer burn. The facility also failed to hold hot food (equal to or greater than 135 degrees Fahrenheit (F) on the steam table during tray line observation. The facility failed to ensure a male dietary staff had all facial hair contained in a face covering. These practices had the potential to affect food served to residents. During the previous complaint investigation survey of 7/19/22 the facility failed to store food off the floor, assure refrigerated items were dated, remove refrigerated items when dates signified food items should be discarded, and to have a working cleaning schedule in place to assure floors and equipment were clean. During an interview on 7/28/23 at 12:42 PM the Administrator explained the original F812 citation occurred a year ago, and the provision of dietary services was subsequently outsourced to a contracted vendor. This resulted in improvement in residents' enjoyment of their food and dining experiences, but some of the other plans and actions didn't carry through regarding sanitation and labeling. He further revealed the facility Quality Assurance and Program Improvement (QAPI) Committee would work with the dietary department to identify the root causes for these problems and implement a system to ensure the defective actions of non-compliance will be corrected in an appropriate manner.

Based on observation, resident interview, and staff interview the facility failed to follow menus for three (Residents # 3, # 5, and # 6) of five residents reviewed for dietary services. Findings included. The Dietary Manger provided the facility's menus during a kitchen tour which took place on 7/18/22 beginning at 10:15 PM. A review of the menus revealed there was an Always Available Menu in addition to the daily menu of scheduled meals. On the Always Available Menu chicken tenders were listed as always available. According to the DM, the facility was currently on Week Four of the scheduled menu. A review of Week Four's menu revealed that on Sunday, 7/17/22, the scheduled lunch menu was for fried chicken, mashed potatoes, mixed vegetables, roll, and peach cobbler. On Monday, 7/18/22, the lunch menu was for pork loin, rice, winter vegetables, roll, and baked cookie. 1a. Resident # 3 was admitted to the facility on [DATE]. One of the resident's diagnoses included [CONDITION(S)]. Resident # 3's quarterly Minimum Data Set assessment, dated 5/23/22, coded the resident as cognitively intact. Resident # 3 had a current order for a low fat and low cholesterol/ no added salt diet with a regular consistency. Resident # 3 was observed on 7/18/22 (Monday) at 12:30 PM in the dining room as staff served the trays. Resident # 3 was served a hamburger steak pattie, whole yellow and green beans, and a cookie. Resident # 3's tray card was observed to have chicken tenders, green beans, and a roll handwritten on the tray card. Resident # 3 stated she had chosen the handwritten items earlier because she knew she could eat chicken tenders and there were many things she could not eat. NA # 1 (Nurse Aide) was in the dining room at the time and talked to the resident. The resident also told NA # 1, that excluding the cookie, she could not eat the food. NA # 1 was interviewed about the missing chicken tenders and the roll and stated she would check with the dietary department. NA # 1 returned after checking with the dietary department and informed Resident # 3 the dietary department had no chicken tenders and they did not have a roll, but they did have a piece of bread. The DON (Director of Nursing) also came to talk to the resident and informed her that they did not have chicken tenders but they could make her something else. Resident # 3 declined other foods offered and stated she would eat some of the food, which her family had placed in her refrigerator within her room. The Dietary Manager (DM) was interviewed on 7/18/22 at 5:20 PM and reported the following. She ordered items twice per week and she had ordered enough chicken tenders so they could offer them on an Always Available Menu for residents who did not like the scheduled meal. The previous day (7/17/22), the facility had served fried chicken and one of the dietary staff members had cut up chicken tenders for the residents who needed mechanically altered diets. Instead the dietary staff should have used diced up chicken and chicken breasts the previous day. These items had been available, but the staff member did not use them. Therefore, they had completely run out of chicken tenders and did not have them to offer on Monday, 7/18/22. The DM was also interviewed regarding how she knew how much to order and reported the following. There were 15 residents who routinely obtained the menus and chose from the menu what they wanted or if they wanted instead to select from the Always Available Menu. For all other residents, when an item was on the scheduled daily menu and also appeared on a resident's dislike food item list, then the dietary staff just chose something from the Always Available Menu to substitute. By ordering twice per week, she tried to keep the Always Available items in stock. 1 b. Resident # 6 was admitted to the facility on [DATE]. Resident # 6's annual Minimum Data Set Assessment, dated 7/11/22, coded the resident as cognitively intact. Resident # 6 had a current order for a no added salt and low concentrated sweets regular diet. Resident # 6 was interviewed on 7/18/22 at 3:55 PM and reported the following. She was given a facility menu from which to choose her meals. Sometimes she did not get what was on the menu and chosen by her. A specific example had occurred the previous day; 7/17/22. She had not received a complete lunch meal per the menu. She did not want chicken with bones and therefore she was served chicken tenders. The only other item served with the chicken tenders was mashed potatoes. There was no bread, additional side item, or dessert. Her responsible party was visiting at the time. She did not ask for anything more because she did not want to bother the nurse aides and she did not want to upset her responsible party about it because her responsible party also was aware food was a problem. He would often offer to go get her other food and she did not want her responsible party to have to do that on 7/17/22. Therefore, she had not complained. Resident # 6 stated the facility should know how much food to cook but food was a problem at the facility. Resident # 6's RP was interviewed on 7/18/22 at 5:05 PM via phone and reported the following. He did not recall what had been served on 7/17/22 but stated he had been present on multiple occasions when Resident # 6 was served her food and would say it was not what she ordered or that he observed she did not get all the portions on her tray. Interview with the Director of Nursing on 7/18/22 at 6:00 PM revealed Resident # 6 was a credible source of information. The DM was interviewed on 7/18/22 at 5:20 PM and reported the following. Resident # 6 should have received additional food items at lunch on 7/17/22. The DM stated she had experienced problems with some of her staff sending out trays without all of the food items on the trays. She had instructed them on multiple occasions, but unless she was standing on the tray line and overseeing them; sometimes they did not follow through and would let trays go out which were not complete. She had not been present on 7/17/22. 1c. Resident # 5 was admitted on [DATE]. Resident # 5's quarterly Minimum Data Set Assessment, dated 5/18/22, coded the resident as cognitively impaired. Resident # 5's Responsible Party (RP) was interviewed on 7/18/22 at 1:07 PM and reported the following. Near the end of June 2022 there was a date when Resident # 5 was supposed to be served a salad with her meal and it was not served when they brought the tray. The only thing served was pizza and dessert. She also observed many other residents did not receive any salads and it was supposed to be on the menu that day. She complained to the dietary staff about it. The DM was interviewed on 7/18/22 at 5:20 PM and confirmed the incident. The DM reported the following. She recalled Resident # 5's Responsible Party approaching her to complain about the lack of salads on the day the incident had occurred. Salads should have been served to the residents but there was a whole hall that did not get salads. The DM stated she talked to her staff and they knew there had been 87 residents that day but they only made 53 salads which was not enough. Her staff went ahead and sent out the trays without the salads anyway. There had been enough of ingredients to have made the salads and when she questioned her staff member after the family member had approached her, the staff member just indicated she had not made enough. The DM did not know why the staff member would not have made enough when the supplies were there and the staff member knew there were more residents who needed them than what was prepared for them. The DM stated it seemed almost as if it was intentional. The DM further reported that when she found out about it, she made her staff make the salads and send them out that day late.

Based on observation and staff interview the facility failed to store food off the floor, assure refrigerated food items were dated, refrigerated food items were removed when dates signified the food items should be discarded, and failed to have a working cleaning schedule in place to assure floors and equipment were clean. The findings included. Kitchen observations were conducted on 7/18/22 from 10:15 AM to 11:10 AM. The Dietary Manager (DM) was present and interviewed at this time revealing the following. The DM was interviewed regarding any live pests she may have observed and stated she had seen some roaches but that the pest control company sprayed routinely. The DM reported she last saw one live roach on Friday (7/15/22). It was near the area where the clean plate wells were; near the serving table. During the 7/18/22 kitchen observation, the DM was observed to lift all the plates out of the wells and at the bottom of one there was a dead roach. The DM reported that the pest control technician had told her to clean the wells and she had taken the storage wells out and cleaned it about three weeks ago with bleach and stainless steel cleaner, and that was the last time it had been cleaned. It was observed that there were particles of matter on the floor where the floor met the wall underneath a table. The table was beside the dishwasher. The DM was observed to sweep all of the particles out and once removed it was evident that there were dead roaches in the particles. The DM reported she also saw the dead roaches and that the staff should be sweeping. Within the dry storage area, the following observations were made and also observed by the DM. The flour container lid was partially open. There was brown residue around the top of the container where the lid was supposed to close onto the container. There was a gritty substance on the top of the lid. There were loose cheerios on the floor underneath two of the shelving/storage units. Additionally, there was a closed individual container of applesauce, a closed individual container (1 serving container) of cereal, and a can of soup on the floor. There was a brown substance adhered to the floor underneath the shelf and beside these food items. The DM reported they had cheerios in bulk and filled individual bowls with them. She speculated that staff may have dropped loose cheerios when filling the bowls. She stated the brown substance on the floor appeared to have dripped from the shelves. On another shelf, which was located in the dry storage, there was a syrup bottle. Beside the syrup bottle there was an uu-opened canned item which had approximately 1 teaspoon of syrup on the top of it. Within the walk in kitchen refrigerator the following items were found: a pack of bologna with a sell by date of 4/5/22; a partially full container of potato salad which was dated 7/2/22; a pan of biscuits with no date; thawed strawberries with no date; 2 salads with no date; and a bag of onions was stored on the floor. The DM stated all the food should be dated and she had told her staff this multiple times but they did not follow through. She was observed to store the onions on a shelf and discarded all of the other items. She stated prepared items should be kept no more than a week. The DM was asked about a cleaning schedule and stated she did have a cleaning schedule and she would look to see if staff had been signing off on the schedules. A follow up interview was done with the DM on 7/18/22 at 5:20 PM. During this interview the DM reported she had not found any schedules for the last two months where staff had been signing off they had completed cleaning. The DM reported the last time the flour would have been used was on Sunday, 7/17/22 and she did not know if the staff had just hit the flour container and left it open by mistake or had not closed it the previous day. She had initially thought the substance on the flour container was brown sugar but was not sure that was the case. There was no set schedule for the plate wells, which had the dead roach in it earlier, to be cleaned. According to the DM she felt the kitchen was being cleaned some although the staff were not signing off on it. The DM was interviewed regarding who would have been responsible for sweeping prior to the morning observations of 7/18/22, and the DM reported that Cook # 1 had been present on the evening shift with one other dietary aide on 7/17/22. It should have been swept before they went home on 7/17/22. Cook # 1 was present and was called over by the DM on 7/18/22 at 5:40 PM to be interviewed about sweeping. Cook # 1 reported there had only been him and one other Dietary Aide on the evening of 7/17/22 and they did not have time to sweep and therefore they had not done so. According to the DM, Cook # 1 came in from 12:00 to 8:00 PM and one other Dietary Aide had been present on 7/17/22 from 4:00 PM to 8:00 PM. The first shift dietary staff had left at 2:00 PM and they did not typically help out her evening shift crew. The DM reported she had hired three staff members who were awaiting clearance to work but in the interim she had multiple staff wanting vacation. Currently she reported two of her staff were out of work on vacation. To have been fully staffed on the evening of 7/17/22, when the kitchen was not swept, the DM reported that there should have been three dietary aides and a cook. Instead they had only had the two dietary staff members. The DM also reported that she was working six days per week helping on the tray line and working to fulfill the responsibilities of her staff.

Based on observation, record review, staff interviews, and pest control employee interviews, the facility failed to assure sanitation practices of removing dead roaches, cleaning up spilled food, and assuring food items were closed were being followed to prevent roaches in the kitchen. The findings include: Kitchen observations were conducted on 7/18/22 from 10:15 AM to 11:10 AM. The Dietary Manager (DM) was present and interviewed at this time revealing the following. The DM was interviewed regarding any live pests she may have observed and stated she had seen some roaches but that the pest control company sprayed routinely. The DM reported she last saw one live roach on Friday (7/15/22). It was near the area where the clean plate wells were; near the serving table. During the 7/18/22 kitchen observation, the DM was observed to lift all the plates out of the wells and at the bottom of one there was a dead roach. The DM reported that the pest control technician had told her to clean the wells and she had taken the storage wells out and cleaned it about three weeks ago with bleach and stainless steel cleaner, and that was the last time it had been cleaned. It was observed that there were particles of matter on the floor where the floor met the wall underneath a table. The table was beside the dishwasher. The DM was observed to sweep all of the particles out and once removed it was evident that there were dead roaches in the particles. The DM reported she also saw the dead roaches and that the staff should be sweeping. Within the dry storage area the following observations were made and also observed by the DM. The flour container lid was partially open. There was brown residue around the top of the container where the lid was supposed to close onto the container. There was a gritty substance on the top of the lid. There were loose cheerios on the floor underneath two of the shelving/storage units. There was a brown substance adhered to the floor underneath a shelf. The DM reported they had cheerios in bulk and filled individual bowls with them. She speculated that staff may have dropped loose cheerios when filling the bowls. She stated the brown substance on the floor appeared to have dripped from the shelves. On another shelf, which was located in the dry storage, there was a syrup bottle. Beside the syrup bottle there was an up-opened canned item which had approximately 1 teaspoon of syrup on the top of it. The DM was asked about a cleaning schedule and stated she did have a cleaning schedule and she would look to see if staff had been signing off on the schedules. A follow up interview was done with the DM on 7/18/22 at 5:20 PM. During this interview the DM reported she had not found any schedules for the last two months where staff had been signing off they had completed cleaning. There was no set schedule for the plate wells, which had the dead roach in it earlier, to be cleaned. According to the DM she felt the kitchen was being cleaned some although the staff were not signing off on it. The DM was interviewed regarding who would have been responsible for sweeping prior to the morning observations of 7/18/22, and the DM reported that Cook # 1 had been present on the evening shift with one other dietary aide on 7/17/22. It should have been swept before they went home on 7/17/22. Cook # 1 was present and was called over by the DM on 7/18/22 at 5:40 PM to be interviewed about sweeping. Cook # 1 reported there had only been him and one other Dietary Aide on the evening of 7/17/22 and they did not have time to sweep and therefore they had not done so. The Director of Nursing was interviewed on 7/18/22 at 3:45 PM revealing the following. The Administrator was currently away but the DON had access to the pests control records and knew there was a pest control contract. The company routinely serviced the facility and was available anytime they called. The DON was not aware of any pest control issues on the residential halls. Review of facility records revealed the facility did have a contract with a pest control company and they had last serviced the facility on 7/11/22. Review of the service record revealed the kitchen area had been treated for German roaches on 7/11/22. The pest control company's branch manager was interviewed on 7/18/22 at 4:25 PM by phone. The branch manager reported the following. Their records showed that the facility was last treated on 7/11/22 and the facility was on a semimonthly routine schedule. The facility could also call them as needed. They had treated the roaches. Part of the treatment included using bait. They told customers it was important to clean up the dead roaches because live roaches would sometimes eat the dead roaches before they would eat the bait. Therefore, it helped with pest control measures to get rid of the dead ones. The branch manager also reported that cleanliness was another important factor in controlling them. The pest control company technician, who routinely serviced the facility, was interviewed via phone on 7/19/22 at 11:00 AM and reported the following. His company had started servicing the facility the previous year and at that time they flushed out the roaches which took care of 80 to 85% of the problem and things had improved but things were still not 100 % clear. In order to treat the roaches, there was also a sanitation component to controlling them. He had not seen any live roaches on his last visit but with each visit he pointed out to them that they needed to mop and sweep in all the corners. He had observed that this had been a problem. The technician also stated that roaches are attracted to the moisture and food around the dishwasher.

Based on observation, record review, resident interview, staff interview, and mechanical lift representative interview the facility failed to assure staff were trained or followed through on training regarding mechanical lift transfers to prevent two residents from sustaining falls from mechanical lifts. The facility also failed to have evidence that mechanical lifts were checked for safety prior to a lift malfunctioning while a resident was being transferred in it. This was for two (Residents # 8 and # 10) of four sampled residents reviewed for falls. The findings included: 1. Resident # 8 was admitted to the facility on [DATE]. The resident had a history of [CONDITION(S)] with right [CONDITION(S)], [CONDITION(S)], history of right shoulder girdle dislocation, and history of right shoulder pain. The resident was advanced in age; being older than [AGE] years of age. Resident # 8's Minimum Data Set Assessment, dated 6/2/22, coded Resident # 8 as cognitively intact and as needing extensive assistance by two staff members with transfers. Resident # 8's care plan, dated 5/27/22, included the resident was at risk for falls due to her decreased mobility. Review of physical therapy documentation revealed Resident # 8 was evaluated on 5/26/22 by the therapy department to need a full body mechanical lift for transfers. On 5/29/22 at 9:41 PM, Nurse # 1 documented Resident # 1 was being transferred to the bed from the wheelchair with two Nurse Aides (NAs). Nurse # 1 further documented the resident slid off the bed and the NA's guided her to the floor without injuries. Further review of nursing notes revealed x-rays of the lumbar spine and the sacrum were completed on 5/31/22 and the results returned on 6/2/22 showing the resident had sustained no fractures. Seventeen days later, there was documentation Resident # 8 sustained another fall from a mechanical lift. On 6/15/22 at 9:20 PM Nurse # 2 documented the following. VSS (vital signs stable) 97.4F-18-95% RA-11/82-83. Witnessed incident occurred by (NA # 1). She stated that the resident slid out of the (full body) lift sling as she was trying to transfer her from wheelchair to bed. She assisted resident safely down to the floor. (Full body) Lift X 1 person assist to assist her back into the bed. She and the resident stated that she did not hit her head. Writer noted no bruising or open areas, +ROM (Range of Motion) of upper and lower extremities without pain. Denies hip pain, some mild to moderate c/o's (complaints) of back pain. Offered to call MD to obtain x-rays of her pelvis, lower back, and coccyx. She refused x-rays at this time. Nurse # 2 further documented he would refer Resident # 8 to therapy for a more effective transfer technique. Resident # 8 was interviewed on 6/16/22 at 12:50 PM and reported the following. She recalled falling from the mechanical lift two times. The first time she fell from the lift, her bottom and spine hurt the night after the accident. She did not recall the specific details of the first fall; only that she had fallen from the lift. During the second fall Resident # 8 reported that she came out of the sling and that the NA was a very good NA but she was by herself when it happened. Resident # 8 reported she was not hurt but she did have some bruises. She lifted her arm sleeves to show several purplish bruises on both arms. The rehabilitation director was interviewed on 6/16/22 and reported the following. The facility's procedures were as follows when a resident was admitted . If there were discharge orders from the hospital for the way a resident could be transferred, then those could be followed. Otherwise residents were to be a full body mechanical lift until evaluated by therapy staff. Once evaluated by therapy, then recommendations were made and given to the nursing staff. Resident # 8 had been evaluated on her admitted by the therapy staff to need a full body mechanical lift because she could not bear any weight. Nurse Aide (NA) # 4 had been the NA who was assisting to transfer Resident # 8 on the evening of 5/29/22 (which was the first incident) with the help of NA # 5. NA # 4 was interviewed on 6/17/22 at 4:15 PM and reported the following. On the evening of 5/29/22 she and NA # 5 had used the sit to stand mechanical lift and she had not known that she was to use the full body mechanical lift. They had been trying to get her from the wheelchair to the bed. Once on the side of the bed, Resident # 8 slipped to the floor and out of the sit to stand mechanical lift. Following the incident facility staff told her the instructions for transfers were on the back of the closet door. She had not known that prior to the incident. She did not recall having any inservice training about mechanical lift transfers since the incident. NA # 5 was interviewed on 6/17/22 at 4:45 PM and reported the following. She had helped care for Resident # 8 on the first day she was admitted and she had used the sit to stand lift. She only worked at the facility every 2 to 3 weeks and she was not familiar with their protocols. She knew the resident seemed alert and it seemed appropriate to use the sit to stand lift. NA # 5 felt Resident # 8 had done okay the first evening she used the sit to stand mechanical lift. On 5/29/22 she was assisting NA # 4 to transfer Resident # 8 with the sit to stand lift again. The resident started to say Oh-oh and stopped helping. She slid down to her bottom. At that time NA # 4 had been assigned to Resident #8 and NA # 5 thought NA # 4 knew which type of lift to use. NA # 5 stated she had worked again last night (6/16/22) and found that Resident # 8 had fallen again from a mechanical lift. She did not know how that could have happened, but she did know that when she reported to work on 6/16/22 they had told her to use a full body sling and the full body mechanical lift. Nurse # 2 was interviewed on 6/17/22 at 3:55 PM and reported the following about the 6/15/22 incident (which was the second incident). He had been passing medications when NA # 1 informed him that Resident # 8 had slid from the mechanical lift when she was transferring Resident # 8 from the wheelchair to the bed. NA # 1 had reported Resident # 8 was anxious and let go of the mechanical lift bars and slid through the sling. NA # 1 had reported to the nurse that she had stood behind Resident # 8 to guide her head so that it would not hit the floor as she fell to the floor. Nurse # 2 stated only NA # 1 was in the room and there was supposed to be two staff members. Resident # 8 complained of some back pain, but she refused to have x-rays done. NA # 1 was interviewed on 6/17/22 at 9:27 AM and reported the following. She had been with Resident #8 on 6/15/22 when she slipped from the full body mechanical lift. There had been another NA with her, but she did not recall who it was. Resident # 8 panicked and let go of the mechanical lift bars. She then slipped through the lift pad. She was using a toileting sling and not a full body sling to transfer her from the wheelchair to the bed. As Resident # 8 was slipping she was no further off the floor than the seat of her wheelchair. She (NA # 1) got behind her to protect her head from hitting anything as she slid through and to the floor. NA # 1 reported she had never really been trained about the type of slings and that she used the one that was with the mechanical lift when she obtained the mechanical lift the evening of 6/15/22. NA # 1 reported she recalled there had been a piece of paper she had been asked to review about the mechanical lifts at some point, but that she was a visual learner. NA # 2 was interviewed on 6/17/22 at 11:00 AM and reported the following. She had worked on the evening of 6/15/22 and she and NA # 3 were sitting at the desk when they saw NA # 1 go into Resident # 8's room alone. She had not gotten anyone to help with the transfer. They then saw her come out of the room calling for help. She (NA # 2) went to the room to help. When she arrived, she saw that it appeared NA # 1 had been using a larger lift sling than was needed for Resident # 8. It was so large that she (NA # 2) crisscrossed the leg straps so the hole would be smaller in order that Resident # 8 not slip back through again when they got Resident # 8 off the floor with the lift. She did not recall for sure but thought that the lift pad was blue. NA # 2 was interviewed regarding whether there had been problems or issues with the slings or the mechanical lifts. She reported that there were not enough slings for the mechanical lifts and at times the full body mechanical lift would get stuck when the controls were pushed. At times it would not stop and would keep going when a staff member tried to make it stop. At other times it would not go when they pressed the control for it to go. Also, the legs on the sit to stand mechanical lifts did not always work. NA # 2 was interviewed about training on the mechanical lifts and stated she had not received training since 5/29/22. A full body mechanical lift located on Resident #8's unit was observed on 6/16/22. There was a notation that it had been last inspected 12/26/19 and due in 12/2020. The DON (Director of Nursing), Administrator, and Assistant Director of Nursing were interviewed on 6/16/22 at 4:30 PM. They reported the following. Following the incident of 5/29/22, they had audited all the residents to determine which type lift was needed. They then made a book and placed it at the desk to show which lift and color of sling were needed. They made sure that the instructions for the type of lift were on the backside of residents' closets' door also. According to the DON, the manufacturer's recommendations were that the lifts could be used with one person and therefore he did not feel as if NA # 1 had done anything wrong in transferring Resident # 8 by herself on 6/15/22. He had not had time to investigate to determine what all had gone wrong and how Resident # 8 slid through the sling to the floor on 6/15/22 since it had just happened the previous day. The ADON stated she had done some inservice training and had watched NAs do transfers following the incident of 5/29/22. She had not made records of inservice training or audits, but she had been checking transfers since the 5/29/22 incident to make sure transfers were done correctly. The DON thought Resident # 8's last fall might have something to do with using a toileting sling, which had an open area in the bottom of the sling, when compared to a full body sling. During a follow up interview with the Administrator and DON on 6/21/22 at 11:10 AM these administrative staff members stated that prior to May they had also done training in April, 2022. The inservice training was presented. A review revealed on 4/12/22 that the ADON had instructed 39 staff members, who signed an education form, about mechanical lifts. Some of the information in the inservice training including that care guides were on back of residents' closet doors denoting which lift and pad to use; and that there needed to be two staff members present with any mechanical lift use. The name of NA # 1, who had reported she was a visual leaner and recalled she had only read a paper, was listed on the 4/12/22 inservice record. The names of NA # 4 and NA # 5 were not on the list. A representative for the manufacturer of the mechanical lifts was interviewed on 6/17/22 at 4:30 PM and reported the following. If everything is used correctly then a resident cannot fall out of the mechanical lift. This would entail making sure the correct sling is used; the correct lift is used based on the resident's weight and abilities; and that the lift is used according to manufacturer's instructions. It does not make a difference if a resident does not hold onto the spreader bar. Even if the resident is not holding on, then they cannot fall through the sling if everything is correct. If the facility had multiple accidents involving mechanical lifts then it sounded as if a lot of it could be attributed to user error. The lifts should also not keep going when the operator wanted it to stop or get stuck if the operator wanted it to stop when used correctly and maintained correctly. The lifespan of a lift is [AGE] years. After that the parts do not work as well and the parts become obsolete. There are recommended maintenance specifications that the manufacturer technicians know to check for these things on a routine basis if the facility has a contract with them. Some facilities have contracts and others check their own equipment and are responsible for the proper functioning. Specifications for the lifts are in a manual. There is a certain amount of torque needed for different bolts of the mechanical lifts. According to the manufacture's representative, both maintenance of the lifts and the proper amount of training are key factors in preventing accidents with them. According to the interview with the Administrator on 6/16/22 at 4:30 PM, the facility did not currently contract with the mechanical lift manufacturer for routine checks and maintenance. Interview with the facility's maintenance director on 6/15/22 at 4:25 PM revealed he did not have a set schedule of checking the lifts but that he did do so when they were broken. At that point he would check the entire lift before putting it back into service. The maintenance director felt all the lifts had been checked at some point within the past year. During a follow up interview with the maintenance director, he stated he had downloaded the list of specifications and recommended checks from the lifts' manufacturer's website and started weekly checks on 6/17/22. He was aware of only one lift that had electrically malfunctioned and it had been taken out of service immediately after the incident. Resident # 8's physician, who serves as the facility medical director, was interviewed on 6/21/22 at 2:40 PM and reported that Resident # 8 was checked after her incidents and did not seem to be experiencing any more pain than was her usual chronic pain. The physician felt as if the resident had not experienced any serious injury from her falls. 2. Resident # 10 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, [CONDITION(S)], hypertension, anxiety, depression, diabetes, spondylolisthesis, and history of compression fracture. Resident # 10's Minimum Data Set assessment, dated 3/3/22, coded Resident #10 as mildly cognitively impaired and as frequently incontinent. Resident # 10's Minimum Data Set assessment, dated 6/3/22, coded Resident # 10 as cognitively intact and as always incontinent. Resident # 10's care plan, last updated on 6/15/22, included the information that Resident #10 was at risk for falls due to poor vision, weakness, and medication use. This had been originally added to the care plan on 9/23/20 and remained as an active part of the care plan. On 5/25/22 at 6:00 AM Nurse #3 documented that Resident # 10 slid out of the sling while on the sit to stand mechanical lift and sat in her recliner chair. Nurse # 3 further documented Resident # 10 was complaining of left shoulder and upper arm pain and lower back pain. X-rays were ordered. On 5/25/22 at 6:21 AM, Nurse # 3 documented she administered Tylenol for Resident # 3 's pain and she tolerated it well. On 5/29/22 at 12:59 PM Nurse # 4 documented Resident # 10 remained sore on her left side and x-rays were obtained at 11:00 AM. On 5/25/22 an intervention was added to the care plan which noted that the resident had sustained a fall and was having left arm/back pain. Physical therapy was to evaluate the appropriateness of the Sit to stand mechanical lift. On 5/26/22 a progress note was entered into the record noting that the interdisciplinary team had met and the full body mechanical lift would be used at the time, and physical therapy would see the resident after the x-rays were complete. On 5/30/22 at 2:50 PM Nurse # 4 documented Resident # 10 was very emotional that day and refused to be lifted in the full body mechanical lift. Nurse # 4 noted Resident # 10 was holding her urine and stool until she was incontinent and it was explained to her that she was not strong enough to use the sit to stand lift. On 5/30/22 physical therapy noted they had worked with Resident # 10 again on the use of the sit to stand lift; and that she was refusing the full body mechanical lift. According to the therapy notes, it was discussed that a bedside toilet would be placed at the bedside so that the time in the sit to stand lift would be lessened and enable Resident # 10 to use it. On 5/31/22 at 7:05 AM Nurse # 3 documented that Resident # 10 refused to use the full body Mechanical lift. According to documentation, the facility physical therapist presented inservice training on 5/31/22 specific for Resident # 10 and transfers with the sit to stand mechanical lift. Ten staff members signed as attending. On 6/5/22 at 10:44 PM, Nurse # 5 documented Resident # 10 had been lowered to the floor by a NA while using the Sit to stand lift and was without injuries. On 6/5/22 Resident # 10's care plan was updated to reflect that staff would be reeducated about the use of the sit to stand mechanical lift. NA # 4 was the NA who had cared for Resident # 10 on 5/25/22 when she slipped out of the sit to stand lift. NA # 4 reported the following. NA # 4 was told that she had not secured Resident # 10 correctly in the sling somehow after the incident. NA # 4 was interviewed regarding if she had received training about the mechanical lifts and stated she may have when she was first hired but could not recall for certain. She had not received any training since the incident. NA # 6 was interviewed on 6/17/22 at 1:31 PM and reported the following. During the end of May while caring for Resident # 10 she and another NA were using the full body mechanical lift with Resident # 10, and the lift kept going when they wanted it to stop. It got stuck in the bathroom door frame and would not come down with the resident in the lift. The NA did not know what had happened to the lift. NA # 6 reported she had not been to inservices about mechanical lift transfers since 5/29/22. On 6/20/22 at 2:43 PM, it was confirmed with the Administrator that the day the resident got stuck in the lift was on 5/27/22, and the lift was taken out of service at that time. On 6/21/22 at 11:10 AM during a follow up interview with the Administrator and the DON, the DON and Administrator reported the lift was stuck in the doorframe so that they could not use the emergency release. It had kept going up while the resident was in the doorframe, and the doorframe blocked access to the emergency release control. Nurse # 4 was interviewed on 6/17/22 at 3:56 PM and reported Resident # 10 did not like the full body mechanical lift, and that being stuck in it when it malfunctioned may have contributed to this. She also thought that having no control while in it disturbed the resident and might also have contributed to her not wanting to use it. The Rehabilitation Director was interviewed on 6/17/22 at 3:27 PM and reported the following. Resident # 10 was currently a sit to stand mechanical lift. Following the incident on 5/25/22, they had tried her in the full body mechanical lift but the incident of 5/27/22, during which she got stuck in it, scared her and she refused to use it. Therapy had then worked to get her a bedside toilet so that they could use the sit to stand lift and get her on the bedside toilet quicker when compared to using the lift to get her all the way in the bathroom. This enabled her to hold on to the sit to stand lift for the shorter time frame needed to get to the BST when compared to getting to the toilet. Thus Resident # 10 was once again made a sit to stand mechanical lift, and the therapist thought this was appropriate. The nurse, who had worked on 6/5/22, was interviewed on 6/17/22 at 3:10 PM and reported the following. On that date (6/5/22) the NA had gotten the resident into the sit to stand lift. The resident turned loose and then they had to lower her to the floor. Resident # 10 was interviewed on 6/21/22 at 10:15 AM. The resident could not recall the incident where the lift malfunctioned and kept going while she was in it. She stated she felt safe in the lifts. A representative for the manufacturer of the mechanical lifts was interviewed on 6/17/22 at 4:30 PM and reported the following. If everything is used correctly then a resident cannot fall out of the mechanical lift. This would entail making sure the correct sling is used; the correct lift is used based on the resident's weight and abilities; and that the lift is used according to manufacturer's instructions. If the facility had multiple accidents involving mechanical lifts then it sounded as if a lot of it could be attributed to user error. The lifts should also not keep going when the operator wanted it to stop or get stuck if the operator wanted it to stop when used correctly and maintained correctly. The lifespan of a lift is [AGE] years. After that the parts do not work as well and the parts become obsolete. There are recommended maintenance specifications and the manufacturer technicians know to check for these things on a routine basis if the facility has a contract with them. Some facilities have contracts and others check their own equipment and are responsible for the proper functioning. Specifications for the lifts are in a manual. There is a certain amount of torque needed for different bolts of the mechanical lifts. According to the manufacture's representative, both maintenance of the lifts and the proper amount of training are key factors in preventing accidents with them. According to an interview with the Administrator on 6/16/22 at 4:30 PM, the facility did not currently contract with the mechanical lift manufacturer for routine checks and maintenance. On 6/20/22 at 2:43 PM the Administrator provided information that the facility's mechanical lifts were approximately [AGE] years old. Interview with the facility's maintenance director on 6/15/22 at 4:25 PM revealed he did not have a set schedule of checking the lifts but that he did do so when they were broken. At that point he would check the entire lift before putting it back into service. The maintenance director felt all the lifts had been checked at some point within the past year for safety. During a follow up interview with the maintenance director on 6/21/22 at 4:40 PM, he stated he had downloaded the list of specifications of the lifts from the manufacturer's website and started weekly checks on 6/17/22. He had never been able to identify the issue with the mechanical lift that got stuck in Resident # 10's doorframe on 5/27/22. It appeared to have been an electrical issue of some nature; which he felt could have happened with a new or older lift. Prior to the incident, he had not been made aware there had been any problems with the lift. The maintenance director felt as if the incident may have happened regardless of whether scheduled checks were being done because sometimes electrical problems occur with no prewarning. Resident # 10's physician, who serves as the facility medical director, was interviewed on 6/21/22 at 2:40 PM and reported that Resident # 10 was checked after her incidents and did not seem to be experiencing any more pain than was her usual chronic pain. The physician felt as if the resident had not experienced any serious injury from her fall or when she was assisted to the floor. The physician also reported the resident was an anxious type of individual.

Based on observation, record review, resident interview and staff interview the facility failed to assure a system was in place for food preferences and choices to be met for five (Residents # 2, # 3, # 4, # 5, and # 6) of five residents reviewed for food choices. The findings included: Review of dietary menus for Sunday (4/24/22) through Saturday (4/30/22) revealed the following menu for Sunday lunch on 4/24/22: baked chicken, garden rice, mixed vegetables, roll, and fruited Jello. The alternate for the meal was listed as soup and sandwich. Available sandwiches were listed as : ham, turkey, bologna, grilled cheese, peanut butter and jelly. Review of the menu revealed that everyday the alternate meal was for soup and the same sandwiches mentioned above. There was no mention of salads as an alternative. There was no mention of the planned soups available for each meal. 1 a. Resident # 4 was admitted to the facility on [DATE]. Some of the resident's diagnoses included [CONDITION(S)] and dysphagia. The resident's current diet order, initially dated 10/26/21, was for a low concentrated sweets diet with a mechanical soft consistency. Resident # 4's care plan, last revised on 3/16/22, directed staff to honor the resident's food preferences. Resident # 4 was initially observed on 4/24/22 at 12:58 PM. A lunch tray was before her but she was no longer eating. She had eaten the fruited Jello. She had not eaten the chopped chicken, mixed vegetables, or rice. Review of her diet card revealed a notation that the resident did not like steamed rice or carrots. The mixed vegetables observed on the plate included many carrots. The resident was asked if she was still hungry and nodded her head to signify that she was. At the time, her roommate had already finished her meal. On 4/24/22 at 1:01 PM, Nurse # 7 was interviewed about the resident's tray card and the items on her tray. Nurse # 7 stated she would check with dietary to see if they could obtain an alternate meal. On 4/24/22 at 1:23 PM Dietary Aide (DA) # 1 was observed to bring an alternate tray for Resident # 4 which had a sandwich and soup on it. DA # 1 confirmed Resident # 4 should not have been served the mixed vegetables with the carrots or the rice because of her preferences not to have them. DA # 1 stated that soup and sandwich were the only alternate for the meal that day. On 4/24/22 at 1:34 PM, Resident # 4 was observed eating the sandwich and nodded her head that she like the sandwich. 1 b. Resident # 3 was initially admitted to the facility on [DATE] and had a diagnosis of dysphagia. Resident # 3's quarterly MDS, dated [DATE], revealed he had mild cognitive impairment. The resident's current diet order was for a low concentrated sweets diet with a mechanical soft consistency and for two cartons of whole milk to be delivered each meal. Review of the resident's current care plan, revised on 4/25/22, revealed meal preferences would be honored. Resident # 3 was observed on 4/24/22 at 12:20 PM. The resident had his lunch tray before him. He complained of a lack of food variety. The resident pointed to the mixed vegetables on his tray and said he did not like mixed vegetables. He loved salad though. A review of the resident's meal tray card revealed it had no likes or dislikes listed on his meal tray card. Resident # 3 was again observed on 4/25/22 at 12:35 PM. The resident had no milk on his tray. The resident stated he loved milk and used to have his own cows for fresh milk but the facility did not send milk. The resident also had green beans and he stated he did not like those either. The resident's tray card still did not denote any likes or dislikes for the resident. 1c. Resident # 5 was last admitted to the facility on [DATE]. The resident had a diagnosis of dysphagia. The resident's annual assessment, dated 3/31/22, coded the resident as cognitively intact. The resident had a diet order, dated 7/1/21, for a No Added Salt diet with a mechanical soft consistency. Resident # 5's care plan, last revised on 4/22/22, noted to honor the resident's food preferences. Resident # 5 was observed on 4/24/22 at 1:06 PM to have her lunch tray before her. The resident was very upset about her food. She stated she did not like the chicken and the mixed vegetables on her tray. She stated the previous day (4/23/22) they had served her fish at lunch and she did not like it either. It took them a very long time to get her a meal replacement the previous day and she ended up drinking a protein drink and making some peanut butter crackers which she had in her room. NA # 3 came into the room while the resident was talking and said they had gotten the resident soup and sandwich the previous day and they would get her another bowl of soup and a sandwich again. NA # 3 stated the resident liked that. Review of Resident # 5's tray card revealed it had no dislikes or likes listed on the tray card. 1 d. Resident # 2 was admitted to the facility on [DATE]. The resident's quarterly MDS assessment, dated 5/6/22, coded the resident as cognitively intact. The resident's diet order, dated 8/17/21, was for a No Added Salt/ Low concentrated Sweets diet. Resident # 2 was observed on 4/25/22 at 1:05 PM with her lunch tray before her. One of the items was mashed potatoes. It was observed that Resident #2's tray card noted that she did not like mashed potatoes. Resident # 2 confirmed that she did not. Resident # 2 complained about the variety of food. Resident # 2 stated she did not like to eat a lot of bread and the only alternate to meals was soup and sandwich. 1 e. Resident # 6 was admitted on [DATE]. The resident's quarterly MDS assessment, dated 4/13/22, coded the resident has cognitively intact. The resident's current diet order, dated 7/5/21, was for a Low Concentrated Sweets diet of regular consistency. Resident # 6 was interviewed on 4/24/22 at 2:48 PM and reported she really liked fresh fruit but the facility did not often have fresh fruit to offer them. The resident stated she disliked canned fruit. The resident reported that one time in the past three months, she had an apple and that was the only fresh fruit she had gotten in that time period. The DM (Dietary Manager) was interviewed on 4/25/22 at 3:30 PM and reported the following. She was new to the facility and had been there for only a few weeks. Multiple dietary managers had been hired in the past year but had not stayed. She was trying to get everything in order. In regards to the residents who had food items on their trays that were listed as dislikes for them, the DM stated this should have been caught on the tray line and not served to them. The DM stated resident preferences should be obtained at time of admission and then updated during their care plan meetings. All residents should have their likes and dislikes listed on their tray cards so that the staff would know when the trays were being prepared. The DM reviewed the dietary department's meal tracker computer system during the interview. The DM found that Resident # 3 and Resident # 5, whose tray cards had not included dislikes and likes, had no information entered into the dietary's computer system about their likes and dislikes. The DM also could not find in their system that Resident # 3 was to have two cartons of milk with each of his meals. The DM stated that Resident # 3's clinical record, which contained the diet order and instructions to send milk, was not the same computer system in the dietary department. The DM reviewed the dietary computer system for Resident # 6 and found that it did include that she disliked canned fruit but made no mention that she liked fresh fruit. The DM stated when she began employment, the dietary department only had fresh apples for fresh fruit, and she was planning on trying to order different fruit; but currently apples were all she had in stock in the dietary department. In regards to Resident # 2's complaint that there was only soup and sandwich for an alternate and the resident did not like bread, the DM stated they did offer tuna salad and chicken salad sandwiches and this could be served without the bread as their entrée. According to the DM, alert residents were given the seven- day planned menu once a week and they could choose to have the soup and sandwich or the planned meal. The RD (Registered Dietician) was interviewed on 4/27/22 at 12:52 PM and again at 2:01 PM and reported the following. The current DM was brand new and she was trying to do things correctly. There had been several DMs prior to the current one and they had not stayed for long periods of time. During the employment of the last two DMs, the facility had implemented a new dietary computer system; called Meal Tracker. The past two DMs were involved in getting training on the new system and implementing it. She knew that one of them had gone around to many residents to try to assess their preferences, but she could not find their notes and it appeared as if all of the information had not been entered into the new meal tracker system. Therefore, some of the residents' meal tray cards had no dislikes or likes listed although they should have been if the information had been put correctly in the new system. If the information had been put in the system, then it would be appearing on the tray cards to facilitate serving residents the foods they preferred. The RD also reported it had always been the facility's practice to offer a comparable alternate for their side vegetables, but she had just learned that day (4/27/22) from talking to the dietary staff that a few weeks ago they had stopped offering an alternative for the side vegetable. Therefore on 4/24/22 when mixed vegetables were served, there had been no comparable vegetable to offer. The RD stated staff had told her this was because of product availability and staff shortages. The RD did say the facility did make chef salads for residents who could eat the consistency of a salad and this should be listed on the menu; but it had not been. For residents, who did not like the entrée, then a salad would be a comparable meal and this had been conveyed to the residents who attended resident council, but it had not been transcribed to the menu so other residents would know it was a daily choice. The kitchen typically wanted to know by 10:00 AM if residents wanted a salad so they could prepare it. She confirmed that Resident # 3, who disliked the mixed vegetables and green beans he had been served, could have salads with some limitations of the salad items because of his diet consistency. The RD stated the menu, from which the alert residents were choosing each week, should have all the sandwich and soup options listed and it did not. The RD did feel as if offering more than just apples when seasonal fruit was in season was a reasonable option for the dietary department to do.

Based on observation, record review, staff interview, Responsible Party interview, Nurse Practitioner interview, and Physician interview, for a dependent resident with altered sleep patterns, the facility failed to assess how the schedule of getting the resident in and out of bed for rest/sleep could potentially be contributing to falls and injuries and thereby implement routines to better help her sleep cycle. This was for one (Resident # 1) of three sampled residents reviewed for falls. The findings included: Resident # 1 was initially admitted to the facility on [DATE]. The resident was [AGE] years of age. The resident had diagnoses of Alzheimer's dementia with behavioral disturbance, delusional disorders, hypertensive [CONDITION(S)], chronic kidney disease, atherosclerosis, anxiety disorder, [CONDITION(S)], vitamin D deficiency, gastroesophageal reflux disease, hypertension, [CONDITION(S)], sensorineural hearing loss, chronic pain, history of breast [CONDITION(S)], history of dizziness and giddiness, and history of [CONDITION(S)] in 2016. Resident # 1's 1/22/22 quarterly MDS (Minimum Data Set) assessment coded Resident # 1 as severely cognitively impaired and as needing extensive assistance with bed mobility, transfers, dressing, and hygiene. She was non-ambulatory and had a history of one fall without major injury since the prior MDS assessment. Resident # 1 was also coded as having daily behavioral problems that were not directed at others. The resident's care plan, last updated and revised on 4/22/22, included the resident was at risk for falls due to her dementia, cognitive loss, weakness, [CONDITION(S)] medication use, polyarthritis to both knees, and no safety awareness. This had been originally added to the care plan on 7/8/2020 and remained an active problem on the resident's current care plan. Interventions, which had been initially added on 7/8/2020, included the following: Make sure room is free from clutter. Keep personal items and frequently used items within reach. Keep call light in reach at all times. Keep bed in lowest position with brakes locked whenever resident is in the bed. Ensure resident is wearing proper footwear when mobilizing in wheelchair. Anticipate and meet resident's needs. On 4/8/21 bedside mat on floor beside bed whenever resident is in the bed. Mat to be put away when resident is out of bed was added to the care plan. This remained part of her active care plan also. Resident # 1 's care plan noted her behavioral problem was wandering and yelling out and included interventions to address her behaviors also. A review of Resident # 1's current and past [CONDITION(S)] medications revealed the following medications. [MEDICATION(S)] .25 mg (mg) twice per day ordered since 6/25/21. [MEDICATION(S)] Sprinkles 250 mg twice per day ordered since 4/21/21 [MEDICATION(S)] 75 mg daily ordered since 3/1/22. (The resident had been on 50 mg daily prior to 3/1/22). Resident # 1 had been prescribed 75 mg [MEDICATION(S)] every day from 8/12/20 until 1/7/22; at which time she was started on a gradual drug reduction and the medication was discontinued completely on 2/14/22. On 1/10/22 at 3:30 PM Nurse # 1 documented Resident # 1 was observed lying on the floor beside her wheelchair on her right side. She complained of some right arm pain. The physician was called and ordered x-rays of her right arm. On 1/11/22 the x-ray results showed no acute fracture or abnormality. Nursing notes on 1/11/22 reflected the resident was no longer complaining of pain and had no other injuries. On 1/11/22 the resident's care plan was updated to reflect she had fallen on 1/10/22 and staff were directed to monitor Resident for wheelchair safety. Nurse # 1 was interviewed on 4/24/22 at 4:35 PM and reported the following. The resident's fall had not been witnessed by anyone. The resident was non-ambulatory and he thought she might have been trying to get up. She had been in the wheelchair. She had no head injury and appeared okay except for initially complaining of some arm pain. Interview with the Director of Nursing (DON) on 4/28/22 at 10:50 AM revealed Resident # 1's 1/10/22 fall was the first fall she had sustained in over a year. The DON reported the resident had not fallen since October 2020 prior to the date of 1/10/22. At the time, the resident's care plan was updated to reflect the staff should monitor her for wheel-chair safety, but the facility's investigation had not been able to reveal with certainty how she had fallen because no one had been present. On 2/12/2022 at 6:18 AM, Nurse # 4 documented Resident # 1 had an echymotic (bruise) spot to her right outer eye. The nurse described it as purplish/red and without any signs of swelling. Nurse # 4 further documented she asked the resident how it had occurred and the resident could not recall. Review of facility records revealed the facility investigated the 2/12/22 eye bruise and reported it as an injury of unknown origin to the state agency. The investigation summary contained the following information. On 2/14/22 while investigating the incident it was observed by me and (Nurse # 2) the resident was laying her head down, on the right side of her face on her bed side table. This was also reported by several staff members that the resident lays her face down on her bedside table throughout the day. She was then observed on 2/16/22 to have her face lying down on the bed side table with her hand balled up under her right eye. The investigation documentation included that the bedside table would be padded to further reduce risk of injury in the future. On 3/8/22 at 12:32 PM, Nurse # 3 documented Resident # 1 had a bruise under her left eye. There was no swelling noted or pain. The nurse noted the resident's bruise was exactly in the area where she rested her hand. The ADON (Assistant Director of Nursing) and Unit Manager were interviewed on 4/26/22 at 11:05 AM and reported the right eye bruise, which was sustained on 2/12/22, was very small; at the most the size of a quarter and was in a half moon shape. The ADON stated she had been the one to investigate the bruise and the resident had a habit of leaning her head on her propped- up hand. When another bruise occurred under the opposite eye, she was again observed resting that area of her head in her hand and they did not do an entire new investigation into the left eye. They felt the left eye was from the compression of her head in her hand as the first bruise was and it was very small. They also reported the resident used to wear glasses, which she no longer used, and the areas could have come from some compression from the frames as she rested her head. The resident was also known to rest her head on the bedside table and the facility had padded the bedside table with a mat after the 2/12/22 right eye bruise. On 3/23/22 at 2:50 AM, Nurse # 4 documented the following in the record. Resident # 1 was heard yelling from her room. When the Nurse Aide checked on her, the resident was found on the floor beside her bed with her right leg on the bed. She was found to have a large contusion (bruise) to her right forehead and small abrasion to the right side of her occipital head with scant bleeding. The nurse assessed the resident's neurological status, found the resident's pupils to be equal and reactive to light, checked the resident's vital signs, applied ice to the contusion, and notified the physician. Nurse # 4 noted she would continue to monitor the resident. Nurse # 4 was interviewed on 3/23/22 at 11:10 PM and again on 4/28/22 at 11:35 AM and reported the following. The resident was assessed. She felt the resident might have hit her head on the bed frame. According to Nurse # 4, the resident had fallen out towards the side of the bed near her window. There was a wardrobe beside that side of the bed, but it did not appear that she had hit the wardrobe. There was no blood on it nor the floor. The floor mat had been in place on the opposite side of the bed because that was the side from which the resident generally tried to get up. She continued to check on the resident throughout the night and she seemed okay. On 3/23/22 at 12:26 PM, Nurse # 3 documented the following. At 8:45 AM the resident was then complaining of pain in addition to having the hematoma and the laceration. The resident's vital signs were assessed and Resident # 1's Responsible Party (RP) was notified that the resident needed to be evaluated at the emergency room . The Nurse practitioner was also called. Nurse # 3 was interviewed on 4/25/22 at 2:33 PM and reported the following. Nurse # 4 had assessed Resident # 1 when she fell out of bed on 3/23/22. She (Nurse # 3) then came on duty and, when she assessed Resident # 1, she felt at that time it was better to have the resident checked at the hospital. She contacted the RP, who agreed. According to hospital Emergency Department records for 3/23/22, the resident was alert and disoriented; well-appearing and in no acute distress on initial assessment. She was assessed to have a hematoma to the forehead and to the back of the head with a scabbed over laceration on the back of her head. A CT scan showed no acute abnormality. She was diagnosed with a contusion of the forehead, a concussion, and a scalp laceration which did not require sutures. The resident was transferred back to the facility on [DATE] after evaluation. According to an interview with the DON on 4/26/22 at 1:40 PM, the fall mat was in place on the right side of the bed (where the wardrobe was not) when the resident fell . She fell towards the wardrobe area of the bed. Following the fall, they did intervene. They moved one side of her bed against the wall, and then the fall mat was placed by the one open side of the bed. They also placed a scoop mattress on the bed. Review of the resident's care plan revealed it was updated on 3/28/22 to reflect the resident had a scoop mattress. On 3/28/22 Resident # 1 was seen by the Psychiatric Nurse Practitioner (NP), who noted staff reported to her that the resident was more restless and awake at night. The Psychiatry NP ordered to change her evening dose of [MEDICATION(S)] to 9 PM, which would be closer to her bedtime. On 4/12/22 at 7:33 AM, Nurse # 3 documented that at shift change staff were called to Resident # 1's room and she was found laying on the floor bleeding from the center of her forehead. The resident was alert, breathing, and complaining of pain to her head. Staff took measures to control the bleeding and EMS was called. The resident was transferred to the hospital for evaluation. Review of emergency department records for 4/12/22 revealed Resident # 1 had a 4 centimeter laceration to her head which required seven sutures. She also had sustained a nondisplaced fracture through the floor of the left maxillary sinus. After her evaluation and laceration repair, she was transferred back to the facility on [DATE]. Nurse # 3 was interviewed on 4/25/22 at 2:33 PM and reported the following. It was near shift change when she had already come on duty for first shift that she was alerted by NA (Nurse Aide) # 1 that Resident # 1 was on the floor. The resident was found on the floor with her feet near the bathroom door. Nurse # 1 reported the resident could not stand up from her wheelchair, and so she was unsure how she fell . Nurse # 5 had come to assist and held pressure to the wound while she called EMS to respond. Nurse # 3 reported that third shift routinely got the resident out of bed and therefore Resident # 1 was already up when she came on duty. Nurse # 3 stated the night shift had been reporting that the resident was not sleeping at night. Nurse # 3 stated that at times staff would lay Resident # 1 in bed to rest and then she would want right back up. NA # 1 was interviewed on 4/25/22 at 2:50 PM and again on 4/26/22 at 9:10 AM. NA # 1 reported the following. He had worked a double shift beginning on 4/11/22 at 11:00 PM and through to 4/12/22 at 3:00 PM. NA # 1 reported Resident # 1 would routinely yell at night and would be awake around 12:00 midnight and could be awake for three or four hours. He stated that she slept more in the daytime than at night. He was not assigned to Resident # 1 on the night shift which began on 4/11/22, but knew that NA # 2 (her assigned NA) had gotten her up between 5:00 and 5:30 AM on 4/12/22. On the AM of 4/12/22 Resident # 1's assigned dayshift NA had been working with another resident and he had walked by Resident # 1's room and saw Resident # 1 by the bathroom door on the floor. He had gotten help immediately. NA # 2, who had worked on 4/11/22 beginning at 11:00 PM, was interviewed on 4/25/22 at 4:45 PM and reported the following. Resident #1 had not been sleeping well since around December 2021. She thought they had changed her medication and it seemed to coincide with this. She was very anxious and would routinely be awake from 11:00 PM until around 3:00 AM. She then would get her up around 5:30 AM. On the morning of 4/12/22, she had gotten her up around that time and her shift was over when Resident # 1 fell . She later heard that she was found on the floor. NA # 2 reported the resident would yell at times and at other times she would get sleepy and lean in her wheelchair. She was afraid the resident would fall when she leaned in the wheelchair, and someone had told her to put the bedside table in front of her. She had been doing that. NA # 2 was interviewed regarding why she was getting Resident # 1 up around 5:30 AM if she was not going to sleep until 3:00 AM. NA # 2 responded that Resident # 1 was on the get up list for third shift along with her roommate. She would go into the room to first get Resident # 1's roommate up and when she turned on the light for the roommate, then Resident # 1 would start yelling. On the AM morning of 4/12/22, NA # 2 reported the resident was awake when she got her up. During the interview with Nurse # 4 on 4/25/22 at 11:10 PM and again on 4/28/22 at 11:35 AM, Nurse # 4 also reported Resident # 1 did not sleep well at night. Nurse # 4 reported the resident had no good sleep pattern at all, and this had been a problem since some medication changes. Her sleep was sporadic. The staff would put Resident # 1 in bed at night, but she called out repetitively to get me up-get me up. Then the staff got her up early and she was still sleepy at times. Nurse # 4 reported that Resident # 1 and her roommate had been on the get up list for third shift since she had started working around November 2021. She knew both residents tended to yell in the AM to get up when they awakened and the get up list had never been adjusted since Resident # 1 had been falling. Nurse # 4 reported that she thought it was a possibility Resident # 1 may have fallen asleep in the wheelchair when she fell on the AM of 4/12/22, but she could not say for sure because no one was present. Nurse # 4 reported she had worked the nightshift which began on 4/11/22 and had been present at shift change when Resident # 1 was found at shift change on 4/12/22. Nurse # 4 reported she had last seen Resident # 1 around 6:00 AM and she was up in her wheelchair, awake at that time, and okay. Review of Resident # 1's care plan revealed it was updated following the fall of 4/12/22 to reflect that the resident would have a therapy evaluation. On 4/26/22 at 12:10 PM this was confirmed with the Rehab director to have been done. The resident had been ordered a smaller wheelchair to see if that would help decrease her falls and a wedge cushion had also been ordered. The rehab director reported all therapy disciplines were continuing to work with Resident # 1 as of 4/26/22. A review of the care plan did not reveal the resident's sleep disturbances and habits were addressed on the care plan as possibly contributing to her falls. Interview with the MDS care plan nurse on 4/26/22 at 2:00 PM revealed no one had mentioned to her about addressing the resident's altered sleep pattern in conjunction with the current schedule of getting her up on third shift, and therefore a new planned schedule had not been re-evaluated. Resident # 1 was initially observed on 4/24/22 at 1:37 PM in her room. The resident was leaning forward in her wheelchair and had her head face-down onto a pillow which was on a padded bedside table. The bedside table was in front of her wheelchair and appeared in a stable position to the extent the resident was not falling further forward out of the wheelchair. She appeared to be asleep. Resident # 1 was observed in this same position on 4/24/22 at 2:19 PM, and again at 3:15 PM. During the 1:37 PM observation, NA # 3 was interviewed about the resident sleeping while leaning over on her bedside table. NA # 3 responded that they let her sleep in her chair; otherwise if they put her in bed, then she would be trying to get up. Nurse # 6 was also interviewed at this time about the resident sleeping with her head on the bedside table and responded that sometimes she does that. At 5:00 PM, Resident # 1 was observed awake and yelling in the hall for the nurse to help her. The resident was observed to be able to maneuver her wheelchair unassisted and roll herself. Staff were observed to try to talk and calm the resident. The resident appeared very anxious. Resident # 1's RP was interviewed on 4/24/22 at 3:30 PM and reported the staff were not consistent in whether they laid the resident down if she was sleeping in the chair. She noted she had been in earlier that afternoon and spoken to the staff about finding her sleeping in the chair and they didn't lay her down. During a follow up interview with the RP on 4/25/22 at 12:30 PM the RP reported she had been the one to put the pillow under the resident's head on the afternoon of 4/24/22 because staff were letting her sleep on the bedside table and did not lay her down. Another NA (NA # 4), who cared for Resident # 1 was also interviewed about what they do when the resident falls asleep in the chair. NA # 4 was interviewed on 4/25/22 at 2:20 PM regarding this and responded that she put the resident to bed if she was sleeping in her chair. Interview with the Director of Nursing on 4/26/22 at 10:15 AM revealed the facility had tried to look into the resident's falls and address each fall or incident to minimize Resident # 1's risk for injury as indicated in their care plan updates. None of the falls were witnessed and therefore they were unable to say what had actually occurred. The DON had not been aware the resident was not sleeping well at night and that staff were getting her up around 5:30 AM. The DON stated there were certain residents, for staff accountability purposes, that were assigned to certain shifts to be assisted out of bed; but Resident # 1's schedule of being on night shift to get up had not been brought to his direct attention as something to evaluate. Resident # 1's routine of getting out of bed early had not been reassessed after her falls. The observations of Resident # 1 sleeping on her bedside table on 4/24/22 at 1:37 PM, 2:19 PM, and 3:15 PM were shared with the DON during the interview. The DON stated if a resident was sleeping for that length of time in their chair, then it would have been a reasonable expectation to assist her to lie down. Interview with the Unit Manager and the ADON on 4/26/22 at 11:05 AM revealed they were unaware Resident # 1 was not sleeping until around 3:00 AM and the staff were continuing to turn on the light to get the roommate up and then also get Resident # 1 up around 5:30 AM. The Unit Manager stated if the resident was sleeping in her wheelchair during the day, it would be a reasonable expectation to lay her down. Resident # 1's physician was interviewed on 4/24/22 at 11:50 PM and reported the following. Resident # 1 was very frail, had no fat padding due to her far advanced age, and could very easily bruise with minimal pressure. The resident used to be on [MEDICATION(S)] to help with agitation but her RP wanted it discontinued because the RP felt it was contributing to sedation and the [MEDICATION(S)] did not help with her agitation as well. The RP was hesitant to add medication. Changes made in her [MEDICATION(S)] on 3/1/22 usually took 4 to 6 weeks to see a difference. She did feel as if the staff were watching the resident and trying to keep her from falling, but that the resident had her days and nights mixed up. It had been difficult to address this because of the RP's hesitancy about medication, which in the physician's opinion, had been helping the resident. The physician did feel the lack of sleep could potentially contribute to falls but over all she felt the facility staff were trying to address her falls. The physician noted the resident was far advanced in age and could fall asleep where ever she was. Resident # 1's psychiatric Nurse Practitioner was interviewed on 4/26/22 at 12:45 PM and reported Resident # 1 had a lot of anxiety and agitation. She constantly was asking staff to take her home and the [MEDICATION(S)] had helped with that. Resident # 1 was calm while her RP was visiting and therefore the RP did not often see the behaviors and was hesitant to have the [MEDICATION(S)] continued. The psych NP stated she did think that the resident's anxiety and restlessness had contributed to her falls, and she had instructed the staff to change the second dose of [MEDICATION(S)] to later in the evening to try to help with that and on 3/1/22 the resident had an increase in her [MEDICATION(S)]. Although the Psych NP was aware the resident was restless at night, she was not aware the resident was not going to sleep until around 3:00 AM and not aware the staff were getting her up around 5:30 AM. The NP did feel as if there were ways to possibly help improve the resident's sleep cycle.

Based on observations, staff interviews, record review, Center for Disease Control (CDC) guidelines for the use of Personal Protective Equipment (PPE), and the CDC COVID-19 Data Tracker for Alamance county's level of community transmission, all facility staff failed to wear eye protection during resident encounters. This failure occurred during a COVID-19 pandemic. In addition, the facility failed to follow infection control standards of practice by placing an indwelling urinary catheter bag on the floor for 1 of 2 residents reviewed for urinary catheters (Resident #38). The findings included: 1. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 9/10/21) read in part: Implement Universal Use of Personal Protective Equipment for HCP: If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE (Personal Protective Equipment) as described below: The list of PPE included Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The CDC COVID-19 Data Tracker was accessed and reviewed on 12/13/21 for Alamance county (where the facility was located). The level of community transmission for COVID-19 within the county was reported as High. The facility policy entitled Coronavirus (Covid-19) Prevention and Control last revised December 2021 was reviewed. The policy read in part upon each entry into the facility, staff must take a temperature, answer screening questions, and wear a mask. Observation made on 12/14/2021 at 9:08 A.M. revealed a Physical Therapist was providing therapy to a resident in the resident's room. The PT wore a surgical mask and no eye protection. Observation made on 12/14/2021 at 10:15 A.M., Nurse #1 was at a resident's bedside administering medication. Nurse #1 was wearing a surgical mask and no eye protection. An observation and interview were conducted on 12/14/2021 at 12:24 P.M. with Nurse Aide (NA) #2 as she walked out of a room after a resident encounter. The observation revealed NA #2 was wearing a surgical mask and no eye protection. During the interview NA#2 was asked what PPE she was required to wear when she worked in the facility, NA#2 revealed she was required to wear a surgical mask. NA#2 further stated eye protection was not required since the Covid-19 vaccines had been released and administered to staff and residents at the facility. An observation and interview were conducted on 12/14/2021 at 12:30 PM with Nurse Aide #3. The observation revealed NA#3 sat at a resident's bedside and provided feeding assistance. NA #3 was observed to be wearing a surgical face mask and no eye protection. During the interview with NA #3, it was revealed eye protection was only required to be worn when care was provided to newly admitted unvaccinated resident. NA stated she was only required to wear a face mask on her assignment. An interview conducted with the Director of Nursing (DON) on 12/14/2021 at 12:39 PM revealed he received Covid-19 updates via email from multiple organizations. During the interview the DON stated he was unaware when the country transmission rate was moderate or high, staff were required to wear eye protection during resident encounters. 2. Resident #38 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 9/10/21 revealed the resident had severe cognitive impairment and required extensive to total assistance with activities of daily living that included total assistance with toileting. The MDS noted the resident had an indwelling urinary catheter. The resident's current care plan noted the resident had an indwelling urinary catheter. One of the interventions stated: Do not allow tubing or any part of the drainage system to touch the floor. On 12/13/21 at 10:47 AM Resident #38 was observed sitting in a reclining chair in her room. The urinary drainage bag was lying flat on the floor. On 12/14/21 at 12:15 PM Resident #38 was observed sitting in a reclining chair in her room eating lunch. The urinary drainage bag was lying flat on the floor near the resident's feet. On 12/15/21 at 9:36 AM Resident #38 was observed sitting in a reclining chair. The urinary drainage bag was lying flat on the floor. During the observation Nursing Assistant (NA) #1 entered the room to answer the resident's call light. The NA was asked why the resident's urine drainage bag was on the floor and NA #1 responded that there was nowhere to hang the bag and the NA left the room and the urine drainage bag remained on the floor. On 12/15/21 at 1:59 AM the Director of Nursing (DON) was in the resident's room and was asked about the urinary drainage bag being on the floor. The DON stated the urinary drainage bag should not be on the floor and was an infection control issue. The DON further stated they would find a way to hang the bag so that it was not on the floor.

Based on record review and staff interview the facility failed to refer a resident for PASARR (pre-admission screening assessment and resident review) screening when a resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident continued to receive antipsychotic medication for [CONDITION(S)] without a PASARR rescreening. The findings included: Review of the record revealed a PASARR level 1 that was conducted on 1/12/18. Resident #69 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The first psychiatry (psych) note found on the clinical record was dated 5/20/20 and noted the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan noted an additional problem of behavioral symptoms dated 5/26/21 and noted the potential for anxiety, combativeness, aggression or agitation related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included to assess the reasons for anxiety, social withdrawal and crying, if resident becomes agitated, stop care task and re-approach later. If resident is yelling or aggressive, ask if she is in pain. Notify the nurse of increased agitation, combativeness, aggression or anxiety. Nursing to report inappropriate behaviors to the physician. Be sure to document behaviors. Review of the most recent comprehensive MDS dated [DATE] noted the resident was a level 1 PASARR. The most recent psych note dated 10/11/21 noted the resident's medications were effective for anxiety but continued to have delusions but was not distressed. There were no changes made to the resident's medications. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and no behaviors during the lookback period. The MDS noted the resident required extensive to total assistance with activities of daily living with the exception she required supervision only with eating. The MDS noted a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not a PASARR screen found on the record since the one dated 1/12/18. On 12/15/21 at 10:03 AM an interview was conducted with the facility's Social Worker who stated the resident was admitted from the hospital on 1/14/18 and the hospital discharge orders did not include an antipsychotic medication or a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Social Worker confirmed the resident had not been referred for a PASARR re-screening since admission to the facility. On 12/15/21 at 3:34 PM a second interview was conducted with the Social Worker. The Social Worker stated all residents must have a PASARR on admission to the facility and since most of the residents are admitted from the hospital the screening was usually done at the hospital. The Social Worker stated she requested a re-screening if the resident had a change in status but did not always do this when residents were put on an antipsychotic medication, but she did receive the psychiatry notes when residents were seen by psychiatry. The Social Worker further stated she was not aware that residents with a new psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/16/21 at 1:49 PM the Director of Nursing stated in an interview that when the resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interview the facility failed to have RN (Registered Nurse) coverage for 8 hours a day for 2 of 77 days reviewed (August 1-31, November 1-30 and December 1-16). The findings included: The staff postings were reviewed for August 1-31, 2021, November 1-30, 2021 and December 1-16, 2021. There was no RN listed to work on November 27 or 28, 2021. On 12/16/21 an interview was conducted with the Director of Nursing (DON). The DON stated the RN supervisor left the facility in early November and he had been trying to hire another RN but had not been able to do so. The DON further stated he and the MDS (Minimum Data Set) Coordinator were the only 2 RNs employed by the facility and he had tried to cover with agency but was not always able to do so.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 30 medication opportunities, resulting in a medication error rate of 10% for 2 of 4 residents (Resident #21 and Resident #67) observed during medication pass. The findings included: 1-a. On 12/14/21 at 8:45 AM, Nurse #2 was observed as she prepared and administered medications to Resident #21. The medications included one and one-half (1 ½) - 50 milligrams (mg) tablets of [MEDICATION(S)] (an antidepressant medication) administered by mouth for a total dose of 75 mg. A review of Resident #21's medication orders included an order written [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tablets (for a total dose of 75 mg) once each morning. The review also revealed this order was discontinued on 12/6/21. A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 12/14/21 at 1:42 PM with Nurse #2. During the interview, the nurse reviewed the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The observation of the med cart confirmed a bubble pack card containing one and one-half tablets of 50 mg [MEDICATION(S)] was stored with Resident #21's current medication cards. Nurse #2 reported a review of the provider's orders showed the Nurse Practitioner had put in an order on 12/6/21 to start 100 mg [MEDICATION(S)] for the resident on 12/7/21. At the time of the interview, the nurse looked in the bottom drawer of the med cart where new meds and extra bubble pack cards for residents were stored. A bubble pack card containing 100 mg tablets of [MEDICATION(S)] was identified to be stored in the bottom drawer of the med cart for Resident #21. Nurse #2 stated this card was the one that should have been used during the morning med pass. She reported an additional 25 mg [MEDICATION(S)] needed to be administered to Resident #21 to equal her currently prescribed dose (100 mg). The nurse was observed as she prepared to administer one-half tablet of 50 mg [MEDICATION(S)] (25 mg dose) to Resident #21. An interview was conducted on 12/16/21 at 9:50 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the medication administration observation were discussed. When asked what his expectation was for medication administration, the DON stated if the nurse had followed the 6 rights of medication administration (the right patient, the right drug, the right dose, the right time, the right route and the right documentation) in accordance with the facility's policy, the error would have been avoided. 1-b. Resident #21 was admitted to the facility on [DATE] with a cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #21's active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is an inhaled medication containing a combination of two medications, [MEDICATION(S)] (a steroid) and [MEDICATION(S)]. It is used for the management of asthma and/or [CONDITION(S)]. On 12/14/21 at 8:45 AM, Nurse #2 was observed as she prepared and administered medications to Resident #21. The medications pulled for administration included 160 mcg / 4.5 mcg [MEDICATION(S)]. The resident was observed as she inhaled two puffs of the aerosol medication. The nurse did not prompt the resident to rinse her mouth out with water; no water was offered to the resident so she could rinse and spit out the water after the [MEDICATION(S)] inhaler was used. After the [MEDICATION(S)] was administered, Nurse #2 administered Resident #21's oral medications, then gave her a cup of water to drink. The resident was observed to drink (and swallow) water to take the oral medications. A review of the full prescribing information from the manufacturer of [MEDICATION(S)] (Revised 7/2019) included the following Administration Information, in part: [MEDICATION(S)] should be administered as 2 inhalations twice daily (morning and evening, approximately 12 hours apart), every day by the orally inhaled route only. After inhalation, the patient should rinse the mouth with water without swallowing. Additionally, the Patient Information Guide (Revised 12/2017) for [MEDICATION(S)] specified the following administration guidelines: Rinse your mouth with water and spit the water out after each dose (2 puffs) of [MEDICATION(S)]. Do not swallow the water. This will help to lessen the chance of getting a fungus infection (thrush) in the mouth and throat. An interview was conducted on 12/14/21 at 8:55 AM with Nurse #2. During the interview, the nurse confirmed she did not provide water or coaching / instruction to Resident #21 to rinse her mouth without swallowing after using the [MEDICATION(S)] inhaler. An interview was conducted on 12/16/21 at 9:50 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the medication administration observation were discussed. When asked what his expectation was for medication administration, the DON stated if the nurse had followed the 6 rights of medication administration (the right patient, the right drug, the right dose, the right time, the right route and the right documentation) in accordance with the facility's policy, the error would have been avoided. 2. On 12/14/21 at 8:24 AM, Nurse #1 was observed as she prepared and administered medications to Resident #67. The medications included 240 milligrams (mg) [MEDICATION(S)] (a stool softener) obtained from a stock bottle stored on the medication cart and administered by mouth to the resident. A review of Resident #67's medication orders included an order initially written on 3/26/20 for 100 mg [MEDICATION(S)] to be given as one tablet by mouth every 12 hours for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 12/14/21 at 1:27 PM with Nurse #1. During the interview, the nurse was asked to review Resident #67's medication order for [MEDICATION(S)]. Upon review, the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of the stock medications on the med cart was also conducted with the nurse at this time. The medication cart contained both a stock bottle of 240 mg [MEDICATION(S)] and a stock bottle of 100 mg [MEDICATION(S)] tablets. The nurse was shown the bottle of 240 mg [MEDICATION(S)] observed to supply the oral medication for this resident during the observation of the morning med pass. At that time, the nurse reported she had intended to give Resident #67 the 100 mg dose of [MEDICATION(S)] instead of the 240 mg dose administered. An interview was conducted on 12/16/21 at 9:50 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the medication administration observation were discussed. When asked what his expectation was for medication administration, the DON stated if the nurse had followed the 6 rights of medication administration (the right patient, the right drug, the right dose, the right time, the right route and the right documentation) in accordance with the facility's policy, the error would have been avoided.

Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the Assessment Reference Date (ARD) of the previous quarterly MDS assessment for 1 of 19 residents reviewed (Resident #1). Findings included: Resident #1 had been admitted on [DATE]. Resident #1's most recent completed quarterly MDS assessment had an ARD of 8/11/2021. A quarterly MDS assessment with an ARD of 12/03/2021 was noted as in progress. An interview with the MDS Coordinator was conducted on 12/14/2021 at 4:23 PM. After reviewing Resident #1's assessments, she stated she had somehow looked at the date wrong. She explained there should not be more than 92 days between assessments. An interview with the Director of Nursing (DON) was conducted on 12/15/2021 at 9:12 AM. The DON stated he would expect the MDS assessments to be completed on time.

Based on staff interviews, Nurse Practitioner (NP) and Medical Director telephone interviews, and facility and hospital record reviews, the facility neglected to provide medication treatment as ordered by the provider and to monitor a resident ' s bowel movements to prevent adverse consequences for 1 of 1 resident (Resident #1) reviewed for constipation. The resident was discharged to a hospital on [DATE] where she was determined to have a massive fecal impaction. The resident expired on [DATE] at 12:28 PM. Immediate Jeopardy began on [DATE] when the facility failed to administer daily scheduled [MEDICATION(S)] medication and transcribed the order into the facility's computer system as an as needed medication on three separate occasions ([DATE], [DATE] and [DATE]). No doses of the [MEDICATION(S)] were administered to the resident during her 11-month stay at the facility. In addition, Resident #1's bowel movements were not consistently monitored in the weeks prior to her [DATE] hospitalization . Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #1 was admitted to the facility on [DATE] with re-entry from a hospital on [DATE]. Her cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] --[MEDICATION(S)] oral powder with instructions to mix 17 grams (g) with 4 ounces of juice or water and drink by mouth once a day for constipation. [MEDICATION(S)] is an osmotic [MEDICATION(S)] used to manage constipation. An osmotic [MEDICATION(S)] is a medication that works by attracting water in the colon, which softens stools and make them easier to pass. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] --polyethylene [MEDICATION(S)] ([MEDICATION(S)]) packet powder; 17g; amt: 17g; oral. Special Instructions: take as needed for up to 3 days, Mix in ,d+[DATE]oz (ounces) fluid for constipation. Once A Day - PRN (as needed). No scheduled medications for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . --Record Bowel Movements (BM) every shift. This was noted as a General POC (plan of care) Task in the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Medication Administration Records (MARs) from [DATE] to [DATE] revealed no doses of [MEDICATION(S)] were administered to the resident. The [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order read: polyethylene [MEDICATION(S)] packet powder; 17 g; amt (amount): 17g; oral. Special Instructions: Mix in at least 4oz of liquid as needed for constipation. Once A Day - PRN. No scheduled medications for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the resident's MARs from [DATE] to [DATE] revealed no doses of [MEDICATION(S)] were administered to Resident #1. Resident #1 re-entered the facility after a hospital stay from [DATE] - [DATE]. An order was written on [DATE] by Resident #1's provider for [MEDICATION(S)] oral powder to be given as 17 grams mixed with 4 ounces of juice or water by mouth and scheduled for administration once daily. A review of the resident's MAR from [DATE] revealed no doses of [MEDICATION(S)] were administered to Resident #1. On [DATE], the previous facility order for [MEDICATION(S)] dated [DATE] was discontinued. A new order for this medication was entered into the facility's record for Resident #1 ' s by Nurse #3 on [DATE]. The order read: polyethylene [MEDICATION(S)] packet powder; 17 g; amt: 17g; oral. Special Instructions: Mix in at least 4oz of liquid as needed for constipation. Once A Day - PRN. No scheduled medications for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's MARs from [DATE] to [DATE] revealed no doses of [MEDICATION(S)] were administered. The resident's most recent MDS dated [DATE] indicated she had moderately impaired cognitive skills for daily decision making. She was independent with locomotion on the unit and for eating. Resident #1 required supervision with transfers, walking in her room, and dressing; and needed limited assistance with bed mobility, toileting, and personal hygiene. She was reported to be occasionally incontinent of bladder and frequently incontinent of bowel. Resident #1's Medication Administration Records (MARs) from [DATE] to [DATE] revealed no doses of [MEDICATION(S)] were administered to the resident. A review of the resident's electronic Vitals Report from [DATE] to [DATE] was conducted and revealed information on the resident's bowel movements (or failure to have a BM) was documented on only 3 days (4 nursing shifts) during this 5-week period of time: --[DATE] at 1:29 PM Bowel Movement; Size: Medium; Type: Incontinent. --[DATE] at 11:06 AM Bowel Movement; Size: Medium; Type: Incontinent. --[DATE] at 12:59 PM Bowel Movement; Size: None. --[DATE] at 9:02 PM Bowel Movement; Size: None. An addendum to nursing documentation for [DATE] from 7:00 AM - 11:00 PM (recorded as a late entry on [DATE] at 1:35 PM by Nurse #2) reported Resident #1 also had a medium bowel movement on [DATE]. A review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No scheduled nor PRN medications were administered to prevent/treat constipation. A Nursing Note dated [DATE] and authored by Nurse #2 reported the resident began vomiting after lunch with approximately 6 ounces of thin brown/green liquid (times two). The emesis tested positive for blood. Resident #1 was described as pale, clammy, and tired. The Medical Doctor (MD) was contacted and orders received to call Emergency Medical Services (EMS) for transportation to the hospital. EMS arrived and left the faciity on [DATE] at 3:39 PM. A Hospital Emergency Department (ED) Provider Note dated [DATE] at 4:07 PM was reviewed. The note reported Resident #1 had coffee ground emesis with distension and generalized abdominal tenderness. A computerized tomography (CT) scan revealed the resident had markedly large stool burden in severe diffuse [MEDICATION(S)] distention of the colon. The appearance was reported to be compatible with fecal impaction. A fecal disimpaction procedure was performed. Resident #1 was then transferred to another hospital for a surgical consultation. She was reported to arrive at this hospital's ED on [DATE] at 9:00 PM. The ED notes reported Resident #1's Past Medical History (PMH) included constipation. Transfer notes indicated she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Assessment / Plan authored by a physician from the ED indicated Resident #1 had a massive fecal impaction, concern for bowel ischemia, now status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Given her clinical state, I do not think surgical intervention is warranted as I think the patient would arrest en route to the OR (Operating Room) or on the operating table. If she were to survive the surgery her likelihood of surviving this hospitalization approaches zero in my opinion. This was noted as discussed with her family. The resident was extubated and placed on comfort care. Resident #1 expired on [DATE] at 12:28 AM. An interview was conducted on [DATE] at 6:40 AM with Nursing Assistant (NA) #1. NA #1 reported she knew Resident #1 well from working with her. She reported the resident would let you know when she wanted to go to the bathroom or needed incontinence care. NA #1 reported she was assigned to work with the resident on [DATE] and noted the resident did not have a bowel movement that night on 3rd shift. She stated the NAs were responsible to chart on each shift in the electronic Kiosk as to whether or not their assigned residents had a bowel movement. NA #1 noted a new process had been implemented ,d+[DATE] weeks ago. At this time, the NAs also needed to inform the hall nurse if a resident has a bowel movement. An interview was conducted on [DATE] at 7:45 AM with Nurse #1. Nurse #1 reported in the past, NAs were supposed to document whether or not a resident had a bowel movement in the Kiosk. The nurse reported she routinely pulled up messages every morning with their computerized system and used that information to alert her to residents who did not have a documented bowel movement over the past 72 hours. The nurse reported the facility ' s new process initiated ,d+[DATE] weeks ago required NAs to let the nurse know when a resident had a bowel movement so this information could be recorded by the nurse on the resident ' s MAR (in addition to the NA documentation via the Kiosk). An interview was conducted on [DATE] at 11:45 AM with NA #2. NA #2 reported she typically worked on 1st shift and cared for Resident #1 on several occasions. She reported Resident #1 was incontinent at times but would often transfer herself to the toilet when she needed to use it. The resident would then ring the call bell or holler for help to clean up after toileting. When asked, NA #2 reported the Kiosk system would prompt nursing assistants to chart every shift regarding bowel movements for their residents. She reported the facility's new process for monitoring bowel movements required NAs to be sure and tell the hall nurse if a resident had a bowel movement on their shift. A telephone interview was conducted on [DATE] at 5:12 PM with NA #4. NA #4 was identified as a nursing assistant who regularly cared for Resident #1 on 1st shift. During the interview, the NA reported the resident was incontinent in the night and at times during the day. Resident #1 did wear an incontinence product during the day but would frequently go to into the bathroom and transfer herself onto the toilet. NA # 4 stated she knew when the resident used the bathroom because she would use the call light to request the nursing assistant bring her a dry incontinence product. Upon further inquiry, the NA reported Resident #1 always used the call light when she had a bowel movement while on the toilet in the bathroom. The resident told this nursing assistant she needed help after having a bowel movement each time because she couldn ' t get herself as clean as she wanted. NA #4 stated she was aware nursing assistants needed to chart each resident's bowel movements on each shift, but noted it was easier to do so on some days more than others. She reported the new process required NAs to chart each resident's bowel movements on each shift. In addition, she reported the Medication Aides and hall nurses were also charting the residents' bowel movements so more staff were now keeping track of them. An interview was conducted on [DATE] at 11:30 AM with NA #3. NA #3 was identified as the NA who was assigned to care for Resident #1 on [DATE] and [DATE]. He reported the resident was up and about in her wheelchair on [DATE] with no problems on this date. The NA also recalled she went to the bathroom once or twice on [DATE] but noted she only voided urine (no bowel movement). When asked, the NA reported Resident #1 could sometimes transfer herself to the toilet when she needed to use it. However, he also noted the resident always activated her call light or yelled for help when she was done using the toilet because she needed help to clean up afterwards. When asked, NA #3 confirmed staff would have known when she had a bowel movement. On [DATE], NA #3 reported Resident #1 ate her breakfast and approximately 25% of her lunch. When he went to pick up the lunch trays on that day, he reported hearing someone vomiting and discovered it was Resident #1. He notified the nurse and cleaned up the resident. The NA reported she was throwing up off and on up until the time the paramedics came. An interview was conducted on [DATE] at 11:56 AM with Unit Manager #1. During the interview, the Unit Manager reported the facility's NAs had always been responsible to chart whether or not each resident had a bowel movement on each shift. She stated, We've always had a bowel protocol in place to implement after 72 hours with no BM (bowel movement). When asked, the Unit Manager reported there was a recent change in the facility's process for documenting and monitoring residents' bowel movements. With the new process, the hall nurse was also prompted to put the bowel movement information into the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on [DATE] at 1:20 PM with the facility's Director of Nursing (DON). During the interview, the DON reported documentation of residents' bowel movements (BM) was, definitely an important monitoring tool. He stated that upon the investigation stemming from Resident #1's hospital records and a review of the facility's records, the facility recognized there was a lack of consistency in terms of the BM documentation. A plan of correction was developed (beginning [DATE]) to be sure this documentation was more consistent and accurate moving forward. An interview was conducted on [DATE] at 4:05 PM with the facility's Medical Director. During the interview, the Medical Director was asked how important documentation of bowel movements were in the care of a resident with a history of constipation. He stated, It is important and part of the clinical assessment of the resident. A follow-up telephone interview was conducted on [DATE] at 1:10 PM with the facility's Medical Director. During the interview, the Medical Director recalled when previously asked if the documentation of a resident's bowel movement was important, he said it was part of the clinical assessment. At this time, he added there were certainly other parts of the assessment. For example, he noted the absence of oxygen saturation levels would not preclude one from assessing a resident's respiratory status. He felt the documentation of a resident's bowel movements could be viewed in the same way. The Medical Director reported he has been told the patient was documented as being at baseline and that she had a drastic turn in her clinical condition prior to being sent out to the hospital. He stated, The missing documentation on the bowel movement log did not contribute to the outcome. The Medical Director reported that patients can have bowel movements of normal consistency and still have an impaction in the large intestine. He stated, The short of it is .it is unavoidable. The documentation may have reported regular bowel movements and there still could have been an obstruction. A telephone interview was conducted on [DATE] at 11:20 AM with the Nurse Practitioner (NP) who was the primary care provider for Resident #1 during her stay at the facility. The NP stated she last saw the resident on [DATE] (for a follow up visit) and again on [DATE] when she saw her roommate. During these visits, the resident did not have any complaints. Upon inquiry, the NP reported she has had an opportunity to review Resident #1's [DATE] hospital records. The NP stated she looked through the records and couldn't figure out how she had gotten such a large fecal mass. She recalled the resident did have diabetes and could have had something going on with her nerves. However, she also reported the resident was on [MEDICATION(S)] every day and was surprised it had gotten to the point of obstruction. At that time, the NP was informed the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP was also informed the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP reported she thought the order for [MEDICATION(S)] was scheduled once daily and wasn't aware it was made a PRN order at the facility. She stated she would review the records further when she had access to them. When asked if she would expect the facility to have been monitoring the resident's bowel movements, she stated she would. The NP added that if the resident had no bowel movement within 72 hours, she would have also expected the facility's standing orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .I think it could have possibly played a role if we had been monitoring that better. It's hard to say. The NP reported that although the documentation from the hospital was not entirely clear, the resident's death may have been from a bowel perforation. She stated, If she was having a lot of small bowel movements, there was a chance she wasn't passing all of the bowel contents. That's where the bowel monitoring would have been helpful. A follow-up telephone interview was conducted on [DATE] at 3:13 PM with the NP who was the primary care provider for this resident. Upon further review of Resident #1's medical record, the NP reported the [MEDICATION(S)] ordered for her was always intended to be scheduled for administration once daily. She emphasized [MEDICATION(S)] was not ordered to be given on a PRN basis. The NP recalled Resident #1's family had reported the resident took [MEDICATION(S)] on most days prior to her admission to the facility. When asked, the NP stated this is pretty significant for the [MEDICATION(S)] to be administered on a PRN basis versus scheduled administration. She noted the error apparently occurred twice during the resident's stay at the facility: 1) one time when Resident #1's was initially admitted to the facility; and, 2) a second time when she re-entered the facility from a hospital on [DATE]. A second telephone follow-up interview was conducted on [DATE] at 1:23 PM with Resident #1's NP. During the interview, the NP reported her provider orders were typically printed out (written) and faxed to the facility. She stated the orders were faxed on the same day they were written. The NP noted even if she gave a verbal order on-site at the facility, the staff usually requested that she send a hard copy (written) order to the facility. A follow-up telephone interview was conducted on [DATE] at 2:25 PM with Unit Manager #1. Unit Manager #1 was identified by the computerized order report as having entered Resident #1's order for [MEDICATION(S)] on [DATE] and [DATE]. During the interview, the Unit Manager reported the DON had shown her Resident #1's orders for scheduled [MEDICATION(S)] earlier on this date ([DATE]). The Unit Manager confirmed she had entered the resident ' s admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She noted the 2nd shift nurse would have usually double checked and initialed the orders. However, she reported she could not find where any other nurse had completed a second check on the order for [MEDICATION(S)]. The Unit Manager noted she was not sure why this order had been put into the computer system as a PRN medication. She confirmed the order was written for [MEDICATION(S)] to be scheduled once daily but it was entered into the computer as a PRN medication. Unit Manager #1 stated, I'm human and I made a bad mistake. Unit Manager #1 reported she had not yet checked into the [DATE] order for [MEDICATION(S)] so was not able to provide details about the discrepancy between the provider ' s order for scheduled [MEDICATION(S)] and the PRN orders put into the computer on this date. A telephone interview was conducted on [DATE] at 2:51 PM with the facility's DON. During the interview, the DON described the process he expected to be followed for verifying and entering provider orders into the computer system for a resident. He reported all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked, he reported the facility did not have a system in place to double check the orders. The DON stated he reviewed Resident #1's admission and re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, he confirmed these orders were put into the computer system as an as needed (PRN) medication. The DON added that unless there was an additional conversation between the nurse and provider to the contrary, his expectation was for the order put into the computer to correspond to the provider's orders. A telephone interview was conducted on [DATE] at 3:33 PM with Nurse #3. Nurse #3 was identified by the computerized order report as having entered Resident #1's order for [MEDICATION(S)] into the computer on [DATE]. During the interview, Nurse #3 discussed the process employed to verify and enter a resident's medication order(s) into the facility's computer system. The nurse reported ideally the nurse coming in on the next shift would have checked the medication order for accuracy. However, she stated some nurses did re-check the orders while others did not. When asked, Nurse #3 reported orders for Resident #1 would have been written her provider's NP. The nurse stated she would have input the NP's written orders unless a verbal order had been given by the NP to change these. Nurse #3 reported she thought she would have documented in the Nursing Notes if the NP gave a verbal order to change Resident #1's written orders. A telephone interview was conducted on [DATE] at 1:52 PM with the Medical Director for Resident #1's primary medical provider. The Medical Director reported she was familiar with Resident #1's case and had reviewed her hospital records. From the review, she was uncertain as to why the orders for [MEDICATION(S)] had been entered into the facility's computer system on a PRN basis instead of being scheduled once daily (as intended). When asked if she would have expected the facility to be documenting/monitoring Resident #1's bowel movements she stated, Yes, I would. She reported if Resident #1 did not have a bowel movement within 72 hours, she would have expected the facility's standing orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 10:51 AM, the administrator was informed of the immediate jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on [DATE] at 12:14 PM. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The resident affected is Resident #1 and any other residents for whom medical orders were improperly transcribed. ROOT CAUSE The incident which is the subject of this internal corrective plan resulted from the facility ' s lack of consistency in documenting one resident ' s bowel movement every shift, updating the resident assessment accordingly and implementing more robust proactive interventions for resident # 1 In addition, on [DATE] the facility was made aware that resident #1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . One order was not accurately entered into the resident ' s medical record; the order was for [MEDICATION(S)] and was entered as PRN when it was intended to be given routinely. Nurse # 1 and Nurse # 2 failed to accurately transcribe the [MEDICATION(S)] order. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. IMMEDIATE ACTION On [DATE] Resident #1 was noted at approximately 12:30, after eating lunch, to have vomited times 1 by the assigned CNA. The assigned licensed nurse assessed resident and instructed the CNA to assist the resident with changing clothes. The resident had a window visit with her family at approximately 1:00 to 1:30 pm the same day and stated to them she did feel well. After the visit, the resident vomited again, and the nursing RN supervisor was notified. Resident assessed. VS Blood Pressure ,d+[DATE], Pulse 73, Temperature 97.0, O2 saturation on room air 99%, and blood glucose 257. Resident became pale clammy and tired. The resident was noted to have vomited coffee ground emesis and was positive for blood upon test by supervisor. The medical provider was paged at approximately 2:21 and 2:45pm. The medical provider responded at 3:09 pm and gave order to send the resident to the emergency department for further evaluation. Notified responsible person, resident ' s sister of resident ' s changes, transfer to local hospital per MD ' s orders, and plan of care going forward. EMS called, they arrived and left facility at 3:39p. Resident was transferred to the emergency department and did not return to the facility. IDENTIFICATION OF OTHERS On [DATE] all residents currently in the facility were audited to determine any resident that did not have a bowel movement documented in MatrixCare during the past 72 hours. Effective [DATE] all residents that were noted to not have a documented bowel movement in the last 72 hours were interviewed/assessed by the nursing manager to identify if the resident had a bowel movement that was not documented by nursing staff. Alert and oriented residents able to communicate the date of their last bowel movement were identified and interviewed, and the last bowel movement date was documented in CareAssist. For those residents unable to communicate when their last bowel movement occurred, the staff identified as providing care for the resident within the last 72 hours was interviewed and asked of the resident had a bowel movement. Those residents identified as not having a bowel movement in the last 72 hours had a bowel assessment completed and bowel protocols initiated. On [DATE] the Medical Directors/providers completed an audit of all resident ' s physician orders, for all residents that are currently in the facility to ensure the orders are accurate. Any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of [DATE] all resident physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . SYSTEMIC CHANGES Effective [DATE] all licensed and non-licensed (medication aide and CNA) nursing staff were re-educated by the Staff Development Coordinator/Designee regarding the facilities bowel protocols Bowel protocols and procedures, documentation, and standing orders, to include the following. All residents have orders in MatrixCare to monitor and document bowel movements every shift. CNA ' s are responsible to monitor and record all bowel movements in CareAssist every shift. The CNA would document in the output tab of CareAssist if the resident had or did not have a bowel movement and document the size of the bowel movement (small, medium, and large). The CNA will report to the responsible nurse, if the resident did not have a bowel movement that shift. The licensed nurse will also be prompted in MatrixCare to document the status of a resident ' s bowel movement every shift. The assigned licensed nurse will monitor each resident ' s bowel movements in MatrixCare utilizing the Vital Signs Widget on their MatrixCare dashboard every shift. The vitals out of range report can be set to reflect all residents that have not have a documented bowel movement within last 72 hours for their specific assignment. If the resident is noted from the Vital Signs Widget, to have had no bowel movement in the last 72 hours, the licensed nurse will assess for bowel sounds, nausea/vomiting, abdominal distension/ pain, or tenderness. This assessment will be documented in the resident ' s progress note section of MatrixCare. The staff will notify the MD of negative findings. If there are none, staff are to proceed with standing order bowel regimen. Based upon the nursing assessment the licensed nurse will initiate the standing bowel protocols. MOM - 30 cc PO X (1) for s/s of constipation. CALL MD IF SYMPTOMS PERSIST. [MEDICATION(S)] - (2), 5mg tab/s PO or (1) [MEDICATION(S)] 10 mg suppository (insert rectally) for constipation unrelieved by MOM. If the resident is nauseous, vomiting, clammy, S/S of moderate/severe pain, etc. CALL MD. Effective [DATE] any nursing staff, licensed or non-licensed, including agency, not in serviced by [DATE] will not be allowed to work until they have completed the in-service conducted by the staff develop coordinator/designee. All staff, including agency staff, not in-serviced have been notified via phone/text by the staff development coordinator of the need to be in-serviced prior to working. Effective [DATE] all new employees will be in-serviced during the new employee orientation and prior to working in resident care by the staff development coordinator/designee. Effective [DATE] all licensed staff will review the vital sign report on the dashboard of their MatrixCare account every shift. Any resident that is flagged as not having a bowel movement in the last 72 will have an abdominal/bowel assessment completed and documented in a resident progress note and bowel protocols will be initiated according to the standing orders. Effective [DATE] The Nurse managers/Unit coordinator/Nursing supervisor will review the vitals alert out of range report and residents that have not have a documented bowel movement within last 72 hours and the nursing progress note documentation, for their specific unit. This report will be discussed in daily clinical standup meeting Monday to Friday. Effective [DATE] the facility implemented a second check process for all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed nursing staff will place all orders that are in a written format (i.e. Hospital Discharge Summaries, Physician Visit Summaries, Hard Script Prescriptions, etc.), in a folder for unit manager/supervisor to review prior to being scanned to the electronic medical record. The licensed nurse manager/supervisor will run an Order Report in MatrixCare daily, print it out and review all orders for accuracy. This report will be brought to the clinical standup meeting daily Monday - Friday for review by the clinical team. On Saturday and Sunday, the nursing supervisor/designee will run an Order Report in MatrixCare daily, print it out and review all orders for accuracy. This report will be reviewed by the clinical team in the Monday clinical standup meeting. Effective [DATE] all licensed staff, currently in the facility were re-in serviced on t

Based on resident, staff and family interviews and record review, the facility failed to protect a resident from verbal abuse by a contracted therapist for 1 of 3 residents reviewed for abuse (Resident #69). The resident stated the way the therapist spoke to her and about her to her family member made her feel like everyone hated her, afraid to say anything, terrible and humiliated. The resident chose to be discharged from the facility and to finish her therapy at home because she did not want to be treated badly by anyone. The findings included: Resident #69 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Care plan dated 9/20/19 identified Resident #69 had as having an activities of daily living (ADL) self-care performance deficit. The goal was for the resident ' s current level to improve. Interventions included 1-person assistance with all activities of daily living. The most recent Minimum Data Set ((MDS) dated [DATE], specified Resident #69 ' s cognition was intact, and she was totally dependent upon staff for all activities of daily living. The facility ' s 24-hour report submitted to the state agency dated 9/26/19, specified that Physical Therapist (PT) #1, who was a contracted employee, stopped in Resident #69 ' s room. The resident ' s family member, who was in the room, stated the therapist told the resident she was now a two person assist because she got somebody in trouble yesterday. The family member told the therapist not to talk or yell at Resident #69 like that. The therapist told the family member to take Resident #69 to another facility that she doesn't need to be here anyway. The report specified, Resident #69 stated she did not want the therapist in her room anymore and she wanted to do therapy at home. Resident #69 stated it hurt her feelings and she had tears in her eyes. The facility ' s 5-day report submitted to the state agency dated 10/1/19, specified PT #1 stated he was never rude to anyone. The report noted, Resident #69 was upset and at times still talked about the interaction with the therapist. The report ' s summary of facility action noted, the therapist was spoken to and sent home. Additionally, both the resident and family member were spoken to about the incident. The family member stated the therapist could have approached the room and situation better. The report noted, that It was decided it was more of the therapist ' s approach. Re-educating staff on abuse and approach would be implemented, making sure staff were knocking before entering rooms and to use certain tones when speaking to a visitor. During a telephone interview on 11/6/19 at 4:08 PM, Resident #69 stated that she put her call light on and was waiting to be changed when a man came to the room, who she thought was with therapy. Resident #69 stated, I told him I was not ready for therapy because I was waiting to be changed. My family member was with me and he began telling me that two people had to get me up because I had gotten a staff in trouble and lied. He was yelling and screaming that I got staff in trouble, I felt bad and that it was a problem for telling my family member about what happened to me. I felt like everyone hated me and was against me, it was terrible. I was afraid to say anything after that. Resident #69 further stated, the therapist said to her family member that she (Resident #69) doesn ' t need to be here anyway. The resident explained, I felt terrible and humiliated. I did not want to do anymore therapy at that place, because he made me feel terrible and accusing me of getting staff in trouble for reporting what happened to me. I would have stayed but I didn't want to be treated badly by anyone, so I asked my family member to get me out of there and let me do therapy at home. Review of PT #1 ' s statement dated 9/26/19 read in part: while walking down E-Hall rehab gym around 7:40 AM I noted a call light on in Resident #69 ' s room. When I walked back to E-Hall around 8:00 AM I noted the same call light on. I entered the room for customer service to educate the resident on the reason there was a delay in the nurse aide responding to her call bell was because on the previous day she reported an incident about a staff member, who was working with her, and got the staff member in trouble. So, it was decided two staff members needed to assist with her care instead of only 1 staff member. PT #1 ' s written statement specified the resident ' s family member said to him, it is a disgrace the way residents are treated around here and PT #1 reminded her that she has a right to take her mother elsewhere. During an interview on 11/7/19 at 10:55 AM, PT #1, confirmed he did go into Resident #69 ' s room on 09/26/19 and told the resident and the family member that the resident now had to have two staff to provide care because the staff had gotten in trouble for doing their job when working with Resident #69. The PT explained, the conversation did get intense between he and the family member. The PT stated, I was a bit snotty when I was walking out of the room and the family member told me to come back. I am being honest all I wanted to do was get out of the room because I was a bit mad. The therapist stated, It was not my intent to verbally abuse the resident and to disclose any part of the investigation or make statements about the resident leaving and going elsewhere. PT #1 specified, I know now that I should have handled the situation much differently and it was not part of the policy or abuse training to share or discuss any part of an investigation. The therapist further explained, I know I did not scream or yell at either of them and should not have said the things I said or in the way I said them. I did speak with the administrator and the director of nursing (DON) following the incident and they all have informed me that I should have handled things differently. The PT specified, I realized after the fact that how things happened it could be perceived as verbal abuse when that was not my intent. During a telephone interview on 11/6/19 at 3:39PM, the family member of Resident #69 stated, on 9/26/19, in the morning she was visiting with Resident #69 to make sure she was alright. When she arrived at the facility Resident #69 turned on her call light at a little after 8:30 AM. PT #1 came to the room and we were thinking he was there to do therapy with Resident #69. The family member stated that Resident #69 told him she could not do therapy right then because she was waiting to be changed. PT #1 was very rude, aggressive and angry. PT #1 told us Resident #69 got staff in trouble, and he was yelling and screaming at her. The family member stated, Resident #69 was upset and was crying that he came in and accused her of getting staff in trouble. The family member explained, that she told PT #1 that he could not talk to Resident #69 in that tone of voice or accuse her of getting anyone in trouble. He was making Resident #69 feel bad and upset. PT #1 was so rude and disrespectful. He was very disrespectful and stated, if we didn't like it here, we could take ______(Resident #69) somewhere else. The family member said, Resident #69 was crying and felt like she had done something wrong and wanted to leave before her therapy was completed at the facility. I had never seen anyone come and talk to a resident like that making Resident #69 feel so small. The family member stated, This should never happen to anyone else. She said, she took Resident #69 home for her safety and wellbeing because she was too scared to stay. The family member stated, she felt Resident #69 was verbally abused by PT #1. The resident ' s family member stated, A therapist should not be talking to anyone like that. The way he was talking to (Resident #69) accusing her of getting someone trouble was appalling. During an interview on 11/6/19 at 2:30 PM, the Director of Nursing stated on 09/26/19 the family member of Resident #69 reported that PT #1 came into Resident #69's room and was yelling and screaming inappropriately at her and making accusations that Resident #69 had gotten a staff person in trouble and was making statements if her and Resident #69 didn't like it at the facility to take the resident somewhere else. The DON stated she did abuse/neglect in-service with direct nursing staff, therapy was not involved. The administrator informed the DON he would handle communication and action for the therapy staff. During an interview on 11/7/19 at 12:40 PM, the Administrator indicated PT #1 was a contract employee at the facility for many years. The administrator stated, the PT should not have made any inappropriate or accusatory statements about Resident #69. The administrator further stated following the incident PT #1 was sent home and when the staff discussed the situation, it was not brought to his attention as verbal or mental abuse toward the resident. The administrator stated the therapist should have followed the abuse/neglect policy to get staff assistance for the resident either from an aide or nurse. There should not have been any verbally abusive dialogue between PT #1 to the resident or the family member. He stated the DON reported the incident to the state agency, but he was unaware of any further action taken after that point, since the resident discharged from the facility. The administrator stated, I didn't think of what was said as verbal abuse or mental abuse. I just kind of said to therapist to change your approach on how you deal or speak with resident.

Based on record reviews, family interviews, facility staff interviews, agency staff interviews, and law enforcement interviews the facility failed to protect a resident from abuse by photographing and distributing a picture of the resident completely disrobed via text message to another staff member for 1 of 3 residents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's most recent comprehensive MDS (Minimum Data Set) revealed it was coded as an admission assessment and dated [DATE]. The MDS had documentation of the resident being admitted to the facility on [DATE]. She had been assessed as being cognitively impaired and as needing extensive assistance with all activities of daily living except for eating. Her eating was assessed as only needing set up assistance with supervision. A review of the Initial Allegation Report had documentation of an allegation of employee to resident abuse regarding Resident #1. The Allegation Report listed NA#1 (Nursing Assistant) as the accused employee. The report had documentation that the facility became aware of the incident on [DATE] at 9:30am. The Allegation Details Section of the Allegation Report had documentation that read: Picture of (Resident #1's name) lying in bed with no clothes on was shown to the DON (Director of Nursing) by a CNA (Certified Nursing Assistant) (NA#2) stating that it was a text message sent to her by NA#1 (NA#1's name) and stated NA #1 had worked with her that day. A review of the completed Investigation Report revealed documentation of the same information as the Initial investigation with additional documentation in Section D: Additions/Changes/Updates to description of allegation details that read (Aides name) NA #2 mentioned that the picture was sent in November. Section H: Investigation Actions documented the allegation was substantiated. Also, under Investigative Actions there was a section titled Summary of Facility Investigation read: Spoke with both (NA#1 and NA#2 names) about the allegation. The number that the picture came from was confirmed to be from NA#1's cell phone. The picture was shown to DON. During an interview with the DON on [DATE] at 11:30am, she confirmed she was the person the allegation was reported to as well as the person that completed both the Initial Allegation Report and the completed Investigation Report. The DON explained the sequence of events of how she found out a picture had been taken and sent through a text message. She stated that on [DATE] while she was driving to work, she received a phone call from NA#2. During the phone call NA#2 stated she had something she needed to show the DON but would prefer to meet her somewhere other than the facility and it was decided they would meet at a gas station near the facility. The DON further explained that once she met NA#2 that she wasn't alone, and a friend was with NA#2. While at the gas station NA#2 showed the DON a picture of Resident #1. She said in the picture, Resident #1 was lying in the bed with no clothes on and had her gown in her left hand. She further stated that she looked at the phone number the text message came from and it was the cell phone number for NA#1. The DON asked NA#2 if she would bring her phone to the facility to show the administrator. She then indicated she immediately called the administrator to report the information that had been given to her. She stated the administrator was not comfortable looking at the picture if the resident was disrobed and instructed another staff member to verify the picture was of Resident#1. She stated the staff member verified that the picture shown to her was Resident #1 and that the number the text message came from was the cell phone number of NA#1. Additionally, she added she called the family and notified them of the incident, put a call in to the police, and started the 24-hour report. After completing the report on [DATE] she sent it via fax to HCPR (Health Care Personnel Registry). She added both nursing assistants involved were terminated on [DATE]. She indicated that NA#1 was working for an agency until the facility hired her on [DATE] and that NA#2 was an agency nursing assistant. She said she called the agency NA#2 worked for to report the incident and that she could no longer work at the facility. The DON continued to say that a detective returned her call on [DATE], came to the facility and took the report of the incident. She indicated the Detective has not closed the case yet and she does not have a police report but would once the detective closed the case. A telephone interview with NA#1 was attempted on [DATE] at 1:30pm, but the number given was no longer a working number. An interview with NA#2 was conducted via telephone on [DATE] at 1:38 pm. During the interview NA#2 stated in late (MONTH) of (YEAR), right before Thanksgiving she received a text message from NA#1. She indicated the picture was of Resident #1 lying on her bed with no clothes on. She stated she couldn't remember the exact date of the text message, she would have to review her schedule of the exact days she worked, but on the day she received the text message she remembered she had worked third shift the previous night. When asked why she didn't report the picture to her supervisor in (MONTH) when she received the message, she indicated she didn't know why she didn't. She further stated, I knew it was wrong, I just didn't think about reporting it. When asked what occurred in (MONTH) of 2019 for her to initiate the call to the DON of the facility to report the incident, she stated she and a friend (name not given) were cleaning out old contacts, messages etc. from their cell phones and her friend noticed the picture of Resident #1 on the phone. NA#2 then said her friend encouraged her to tell the facility because that was wrong. NA#2 further stated she agreed with her friend and called the DON of the facility and asked her to meet her to show her the message and picture before she deleted it from her phone. She added that she had also been called by a detective regarding the same text message and picture. She stated she took her phone to the county sheriff department as requested by the detective, so they could hook her phone to a machine that could recover deleted information but that something was wrong with the machine and the picture and text message was unable to be recovered. NA#2 indicated she would take her phone to her phone service carrier later in the evening to see if they could retrieve the information. On [DATE] at 2:15pm a phone call was made to the Detective listed on the Investigation Report. The Detective was not available. An interview was conducted with Resident #1's daughter on [DATE] at 3:05pm. During the interview, the daughter stated she was the one contacted by the facility on [DATE] and was told that a picture was taken of her mother while in the bed unclothed by a nursing assistant. She was also told the nursing assistant had sent the picture to another nursing assistant via text message back in (MONTH) of (YEAR). She further added that the nurse that called to report the incident was the DON and that the DON told her both nursing assistants had been terminated and an investigation was started. The daughter indicated that she was aware law enforcement was involved and that she hoped the case would be prosecuted. Additionally, the daughter explained that several members of the community were aware of the incident due to a conversation being over heard about pictures being taken of residents in the facility while she was at a sweepstakes parlor one evening. She said she couldn't remember what evening, but that she mentioned it to her daughter (the resident's granddaughter) and that the granddaughter had told her she had heard the same thing from her (The granddaughter's) next-door neighbor. The daughter stated that once she started putting the pieces together after talking to the DON, she realized the picture she had heard about in the community was of her mother and it upset her terribly. She further stated that taking a picture of her mother in such a vulnerable position was completely unacceptable to her and would be to her mother if her mother knew it was taken. During a follow-up telephone interview with NA#2 on [DATE] at 10:42 am, after reviewing her schedule, NA#2 confirmed she received the text message on [DATE]. On [DATE] at 11:00am, the detective working the case came to the facility. Once in the facility an interview was conducted. During the interview the Detective stated that she picked up the case on [DATE] and came on-site to the facility to interview the staff involved. She further stated that she had talked to both nursing assistants. Additionally, she said that NA#2 was asked to bring her cell phone to the police station so they could put her cell phone on a Cell Bright (a piece of equipment that retrieves cell phone data). She indicated that NA#2 brought her phone to the police station but the Cell Bright could not retrieve the information. She further stated the same was asked of NA#1, but NA#1 has yet to bring in her phone. When asked about what the next step in the investigation was, the detective stated that now that a timeline had been established with a date certain of the text message being sent, she would request a warrant for each nursing assistant's phone. She further added once the warrant was obtained, and the picture and text message recovered that she would be seeking the advice of the District Attorney to pursue charges against NA #1. When asked specifically what charges she thought would be pursued, she replied Elder Abuse. At the end of the interview the detective stated she would share any information obtained through her investigation with DHSR (Division of Health Service Regulation). An interview was conducted with the Administrator on [DATE] at 12:45pm. During the interview the administrator confirmed that the DON met with NA#2 on [DATE] and saw the text message and picture she received. He stated the DON called him from her car to inform him of what she saw. He explained that he did not want to look at the picture due it being of a female resident in a compromising position because he had no need to see it, it would make him uncomfortable. He further added so there would be an additional witness to the text message and picture, he had a staff member that knew the resident verify the picture and if the picture was of Resident #1. He then stated it was Resident #1 in the picture and the DON immediately started the investigation process. The Administrator and the Director of Nursing were notified of the immediate jeopardy on [DATE] at 4:18 PM and the team was presented with their corrective action plan. Resident 1 is A/O X 1 WITH a BIMS score of 2. CNA 1 showed the DON a picture of a resident that had no clothing on while lying in bed. Look at how they left this MF was the message attached along with the picture. CNA 1 reported that the picture was sent via text message from CNA 2. Incident reported on the morning of [DATE]. On investigation, CNA 1 was asked to bring the phone to the facility for verification on the number which it was sent from and to verify with another female worker that the person on the picture was a resident of the facility. The phone number that the picture was sent from matched the phone number on file for CNA 2. The person in the photo was also identified as our resident. On assessment findings, the resident was not able to remember or engage in conversation. The agency CNA 2 failed to follow the abuse policy which states, It is the policy of the Presbyterian Home of Hawfields, Inc. to maintain zero tolerance for alleged, suspected, or validated resident neglect or abuse. Every resident at the Presbyterian Home of Hawfields, Inc. has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members or legal guardians, friends or any other individuals. The agency CNA 2 also failed to follow the abuse policy which states, All alleged violations - if the alleged violation involves abuse or results in serious bodily injury - shall be reported to state agency no later than 2 hours. All other alleged violations will be reported no later than 24 hours. All reports shall be followed with a five day investigation report. In addition, the Presbyterian Home of Hawfields, Inc. will notify the State Nurse Aide Registry or State Licensing Authority of any knowledge of any actions by a Court of Law. Both CNA's were terminated from employment at the facility and reports were filed with DHSR on [DATE]. The resident is doing OK and continues to reside in the facility. Based on information supplied by CNA 1, the sheriff's department was contacted by the facility and their investigation continues. Presbyterian Home of Hawfields will continue to ensure all staff and agency staff are educated and reeducated on abuse and cell phones. The Abuse and Neglect Policy and Procedure Policy and Cell Phone Policy will continue to be given to new employees and new agency staff, abuse policy and procedures are posted throughout the facility visual for employees, families and resident to read, issued quarterly to all employees and agency staff, and reissued at the Annual Employee In-service. For employees and agency staff that is out on leave will also be educated on abuse cell phones on return. DON and or administrator will keep a log of signatures confirmation that they received the information on abuse and the agency staff will be included in in-services training on abuse to ensure safety and evaluation will be done per DON or administrator. Also, families and resident are educated on abuse during care plan meetings and during resident council meetings. Families and residents are educated on reporting these findings immediately. DON reeducated staff on abuse and types of abuse and when to report allegations of abuse immediately as well as on cell phones. All staff, including DON reeducated on abuse and cell phones which there will be updates and information sent out with employees and agency biweekly. This was completed on [DATE]. The Abuse and Neglect Policy and Procedure Policy and Cell Phone Policy will continue to be given to new employees, Education and training on abuse and cell phones will immediately start upon hire and orientation, reissued quarterly to all employees, and reissued at the Annual Employee in-service. On [DATE] the DON talked to residents about staff utilizing cell phones during work hours, and in what type of situations. She advised the residents at that time about the cell phone usage and that staff should not be using cell phones. Also starting on [DATE] going forward cell phone usage will be discussed during care plan meetings. The monitoring tool for cell phone usage was started on [DATE] and the completion date would be [DATE]. It will be utilized weekly for a month and then quarterly further monitoring after the quarter will be reviewed in QA committee. Policy and procedure has been updated on privacy and confidentiality that the facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident. Policy has updates on mental abuse including that abuse that is facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it used, demeans or humiliates a resident(s), regardless of whether the resident provided consent and regardless of the resident's cognition status, the surveyor must consider non-compliance related to abuse. This includes, but not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating an resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the residents face, labeling resident's picture and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position. Policy on cell phones, videotaping, photographing, and other imaging of residents also has been updated stating residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recording during resident care or other facility activities. All personal cellular telephones shall remain off while employees are on duty and only utilized during breaks while in the break rooms or outside of the facility and away from residents. Employees shall not utilize personal cellular telephones while in work areas or on duty. Personal cell phones are to be left in the car, purse, desk, locker or other secure areas during working hours. Any violation of the policy will result in disciplinary action and/or termination. Immediately, spoke with all a/o residents on abuse and if they have seen any employees using cell phones while in their rooms, updated cell phone policy and reeducated staff on abuse policy. This was completed on [DATE] and all a/o residents denied that they have seen staff on cell phones while in their rooms. Presbyterian Home of Hawfields will continue to ensure that incidents and accidents are being reported to residents nurse, nurse supervisor on duty, DON, and Social Worker. DON will report to administrator immediately. The nursing staff as well as DON has been reeducated on the proper chain of command to follow when incidents and accidents occur. Education completed on [DATE]. The nursing staff was reeducated to notify DHSR within 2 hours of any alleged violation involving abuse or has resulted in serious bodily injury and 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Also, investigation will start immediately. This was completed on [DATE]. DON or designee will use a QA audit tool every week for a month and then bi monthly for the next three months for review of proper procedures on reporting. It will be reviewed weekly by the DON, Administrator and/or designee. Residents and family members will also be updated on the abuse policy as well as knowing where and who to report to in such event. Residents and families will be educated on different types of abuse and what abuse may look like. This will take place during care plan meetings and will be done by DON, Social Worker and or designee. Care plan meetings for each resident are done quarterly each year and as needed. During every resident council meeting there will also be reeducation on abuse policy. Resident council meetings are held monthly each year. DON, administrator or designee will monitor cell phone usage and abuse policy to ensure resident safety. QA Committee will review the QA Action Plan once a month for three (3) months and revise the action plan to ensure continued compliance. DON and administrator will be responsible for implementing and evaluating the plan of correction. The corrective action plan was verified on [DATE] at 12:45PM as evidenced by: A review of updated cell phone policy as well as interviews with the staff revealed they had received education on abuse with emphasis placed on mental abuse regarding photographs of residents and the use of cell phones in resident care areas.

Based on record review and interviews with the resident, family and facility staff, the facility failed to prevent staff-to-resident physical abuse resulting in bruising, soreness and fear for one of three residents (Resident #1) reviewed for abuse. Immediate Jeopardy began on 06/01/18 when Resident #1 was physically mishandled during provision of evening care. Nurse Aide #1 held the Resident #1's left arm by the wrist, squeezed and shook it repeatedly after dressing her in bed clothes. The Immediate Jeopardy was removed on 07/11/18 when the facility provided and implemented an acceptable credible allegation of removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put in place are effective to prevent resident abuse. The findings included: Resident #1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident had no cognitive impairment and had a recorded a Brief Interview for Mental Status (BIMS) score of 14 for Resident #1 who needed extensive assistance for all activities of daily living (ADLs) with the exception of independent eating. Resident #1 was frequently incontinent of urine. The resident had left-sided [MEDICAL CONDITION] as a result of a [MEDICAL CONDITION]. She received anti-coagulant therapy. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #1's nursing care plan updated 06/14/18 and signed by the interdisciplinary team indicated that she had an ADL self-care performance deficit. The resident required one-person assistance for bed mobility, bathing, dressing, eating, toileting, and personal hygiene as well as one-person assistance with the sit-to-stand lift. In an interview on 06/20/18 at 11:00 a.m., Resident #1 stated that she was alone in her room lying in her bed on the evening of Friday 06/01/18, the date of the incident. Nurse Aide #1 had just finished helping her into a patient gown. The aide was squeezing her hand so hard I could see stars. The resident told her to stop but the aide didn't say anything. Then Nurse Aide #1 pulled on her arm so hard she was afraid my arm would pop loose. Resident #1 stated that the aide continued to manipulate her arm despite her protests to stop. Nurse Aide #1 had checked her brief during the interaction but she did not need changing. When asked, Resident #1 characterized the actions of the aide as intentional mishandling. Resident #1 stated Nurse Aide #1 had cared for the resident on several previous occasions but Resident #1 had no concerns about the care provided. Resident #1 mentioned the demeanor of Nurse Aide #1 when she entered the room on 06/01/18, stating she didn't even greet me or talk to me. On 06/11/18 the DON typed a summary of conversations she had with Resident #1 and a family member. Resident #1 told the DON that Nurse Aide #1 had .started squeezing her arm as hard as she could, took both her hands to grab her hand and just squeezed it with force, pulled her arm in all directions as hard as she could and stated it felt like she was trying to break it. There were no witnesses to the incident. During the interview on 06/20/18 at 11:00 a.m., Resident #1 stated her left shoulder and arm were still sore. She admitted that she cried the night of the incident but didn't see the night nurse to tell her. When she woke the next morning on Saturday 06/02/18, she described being ambivalent about deciding to report what had happened. She did not report it to a nurse aide because she didn't want to hear any excuses or anything stupid. She decided to report it to the Social Worker because it could get worse or it might happen to someone who can't talk. Resident #1 stated that she left her room the morning after the incident in her wheelchair to go to the Social Worker's office and encountered Nurse #1 along the way. She reported the incident involving Nurse Aide #1 to her. Nurse #2 then joined the conversation and she shared the incident with her also. Resident #1 stated that the nurses thanked her for letting them know and assured her that Nurse Aide #1 would not work with her again. Resident #1 verified that she has not seen the aide since. In the interview, Resident #1 confirmed that she had lived in the facility about eight years. She stated the incident frightened me so much it will be awhile till (until) I feel safe in here. In an interview on 07/09/18 at 11:15 a.m., Resident #1 confirmed that she had been on [MEDICATION NAME] for many years. She denied noticing any tendency to bruise easily. She stated that when the pain began (after the incident), she started looking for any damage (bruising) a few days later. She stated she was interviewed by an officer from the Sheriff ' s Office. Later she was shown photographs of her left arm. She stated that at first she did not recognize her arm in the photos but now did remember the officer taking pictures. She described the bruising as darker and bigger than a fingerprint. When asked about pain after the incident, she confirmed that she had Tylenol available to take on an as-needed basis but she did not request any in the days following the incident. In a phone interview on 06/20/18 at 2:50 p.m., Nurse Aide #1 confirmed she was working on the evening of 06/01/18 and was assigned to Resident #1. She stated that she was making her rounds and had stopped to help the resident dress for bed. She told the resident she was not touching her arm when the resident confronted her. She stated she was pulling on the draw sheet and thought the resident's arm may have been pinned. She did not believe that she mishandled Resident #1 in any way or that she was being too rough. Resident #1 did not seem unduly irritable to her that evening and she stated that she was not irritated with the resident. In the same interview Nurse Aide #1 stated that she worked for a staffing agency and had been a nurse aide for eight years. This was the first time anyone had accused her of roughness. She felt her assignments at the facility were manageable and she did not feel rushed to complete care. Nurse Aide #1 stated she had worked with Resident #1 on several other occasions and there was no indication of a strained relationship. A written statement was obtained by the facility on 06/02/18 Nurse Aide #1. In it the aide wrote that she was providing care to Resident #1 on the evening of 06/01/18. When she pulled back the bed covers, (Resident #1) stated 'Let go of my arm' .The resident kept stating the same quote as I was cleaning her up and getting her brief changed. I continued to inform the resident I was not touching her arm. In an interview on 06/20/18 at 1:20 p.m., Nurse #1 confirmed that Resident #1 had reported the allegation of abuse to her around lunch time on 06/02/18. Nurse #1 was assigned to another hall and was walking to get her lunch when the resident approached her. During their conversation, Nurse #2 joined them. Nurse #1 stated that she allowed Nurse #2 to begin the paperwork and she returned to her hall. In an interview on 07/09/18 at 12:00 p.m., Nurse #1 stated that Resident #1 was sensitive about her weak left side and most aides that work with her knew that. Nurse #1 stated that she had worked at the facility for [AGE] years and has known the resident for about [AGE] years. She found Resident #1 reliable and, if the resident said an incident took place, it should be checked out. She described the resident as alert and oriented and had never seen her confused. In an interview on 06/20/18 at 1:30 p.m., Nurse #2 confirmed that she joined the conversation between Nurse #1 and Resident #1. The resident repeated to her that Nurse Aide #1 was rough with her the evening before (06/01/18). The resident was still a little upset and worried as she gave details of the incident. Resident #1 could not identify Nurse Aide #1 by name but was able to describe her. Nurse #2 discovered that the aide was working in the facility that day. She contacted her, asked her to provide a written statement, and instructed her to leave the facility. In an interview on 07/09/18 at 1:30 p.m., Nurse #2 stated that she assessed Resident #1 in her room on 06/02/18. The resident denied pain at the time but stated her arm was a little sore. Nurse #2 noted that she saw two dark circles on the resident ' s inner left forearm about four inches above her wrist. Resident #1 described the aide ' s care as rougher than normal care should be. She really was rough with me, grabbed my arm. Nurse #2 stated that the resident seemed relieved to learn the aide was sent home. In the interview, Nurse #2 judged Resident #1 to be a reliable historian. Nurse #2 stated that she has been employed at the facility for eight years. As MDS Coordinator, she did not have daily contact with Resident #1 but assessed her as alert and oriented. She had not noticed any periods of confusion during interactions with her. An Initial Allegation Report of Resident Abuse was completed on 06/02/18 by Nurse #2 and submitted the same day to the state agency. The report indicated that the alleged abuse occurred on 06/01/18 and was reported by Resident #1 the following day. The Allegation Details section documented that (Nurse Aide #1) was being rough with her arm when getting her ready for bed. The reporting nurse (Nurse #2) indicated that on physical exam she saw a small dark area that appeared to be very dry. It does not appear to be any new injuries to her arm. No swelling seen. She (Resident #1) stated that she is upset that someone would be that rough. The Investigation Report completed and submitted on 06/06/18 referred to an undated assessment in which the resident stated pain of 4 out of 10, 10 being the worst. In a later interview on 07/09/18 at 4:30 p.m., the DON stated that she conducted this pain assessment on 06/04/18. In an interview on 06/20/18 at 9:25 a.m., Resident #1's family member stated that she learned of the incident from a phone call by Nurse #1 on 06/02/18 who said that an aide had gotten rough with the resident. The family member stated that when she had the opportunity to visit Resident #1 on 06/10/18 the resident complained that her arm was still burning. She stated that Resident #1 was stressed because she didn't feel safe. She indicated that Resident #1 had been on [MEDICATION NAME] since 2001 or 2002. She has never known her to bruise easily. Resident #1 was seen by Nurse Practitioner #1 on Monday 06/04/18 at 2:27 p.m. The NP documented that the resident stated my shoulder and back hurt .Pain is 2-3 on a scale of 10. Upon examination, PROM (passive range of motion) elicits no increase in pain but palpation of her medial upper back is tender .Some ecchymosis noted left forearm, inner wrist. X-rays were ordered 06/04/18 to evaluate painful scapula area. The results were negative for fracture and dislocation of the left shoulder. In an interview on 06/20/18 at 12:40 p.m., Nurse Practitioner (NP) #1 stated that she was first notified of the incident on Monday 06/04/18 by the DON. Resident #1 was upset as she told her that a nurse aide pulled on me really hard in the bed. She stated that the ecchymosis noted on physical exam revealed that the bruising was not fresh. She explained that it was not the bright purple or red of an acute bruise nor was it the green of a healing bruise. NP #1 stated her conclusion that the bruising was suspicious and the color was consistent with them being generated a few days prior to her exam. In an interview on 07/09/18 at 8:05 a.m., NP #1 described the bruising. She indicated there were at least two bruises: one round bruise about three centimeters (cm) in diameter on the inner left wrist and one oblong bruise about five cm by two cm near the antecubital area of the left forearm. She stated that she saw Resident #1 monthly for a comprehensive exam. She was not aware of any tendency for Resident #1 to bruise easily based on [MEDICATION NAME] use and did not remember noting bruising on her monthly exams. She described an excellent memory and had not witnessed any periods of confusion. In an interview on 06/20/18 at 1:45 p.m., the DON stated that she first heard of the allegation of abuse on the morning of 06/04/18, two days after it was reported to Nurse #1 and Nurse #2. The DON spoke with the resident and did a pain assessment which she recorded on the Investigation Report dated 06/06/18. The resident estimated her pain level as 4 on a 10-point scale with 10 being the highest pain. Resident #1 told her the aide was pulling on her arm when dressing her for bed. When she directed her to stop pulling and yanking, she reported that the aide commented that you must not want my help. Resident #1 corrected her with that ' s not what I said. In the interview, the DON described the demeanor of Resident #1 on 06/04/18 as matter-of-fact. Only at the end of their conversation did the resident hang her head down and state I don't want to be here anymore. Her later conversations with the resident and a family member were summarized in a typed statement on 06/11/18. Resident #1's assertion that the aide was trying to break her left arm led the DON to report the incident to local law enforcement on 06/11/18. In an interview on 07/09/18 at 4:30 p.m., the DON described the bruising she saw on her initial physical assessment of Resident #1. There were two bruises on her left arm next to each other. Each were about one inch in diameter, darker than her skin color, and similar but not identical to hand prints. She stated that she did interview the alleged perpetrator Nurse Aide #1. She stated the aide stuck by her written statement obtained on 06/02/18. She indicated the aide was shocked by the allegation. The DON did not believe Nurse Aide #1 entered the room of Resident #1 with the intention of deliberately hurting her. In the interview, the DON stated her belief that Resident #1 was a reliable historian; however, little things (in her story) were a little different as the investigation went on. She concluded that the allegation was unsubstantiated. The final Investigation Report was faxed to the state agency on 06/21/18. In the interview on 07/09/18, she shared her expectation that staff members were sensitive to the physical limitations of residents for whom they provided care and that they handle residents carefully. She expected that staff members follow facility policy in reporting abuse allegations to her or the social worker immediately. In the 07/09/18 interview, the DON admitted that the investigation of the abuse allegation was delayed until two days after it was first reported to a staff member. As part of the delayed follow-up, she stated that she spoke with other residents who were assigned to Nurse Aide #1 but no one mentioned being mishandled during care. The DON stated that she also interviewed nurses and nurse aides familiar with Nurse Aide #1 but none had prior concerns about the care she had provided. In an interview on 06/20/18 at 3:30 p.m., the Administrator stated that he first learned of the abuse allegation about noon on 06/02/18 when he phoned the facility about another matter. He was not aware at the time that the DON had not been informed of the incident. He knew the matter was later reported to local law enforcement. He shared his expectation that residents were free from unnecessary roughness during care. He expected that the staff member to whom abuse is reported should notify the DON or social worker immediately and that an investigation should begin as soon as the report is received. The Administrator was informed of the Immediate Jeopardy on 07/10/18 at 10:46 a.m. On 07/11/18 at 3:45 p.m., the facility provided the following credible allegation of removal: Resident #1 is alert and oriented x 4 (oriented to person, place, time and situation) with a BIMS score of 15. The resident reported that she was abused by an agency CNA (certified nurse aide) one day earlier. Incident reported on the morning of 06/02/2018. Resident stated that the CNA was being rough with her arm when getting ready for bed. On investigation, resident stated that CNA took her arm and squeezed it as hard as she could, pulled her arm as hard as she could, stated it felt like she was purposely trying to break it and then the CNA took both her hands and placed them on resident's hand and squeezed her hand as hard as she could. On assessment findings it appeared to be bruising on the left forearm. The agency CNA failed to follow the care plan for this resident which states that 2 people should be working with this resident at all times. The agency CNA was terminated from employment at the facility on and reports were filed with DHSR (Department of Health Service Regulation) on 06/02/2018. The resident is doing okay and continues to reside in the facility. Based on information supplied by the resident and her daughter a week after the initial report, the sheriff's department was contacted and their investigation continues. Presbyterian Home of Hawfields will continue to ensure all staff are educated and reeducated on abuse. The Abuse and Neglect Policy and Procedure Policy will continue to be given to new employees, abuse policy and procedures are posted throughout the facility visual for employees, families and resident to read, issued quarterly to all employees, and reissued at the Annual Employee In-service. For employees and agency staff that are out on leave will also be educated on abuse on return as well as information on abuse will be mailed out biweekly. Information on abuse will be emailed to the agency with confirmation that it has been sent out to their agency staff that staff at Presbyterian Home of Hawfields. DON and or administrator will keep a log of signatures confirmation that they received the information on abuse and the agency staff will be included in in-service training on abuse to ensure safety and evaluation will be done per DON or administrator. Also, families and resident are educated on abuse during care plan meetings and during resident council meetings. Families and residents are educated on reporting these findings immediately. DON reeducated staff on abuse and types of abuse and when to report allegations of abuse immediately. All staff, including DON reeducated on abuse and there will be updates and information sent out with employees biweekly as well as agency staff. This was started on 06/29/18 and was in progress. The Abuse and Neglect Policy and Procedure Policy will continue to be given to new employees, Education and training on abuse will immediately start upon hire and orientation reissued quarterly to all employees and reissued at the Annual Employee in-service. Policy and procedure has been updated on abuse to report serious bodily injury within 2 hours of any alleged violation involving abuse or has resulted in serious bodily injury and 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Also, investigation will start immediately. Policy also includes updates on who to contact in such event. Policy has updates on the role of the administrator, role of the investigator, and reporting. Immediately, skin checks were done on all residents for signs of abuse, spoke with all a/o (alert and oriented) residents on abuse and if they have been rough handled by any staff including agency at any given time, and updated physicians and NPs on abuse as well. This was completed on 07/11/2018 and nothing was found on assessments. Presbyterian Home of Hawfields will continue to ensure that incidents and accidents are being reported to resident's nurse, nurse supervisor on duty, DON, and Social Worker. DON will report to administrator immediately. The nursing staff as well as DON has been reeducated on the proper chain of command to follow when incidents and accidents occur. Education completed on 06/04/2018. The nursing staff was reeducated to notify DHSR within 2 hours of any alleged violation involving abuse or has resulted in serious bodily injury and 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Also, investigation will start immediately. This was completed on 07/10/2018. DON or designee will use a QA (quality assurance) audit tool every week for a month and then bi monthly for the next five months for review of proper procedures on reporting. It will be reviewed weekly by the DON, Administrator and/or designee. Residents and family members will also be updated on the abuse policy as well as knowing where and who to report to in such event. Residents and families will be educated on different types of abuse and what abuse may look like. This will take place during care plan meetings and will be done by DON, Social Worker and or designee. Care plan meetings for each resident are done quarterly each year and as needed. During every resident council meeting there will also be reeducation on abuse policy. Resident council meetings are held monthly each year. DON, administrator or designee will monitor incident reports, skin assessments, and abuse policy to ensure resident safety. This will be monitor quarterly for six (6) months. All residents were given skin checks and interviewed about any type of potential abuse. This was completed by 07/11/2018. QA Committee will review the QA Action Plan once a month for six (6) months and revise the action plan to ensure continued compliance. DON and administrator will be responsible for implementing and evaluating the plan of correction. The credible allegation of immediate jeopardy removal was validated on 07/11/18 at 5:45 p.m. The Abuse/Neglect Policy and Procedure was updated to include reporting of allegations of abuse and serious bodily harm within two hours to the N.C. Department of Health and Human Services. Updates on the roles of the Administrator and the investigator in cases of suspected abuse or neglect were added. Agency and permanent staff in all departments were re-educated by the Social Worker on the prevention and reporting of abuse and neglect. The training record was reviewed. The in-service offered on 07/11/18 included information on types of abuse and the immediate reporting of suspected or witnessed resident abuse or neglect. Using the proper chain of command was a topic of review with staff members. Re-education was in progress for second-shift nursing and dietary staff. Written reminders about Incident and Accident reporting and proper notification of management were posted at nurses ' stations throughout the facility. A copy of the new employee orientation packet was reviewed for inclusion of abuse and neglect prevention and reporting. Documentation was provided of random interviews of residents and family members for knowledge of how to identify abuse or neglect and how to report it. Documentation that skin assessments had been completed or were in progress on some units was provided. Interviews were conducted with residents, nurse aides, nurses, a nursing supervisor and a dietary supervisor to confirm understanding of the facility policy on abuse and neglect and the need for immediate reporting using the chain of command. Resident rights were currently being reviewed at monthly Resident Council meetings. The Social Worker stated she recently started to include identification and reporting of abuse and neglect as a topic of discussion during resident care plan meetings. The monitoring tool for staff knowledge of identifying and reporting abuse was reviewed. The tool included a section to indicate if the Quality Assurance Action Plan needed revision and what revisions were needed.

Based on record review and interviews with the staff members, the facility failed to develop a revised reporting component of the abuse policy that reflected allegations of abuse must be reported immediately, but not later than two hours after the allegation was made when the allegation involved abuse and follow its abuse policy for investigating abuse for one of three residents reviewed (Resident #1) for staff-to-resident abuse. Immediate Jeopardy began on 06/01/18 when Resident #1 was physically mishandled during provision of evening care. Nurse Aide #1 held the Resident #1's left arm by the wrist, squeezed and shook it repeatedly after dressing her in bed clothes. The Immediate Jeopardy was removed on 07/11/18 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and ensure that monitoring systems put in place are effective to prevent abuse of residents. The findings included: Resident #1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 14 for Resident #1 who needed extensive assistance for all activities of daily living (ADLs) with the exception of independent eating. Resident #1 was frequently incontinent of urine. The resident had left-sided [MEDICAL CONDITION] as a result of a [MEDICAL CONDITION]. She received anti-coagulant therapy. Resident #1's nursing care plan updated 06/14/18 and signed by the interdisciplinary team indicated that she had an ADL self-care performance deficit. The resident required one-person assistance for bed mobility, bathing, dressing, eating, toileting, and personal hygiene as well as one-person assistance with the sit-to-stand lift. The facility's Abuse Neglect Policy and Procedure signed 09/09/16 by the Administrator and former Director of Nursing (DON) was reviewed. a. The facility abuse policy did not include a component to report allegations of abuse immediately to the state agency, but not later than two hours after the allegation was made. Resident #1 reported an allegation of abuse to Nurse #1 and Nurse #2 on 06/02/18. She identified the alleged perpetrator as Nurse Aide #1. Nurse #2 entered details of the incident on an Initial Allegation Report. The Date and Time Facility Became Aware of Incident was listed on the report as 06/02/18 1:30 p.m. The report was faxed to the state agency on 06/02/18 at 4:37 p.m. In an interview on 07/09/18 at 1:30 p.m., Nurse #2 indicated that her submission was not within the required timeframe due to a delay in gathering identifying information about the alleged perpetrator from the aide's staffing agency. Nurse #2 stated that the form required a Date of Birth and Social Security number. Nurse #2 attributed the delay in the staffing agency's response to the fact that it was a weekend. b. The facility's Abuse Neglect Policy stated that An immediate investigation will be made. In an interview on 06/20/18 at 1:30 p.m., Nurse #2 stated that she obtained a written statement from Nurse Aide #1, after receiving Resident #1's report of alleged abuse. She instructed the aide to leave the facility. She interviewed and assessed the resident for injuries. It was her understanding that management would take the lead in the actual investigation of the abuse allegation upon their return to work. There was no documentation of a statement given by Resident #1 on 06/02/18 providing any details of the incident. No nursing progress notes were present in the medical record for the dates of 06/02/18 or 06/03/18 that documented if a pain assessment was done or if the medical provider was notified. In an interview on 06/20/18 at 1:45 p.m., the DON confirmed that she was notified on 06/04/18, two days after it was first reported to Nurses #1 and #2. She admitted that the investigation of the abuse allegation was delayed and that interviews of other residents for potential mishandling during their care was not done immediately after the allegation was reported. c. The facility's Abuse Neglect Policy stated The investigation must include an outline of the steps taken in the investigation .Investigation files related to alleged, suspected or confirmed cases of abuse and/or neglect will be maintained in the Administrator's office. The policy did not specify who was in charge of conducting the investigation. In an interview on 06/20/18 at 1:45 p.m., the DON stated that she was responsible for conducting the investigation but that she did not keep an outline or a file of paperwork documenting her facility investigation. She stated that she entered the information she gathered directly on the Initial Allegation Report and Investigation Report forms provided by the state. The DON stated that she spoke with other residents about the care Nurse Aide #1 provided and any possible roughness but she could not provide documentation of who she interviewed and when. The Investigation Report submitted 06/06/18 included the statement, Also spoke with other workers (CNAs (certified nurse aides) and nurses) that worked that day about details they may know. There was no documentation or elaboration on who was interviewed or the results of those interviews. In the interview, she shared her expectation that any nurse accepting a report of alleged abuse or neglect would follow the Abuse Neglect Policy that included notifying management and beginning an immediate investigation. In an interview on 06/20/18 at 3:30 p.m., the Administrator stated that he was informed of the abuse allegation on 06/02/18, the same day it was reported by Resident #1, when he phoned the office about another matter. He did not notify the DON and assumed that Nurse #2 had contacted her or would contact her. He was unaware of the required two-hour timeframe to report allegations of abuse to the state agency. It was his expectation that staff members meet this timeframe and follow the guidance provided by the facility's Abuse Neglect policy. The Administrator was informed of the Immediate Jeopardy on 07/10/18 at 10:46 a.m. On 07/11/18 at 4:00 p.m., the facility provided the following credible allegation of immediate jeopardy removal: Resident #1 is alert and oriented x 4 (oriented to person, place, time and situation) with a BIMS score of 15. Resident reported that she was abused by an agency CNA (certified nurse aide) one day earlier. Incident reported on the morning of 06/02/2018. Resident stated that the CNA was being rough with her arm when getting ready for bed. On investigation, resident stated that CNA took her arm and squeezed it as hard as she could, pulled her arm as hard as she could, stated it felt like she was purposely trying to break it and then the CNA took both her hands and placed them on resident's hand and squeezed her hand as hard as she could. On assessment findings it appeared to be bruising on the left forearm. The agency CNA failed to follow the care plan for this resident which states that 2 people should be working with this resident at all times. The agency CNA was terminated from employment at the facility on and reports were filed with DHSR (Department of Health Service Regulation) on 06/02/2018. The resident is doing okay and continues to reside in the facility. Based on information supplied by the resident and her daughter a week after the initial report, the sheriff's department was contacted and their investigation continues. Presbyterian Home of Hawfields will continue to ensure all staff including DON are being educated and reeducated on abuse. The Abuse and Neglect Policy and Procedure Policy will continue to be given to new employees, Education and training on abuse will immediately start upon hire and orientation, abuse policy and procedures are posted throughout the facility visual for employees, families and resident to read, reissued quarterly to all employees, and reissued at the Annual Employee in-service. Policy and procedure has been updated on abuse to report within 2 hours of any alleged violation involving abuse or has resulted in serious bodily injury and 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Also, investigation will start immediately. Policy also includes updates on who to contact in such event. Policy has updates on the role of the administrator, role of the investigator, and reporting. DON and or designee will use QA (Quality Assurance) audit tool to monitor and evaluate the outcomes of the abuse policy quarterly and make changes accordingly. DON reeducated staff on abuse and types of abuse and when to report allegations of abuse immediately. DON has also been educated on abuse and reporting. All staff members are instructed to notify department heads immediately in event of incidents and accidents. Department heads will notify DHSR (Department of Health Service Regulation) within 2 hours of any alleged violation involving abuse or has resulted in serious bodily injury and 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Also, investigation will start immediately and will be completed within five working days. Presbyterian Home of Hawfields will continue to ensure that incidents and accidents are being reported to resident's nurse, nurse supervisor on duty, DON, and Social Worker. DON will report to administrator immediately. All staff members will be reeducated on the proper chain of command to follow when incidents and accidents occur. This was completed by 07/11/18. All staff members will be educated on reporting abuse allegations and serious bodily injury accidents or incidents to Department of Health and Human Services within 2 hours of notification. For employees and agency staff that are out on leave will also be educated on abuse on return as well as information on abuse will be mailed out biweekly. Information on abuse will be emailed to the agency with confirmation that it has been sent out to their agency staff that staff at Presbyterian Home of Hawfields. DON and or administrator will keep a log of signatures confirmation that they received the information on abuse and the agency staff will be included in in-services training on abuse to ensure safety and evaluation will be done per DON or administrator. This was completed by 7/11/18. DON or designee will use a QA (quality assurance) audit tool every week for a month and then bi monthly for the next five months for review of proper procedures on reporting. It will be reviewed weekly by the DON, Administrator and/or designee for six months. QA Committee will review the QA Action Plan once a month for six (6) months and revise the action plan to ensure continued compliance. DON and administrator will be responsible for implementing and evaluating the plan of correction. The credible allegation of immediate jeopardy removal was validated on 07/11/18 at 5:45 p.m. The Abuse/Neglect Policy and Procedure was updated to include reporting of allegations of abuse and serious bodily harm within two hours to the N.C. Department of Health and Human Services. The policy was amended to include the start of an immediate investigation and the timeline for its completion. Updates on the roles of the Administrator and the investigator in cases of suspected abuse or neglect were added. Agency and permanent staff in all departments were re-educated by the Social Worker on abuse and neglect prevention and reporting. The training record was reviewed. The in-service included information on types of abuse and the immediate reporting of suspected or witnessed resident abuse or neglect. Using the proper chain of command was a topic of review with staff members. Re-education was in progress for second-shift nursing and dietary staff. Written reminders of Incident and Accident reporting and proper notifications were posted at nurses' stations throughout the facility. A copy of the new employee orientation packet was reviewed for inclusion of abuse and neglect prevention and reporting. Documentation was provided of random interviews of residents and family members for knowledge of how to identify abuse or neglect and how to report it. Interviews were conducted with nurse aides, nurses, a nursing supervisor and dietary supervisor to confirm understanding of the facility policy on abuse and neglect and the need for immediate reporting using their chain of command. Resident rights were currently being reviewed at monthly Resident Council meetings. The Social Worker stated she recently started to include identification and reporting of abuse and neglect as a topic of discussion during resident care plan meetings. The monitoring tool for staff knowledge of identifying and reporting abuse was reviewed. The tool included a section to indicate if the Quality Assurance Action Plan needed revision and what revisions were needed.