Every finding on record at Iredell Memorial Hospital Inc

Based on record review, staff, and family interviews, the facility failed to have an effective discharge planning process that ensured home health services were set up prior to discharge to the community for a resident who had a wound vac (a therapeutic device that uses controlled negative pressure [suction] to accelerate the healing of acute or chronic wounds). This failure was for 1 of 4 residents reviewed for discharge (Resident #64).The findings included:Resident #64 was admitted to the facility on [DATE] with diagnoses that included history of sleeve gastrectomy (a common, irreversible weight-loss surgery), Surgical wound dehiscence (the partial or total separation of previously stitched surgical incision edges), encounter for surgical aftercare following surgery of the digestive system, and small bowel perforation (a life-threatening, full-thickness hole in the small intestine wall that leaks digestive contents into the abdominal cavity, causing severe abdominal pain, peritonitis, and potential septic shock).Resident #64's admission Minimum Data Set assessment dated [DATE] revealed Resident #64 was cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. Resident #64 was coded as independent with eating, needed supervision with oral hygiene, and limited assistance with bed mobility, transfers, personal hygiene, upper body dressing, and bathing. Resident #64 was dependent on others for toileting hygiene, lower body dressing, and putting on and taking off footwear. Resident #64 was also coded as having a recent gastrointestinal surgery that required active skilled nursing facility care and had a present surgical wound. Her goal was to discharge to the community and active discharge planning was in process.A physician order dated 09/19/25 read: wound vac dressing change every Monday, Wednesday, and Friday to abdomen. Review of the Discharge Planner's note dated 10/01/25 revealed the Discharge Planner had verified Resident #64's wound vac was to be delivered and that a referral was sent out to a home health agency that morning at 11:38 AM on 10/01/25. The note also revealed that the Discharge Planner was contacted at 4:15 PM on 10/01/25 by the home health agency who indicated they would not be able to provide services to Resident #64 due to her geographical location. The note indicated that the Discharge Planner reached out to 3 additional home health agencies on 10/01/25 that reported they too, would not be able to service Resident #64 due to her geographical location.Per Resident #64's progress notes, Resident #64 discharged home with their spouse to their private home on [DATE] approximately 2:45 PM.An interview with Resident #64's Family Member on 03/03/26 at 12:32 PM revealed Resident #64 had a medical procedure in her abdominal area which resulted in the placement of a wound vacuum for wound healing prior to her admission to the facility on [DATE]. She stated that when it came time for Resident #64 to discharge home on [DATE], she and Resident #64's spouse worked with the Discharge Planner to facilitate Resident #64's discharge home. During the discharge planning process they (Resident #64's) family was concerned about ensuring that home health was scheduled to see Resident #64 when she returned home due to the significant abdominal wound that still required the placement of a wound vac. Resident #64's Family Member indicated the Discharge Planner reported to them on 10/01/25 that a local home health agency referral had been sent on behalf of Resident #64 and that the home health agency had agreed to see Resident #64 upon her return home. Resident #64's Family Member reported Resident #64 was discharged home on [DATE]. Resident #64's Family Member stated Resident #64 was home for 2 days and had not heard from the home health company so Resident #64's Family Member contacted the home health company who told her they had received the referral but had denied the referral due to Resident #64 residing outside of their services area. Resident #64's Family Member reported that the home health company stated they had informed the Discharge Planner they were unable to provide their services to Resident #64 prior to Resident #64 discharging from the facility. Resident #64's Family Member stated she contacted the Discharge Planner who insisted that the home health agency had accepted the referral. Resident #64's Family Member stated Resident #64's Family member stated they requested assistance from the facility in locating another home health agency and assistance was provided; however it took approximately 3 weeks until they were able to get Resident #64 in to see a local wound care clinic who began treating the resident and provided wound care to Resident #64. Resident #64's Family Member reported during the timeframe they were trying to find wound care for Resident #64; she drove 3 hours, round trip, to provide Resident #64's wound care as she was a registered nurse and was familiar with the wound care that needed to be provided to Resident #64. Per Resident #64's Family Member, there were no ill effects during this time despite not having home health at the time and there was no decompensation of Resident #64's wound. An interview with the Discharge Planner was completed on 03/04/26 at 12:01 PM. The Discharge Planner indicated that Resident #64 had admitted to the facility for short term rehabilitation with a goal to return home with their spouse. The Discharge Planner remembered Resident #64 and stated she had sent out the home health referral to the home health agency around 11:00 AM the day of Resident #64's discharge (10/01/25) and that Resident #64 was allowed to discharge home around 2:45 PM. The Discharge Planner stated around 4:00 PM on 10/01/25 the initial home health agency contacted her and stated they were unable to provide services to Resident #64 due to her living outside of their service area. She continued, stating she immediately contacted several other home health agencies but was unsuccessful in locating one that would provide services to Resident #64 due to her geographic location. The Discharge Planner stated she struggled to find a home health agency that was willing to provide services to Resident #64 so she expanded her search to wound care clinics to provide services to the resident as a home care patient or as an outpatient. She stated she was able to locate a local wound care clinic that was close to Resident #64 who stated they would provide Resident #64 with wound care as an outpatient, but Resident 64 and her family were unwilling to consider outpatient wound care initially. She stated ultimately, Resident #64 did begin seeing the local wound care clinic as an outpatient. The Discharge Planner stated Resident #64's family member was a nurse at the local hospital, and it was her understanding that Resident #64's family member was able to provide the needed wound care to Resident #64 until they were able to get into the outpatient wound care clinic. An interview with the Former Director of Nursing via telephone was conducted on 03/05/26 at 10:39 AM. She stated she vaguely remembered the situation with Resident #64 but stated that the Discharge Planner was way more involved than she was. She stated it was her understanding that Resident #64 had been prepared to return home after a short term rehabilitation stay and that home health had supposedly been set up and verified by the Discharge Planner. She stated that shortly after Resident #64 was discharged home, the facility was notified by the original home health agency that they had not been able to accept Resident #64 as a patient due to her geographical location. The Former Director of Nursing reported she reached out to Resident #64 and her family and offered to drive to Resident #64's home and complete the wound care until home health services or a referral to a local wound care clinic could be established. She reported the family completed the wound care. The Former Director of Nursing reported approximately a week or so after Resident #64 discharged , the facility was able to get her admitted to a local wound care clinic as outpatient. An interview with the Administrator on 03/05/26 at 11:47 AM revealed he did not have any interactions with Resident #64's discharge situation but reported he expected his team to be aware of all plans regarding a resident's discharge, including care or services when the resident returns home before a resident was discharged from the facility.

Based on record review, and staff, Nurse Practitioner, and Pharmacy Clinical Director interviews, the facility failed to have a documented diagnosis for the use of an antipsychotic medication (Seroquel/quetiapine) for 1 of 5 residents reviewed for unnecessary medications (Resident #54). The findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included anxiety and hypertension. Review of Resident #54's care plan initiated on 12/02/24 revealed she had a care plan for the use of psychotropic medications. A physician order dated 12/02/24 read; quetiapine (an antipsychotic medication) 25mg - give 1 tablet at bedtime. The order was discontinued on 12/08/24. A physician progress note dated 12/08/24 written by Nurse Practitioner #1 read in part; Patient is requesting scheduled extra strength [acetaminophen] for chronic back pain. She is also requesting something more for insomnia. Seroquel (quetiapine) increased . A physician order dated 12/08/24 read; quetiapine 50mg - give 1 tablet at bedtime. The order was discontinued on 12/16/24. Review of Resident #54's admission Minimum Data Set assessment dated [DATE] revealed Resident #54 was cognitively intact with no delusions, behaviors, rejection of care, or instances of wandering. Resident #54 was coded as taking antipsychotic medication on a routine basis, a gradual dose reduction had not been attempted and was not clinically contraindicated. A physician progress note dated 12/16/24 written by Nurse Practitioner #2 read in part: Patient reports she is feeling great today. She denies any increase dyspnea or cough. She reports difficulty with sleep since previous admission. Seroquel increased. A physician order dated 12/16/24 read; quetiapine 100mg - give 1 tablet at bedtime. An interview with Nurse #1 on 01/09/25 at 8:55 AM revealed she was familiar with Resident #54 and reported she was aware that she was receiving scheduled quetiapine and stated she was being monitored for potential side effects of the medication. Nurse #1 indicated that she did not see a psychological condition listed in Resident #54's diagnoses that would indicate a reason for her to take quetiapine but reported she was aware that some of the physicians in the hospital used it as a sleep aide. Nurse #1 indicated it appeared as though Resident #54 was being prescribed quetiapine as a sleep aide. An interview with Nurse Practitioner #1 on 01/09/24 at 09:06 AM revealed she was familiar with Resident #54 and stated she was also aware Resident #54 was prescribed a scheduled dose of quetiapine. Nurse Practitioner #1 revealed she believed that Resident #54 had been taking the quetiapine at home prior to her admission to the hospital as a sleep aide. Nurse Practitioner #1 stated she would not typically use quetiapine as a sleep aide but since Resident #54 had admitted to the facility already taking it for help with sleep, she just continued it. She continued, stating that typically, when a resident transitioned from the acute care side of the hospital to the long-term care side, the pharmacy staff reviewed the resident's medications and would flag any medications that did not have supporting diagnoses for so they can be discontinued, or the resident could be reevaluated for a supporting diagnosis. She stated based on the records she could see in her charting system; it did not appear as though the pharmacy had sent that initial medication review to her with the quetiapine flagged for not having a supporting diagnosis. Nurse Practitioner #1 indicated there did not appear to be an appropriate supporting diagnosis for the continued use of Resident #54's quetiapine. An interview with Pharmacy Clinical Director on 01/09/24 at 11:02 AM revealed that when a resident transitions from acute care to long-term care, they reviewed their medications and flagged any medications that did not have supporting diagnoses so the clinicians could adjust, discontinue, or reevaluate the residents. She stated according to her records, a review was completed on 12/03/24 and they flagged Resident #54's quetiapine for not having a supporting diagnosis. She reported her records indicated the alert was emailed to Nurse Practitioner #1. She stated once they flag the medication, they have no follow-up procedures to ensure the recommendation was addressed and stated if it was not addressed, they would not know until the following monthly medication review was completed. An interview with the Director of Nursing on 01/09/24 at 12:52 PM revealed she was aware of federal regulation that required appropriate diagnoses for the use of antipsychotic medications and the hospital would occasionally prescribe quetiapine as a sleep aide. She also reported most of the time, the residents admitted to her unit were only there for a very short period and so they continue the medications they were admitted with. She stated the pharmacy usually notified them, along with the physicians, when there was a lack of a supporting diagnosis for the use of antipsychotics. She stated if the facility would be notified that there was a lack of a supporting diagnosis for the use of antipsychotics, it would be solely up to the attending physicians to address the discrepancy. The Director of Nursing indicated she was unsure whether the initial medication review occurred and reported the lack of a supporting diagnosis should have been caught by pharmacy and or the physician and addressed.

Based on record review, staff interviews, Assistant Director of Dialysis and Medical Director interview, the facility failed to monitor and assess the right subclavian catheter (temporary or permanent, simple, tunneled, or connected to a port under the skin to provide dialysis treatment) and the left arteriovenous dialysis fistula (AVF is a fistula created between an artery and a vein to provide dialysis treatments) for a resident receiving hemodialysis for 1 of 1 sampled resident (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE] with a diagnosis of renal insufficiency and treatment with renal dialysis. A review of the physician orders dated 7/19/23 stated that hemodialysis on Monday, Wednesday, and Friday, and for dialysis nurse to change dialysate based on morning Potassium levels. A review of the most recent care plan last updated 7/20/23 indicated scheduled dialysis treatments on Monday, Wednesday, and Fridays. The interventions were to provide dialysis treatments as scheduled, monitor abdomen for signs of infection, daily weights, and evaluate access sites for signs of infection. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no cognitive impairment with memory problem. The resident was coded as limited assistance for bed mobility and required extensive assistance with activities of daily living. An undated document titled, Dialysis training (a document used by nurses that explained all possible sites, assessments, adverse reactions, and when to contact the doctor), specified to check the bruit and thrill (a thrill was a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above your incision line. A bruit was the whooshing sound while auscultating with a stethoscope) daily and to notify patient nephrologist immediately with decreased or absent. Record review of Resident #7's electronic record, the medical chart, nursing notes, and spreadsheets revealed no documentation or evidence of the monitoring of the right subclavian catheter and the left arteriovenous dialysis fistula by the facility nursing staff. An interview on 10/26/23 at 9:00AM with Nurse #1 stated she was not tasked to check the dialysis accesses. She had never had an order or task to check an AVF or a subclavian catheter. She stated that the bruit and thrill was checked by dialysis. She revealed she had training on the dialysis site assessment when she was hired and was aware to check the condition of the dialysis access (s). She stated the required task appeared on the chart to complete. Tasks that do not appear on the task list, do not get completed. Nurse #1 reported she was routinely assigned to Resident #7. An interview on 10/26/23 at 4:00PM Director of Nursing stated the nurse should check the thrill and bruit of the AVF or the subclavian catheter at least once a day and document in the medical record. An interview 10/27/23 at 9:00AM Assistant Director (AD) of the dialysis unit indicated the standard of care after dialysis was to monitor access(s) for bleeding, swelling, and patency. The dialysis nursing staff or physician were contacted after treatments, with any bleeding or change to the access site. An interview with the Medical Director on 10/27/23 at 11:16AM revealed the nursing staff assessed every resident who received dialysis. Check the bruit and thrill at least daily a complete set of vital signs and monitor for any signs of infection every shift.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services to 2 of 3 residents reviewed for beneficiary protection notification review (Residents #3 and #31). Findings included: 1. Resident #3 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was issued on 2/3/2022 to Resident #3 which explained Medicare Part A coverage for skilled services would end on 2/19/2022. Resident #3 remained in the facility at the time the survey was being performed from 7/19/2022 through 7/22/2022. A review of the medical record revealed a CMS- Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) was not provided to Resident #3. The SNF-ABN form advises residents of the potential cost they will need to pay for skilled services that Medicare will not cover. An interview was completed with the Lead Unit Discharge Coordinator on 7/22/2022 at 9:13 AM. She stated she was not aware a SNF-ABN had to be issued if Medicare Part A days were remaining. She revealed that she had no training with SNF-ABN. An interview was completed with the Director of Nursing (DON) on 7/22/2022 at 9:20 AM. She stated that the lead unit discharge coordinator would handle SNF-ABN notices. She revealed that the notices have not been given out for remaining days and the residents should have been given a SNF-ABN notice. An interview was completed with the Administrator on 7/22/2022 at 10:23 AM. She stated the facility should have issued the SNF-ABN to Resident #3. She explained this was an oversight by staff and that education would be provided immediately. 2. Resident #31 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was issued on 7/1/2022 to Resident #31 which explained Medicare Part A coverage for skilled services would end on 7/13/2022. Resident #31 remained in the facility at the time the survey was being performed from 7/19/2022 through 7/22/2022. A review of the medical record revealed a CMS- Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) was not provided to Resident #31. The SNF-ABN form advises residents of the potential cost they will need to pay for skilled services that Medicare will not cover. An interview was completed with the Lead Unit Discharge Coordinator on 7/22/2022 at 9:13 AM. She stated she was not aware a SNF-ABN notice had to be issued if Medicare Part A days were remaining. She revealed that she had no training with SNF-ABN. An interview was completed with the Director of Nursing (DON) on 7/22/2022 at 9:20 AM. The DON stated that the lead unit discharge coordinator handled SNF-ABN. She revealed that the notices had not been given out for remaining days and the residents should have been given a SNF-ABN notice. An interview was completed with the Administrator on 7/22/2022 at 10:23 AM. She stated the facility should have issued the SNF-ABN to Resident #31. She explained this was an oversight by staff and that education would be provided immediately.

Based on record review and staff interview, the facility failed to include the resident census information on the posted nurse staffing sheets for 14 of 14 days reviewed for sufficient nurse staffing. Findings included: Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was completed on 7/22/2022 at 9:55 AM with the Director of Nursing (DON). The DON explained she would review the posted nurse staffing sheets but did not include the total census information. The DON expressed the hall nurses should update the census information on the posted nurse staffing sheet on each shift when there were changes. The DON stated it was an oversight and she would begin looking for the total census information section to be completed and updated with changes.

Based on record reviews, staff interviews and nurse practitioner interview, the facility failed to follow the medication order for [MEDICATION(S)] (a medication that lowers blood pressure) and administered the [MEDICATION(S)] outside of the parameters specified in the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #43 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) dated [DATE] showed Resident #43 was cognitively intact. August 2021 physician orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #43 showed a parameter for the order that stated to hold if systolic blood pressure was less than 100. The start date for this order was 6/23/2021. Vital sign record revealed that on 8/3/2021 at 7:48 AM Resident #43's blood pressure was 92/60. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Nurse #1 on 8/5/2021 at 12:00 PM, she stated that she had given Resident #43 the [MEDICATION(S)] 5mg at 10:42 AM on 8/3/2021 and had not rechecked the residents blood pressure prior to administration. During an interview with the Nurse Aide (NA) on 8/5/2021 at 12:12 PM, she stated that the normal process for when vital signs were due in the morning was the NA wrote all their resident's vital signs on a piece of paper and then gave a copy to the nurses. She further stated that the vital signs were then documented in the system by the NA. During an interview with the Director of Nursing on 8/5/2021 at 12:20 PM, she stated due to Resident #43's blood pressure reading on 8/3/2021, the [MEDICATION(S)] should not have been administered due to the blood pressure parameter on the physician order. During an interview with the Nurse Practitioner on 8/5/2021 at 12:24 PM, she stated that the parameters were in place for the use of the [MEDICATION(S)] and if Resident #43's blood pressure was 92/60 the medication should not have been administered. She further stated in a second interview on 8/6/2021 at 3:00 PM, that the resident could have become hypotensive (low blood pressure) due to administration of the [MEDICATION(S)] when blood pressure was already below the parameters given in the order.

Based on observations, record review, staff interviews and pharmacy consultant interview, the facility failed to give a clinical indication for a scheduled antipsychotic medication and failed to ensure physician orders for as needed (PRN) antipsychotic medication was time limited in duration for 1 of 5 residents (Resident #281) reviewed for unnecessary medications. Findings included: Resident #281 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)], generalized weakness and recent history of Covid-19. There was no psychiatric diagnosis listed in Resident #281's medical record. No Minimum Data Set assessment was available due to Resident #281 was a new admission. During an observation and interview with Resident #281 on 8/3/2021 at 2:18 PM, resident was amicable and there were no observations of behaviors. a. Physician orders reviewed for Resident #281 revealed an order for [MEDICATION(S)] (antipsychotic) 2 tabs to equal 50mg by mouth every night that had a start date of 7/31/2021. The Pharmacy Consultant's drug regimen review dated 8/3/2021 included a notation for clarification of a diagnosis for the use of the [MEDICATION(S)]. The response from the physician stated that there was no indication for the use of [MEDICATION(S)] found in Resident #281's documentation. The Medication Administration Record (MAR) was reviewed and revealed that Resident #281 received [MEDICATION(S)] 50mg each night from 7/31/2021 through 8/5/2021. b. Physician orders reviewed for Resident #281 revealed an order for [MEDICATION(S)] (antipsychotic) 3mg- 0.6mL intravenous push every 4 hours PRN for agitation that also had a start date of 7/31/2021. There was no stop date on the order for [MEDICATION(S)] for Resident #281. Pharmacy Consultant's drug regimen review dated 8/4/2021 included a recommendation to the physician to review the risk benefit in geriatric resident for the use of [MEDICATION(S)] PRN. There was no response from the physician in the drug regimen review for use of [MEDICATION(S)] PRN as of 8/6/2021. MAR review revealed the [MEDICATION(S)] PRN order had not been administered to Resident #281 since resident was admitted to facility on 7/31/2021. During an interview with Nurse #2 on 8/6/2021 at 11:30 AM, he stated that he was not sure why Resident #281 was on the [MEDICATION(S)]. He further stated that he did not see a stop date on the [MEDICATION(S)] in Resident #281's MAR or physician orders and stated that these orders had come over from the hospital. During an interview with the Nurse Practitioner on 8/6/2021 at 3:00 PM, she stated that there was no diagnosis to support the use of the [MEDICATION(S)] and further stated that for PRN antipsychotics, she usually went into the system and discontinued them if they were not being used. During a phone interview with the Pharmacy Consultant on 8/6/2021 at 3:51 PM, he stated that PRN antipsychotics should have a stop date. He further stated that Resident #281 did not have a diagnosis to support the use of the [MEDICATION(S)]. An interview with the Director of Nursing (DON) on 8/6/2021 at 4:08 PM revealed that the order for [MEDICATION(S)] should not have been on Resident #281's physician orders and further stated that it should have had a stop date. The DON also stated that the [MEDICATION(S)] should not have been administered to Resident #281 without a diagnosis to support the use of the medication.

Based on record review and staff interviews, the facility failed to complete a comprehensive admission MDS assessment within 14 days of admission for 2 of 11 sampled residents (Resident #5 and #15). The findings included: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident #5's most recent MDS (minimum data set) and electronic medical record revealed an entry tracking MDS was completed on 12/29/18. A comprehensive assessment was in progress with an ARD of 01/05/19. The comprehensive assessment was not complete. On 01/16/19 at 11:35 am an interview was conducted with the MDS coordinator. She stated she has had problems with the assessments in the past being deleted due to a switch in software. When asked if either of the two assessments in question were inadvertently deleted during the change in software, she replied No. She further indicated that the MDS assessments were behind and unfortunately Resident #5's and Resident #15's assessment had not been completed 100%. She stated that she would complete both assessments before the end of the day. On 01/17/19 at 9:30 am an interview was conducted with the Administrator of the facility, who stated that she oversees the MDS nurses. The Administrator indicated that it was her expectation that all comprehensive admission MDS assessments were completed within 14 days of admission. 2. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident #15's most recent MDS (minimum data set) and electronic medical record revealed an entry tracking MDS was completed on 12/31/18. A Comprehensive Assessment was noted to be in progress with an ARD (Assessment reference date) of 01/07/19. The comprehensive assessment was not complete. On 01/16/19 at 11:35 am an interview was conducted with the MDS coordinator. She stated she has had problems with the assessments in the past being deleted due to a switch in software. When asked if either of the two assessments in question were inadvertently deleted during the change in software, she replied No. She further indicated that the MDS assessments were behind and unfortunately Resident #5's and Resident #15's assessment had not been completed 100%. She stated that she would complete both assessments before the end of the day. On 01/17/19 at 9:30 am an interview was conducted with the Administrator of the facility, who stated that she oversees the MDS nurses. The Administrator indicated that it was her expectation that all comprehensive admission MDS assessments were completed within 14 days of admission.

Based on resident and staff interviews and record review, the facility failed to code a resident's significant weight loss for 1 of 3 sampled residents reviewed for weight loss (Resident #135). The findings included: Resident #135 was admitted to the facility on [DATE] and discharged home on[DATE] but was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of her medical record revealed she weighed: 11/30/16 219 pounds 12/14/16 208 pounds 12/15/16 208.6 pounds 12/21/16 197 pounds 12/28/16 197 pounds 01/02/17 162 pounds 01/04/17 162 pounds 01/10/17 158.8 pounds Resident #135 lost approximately 27% of her body weight from 11/30/16 to 01/10/17. The Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact and her weight was 163 pounds which was not a significant weight loss. On 01/18/17 at 11:09 AM Resident #135 was interviewed and state she had lost at least 50 pounds in a few months. She was wearing a gown and stated her gowns were loose and she was pleased with the weight loss. On 01/18/17 at 1:11 PM the MDS Coordinator was interviewed and explained she was responsible for coding the MDS Section K that included significant weight loss. The MDS Coordinator reported that when coding the section for weight loss, she relied on the resident interview and Registered Dietitian notes to determine if a resident had experienced a significant weight change. The MDS Coordinator explained that Resident #135's weight loss was an oversight and she was unaware the resident had lost a significant amount of weight in her two admissions to the facility.

Based on staff and family interviews and record review the facility failed to record weight loss in the medical record and address weight loss for 1 of 3 sampled residents with significant weight loss (Resident #126). The findings included: Resident #126 was admitted to the facility on [DATE] diagnosed with [REDACTED]. On [DATE] Resident #126 weighed 130 pounds. Resident #126 had an Adult Nutrition initial Assessment dated [DATE] completed by the Registered dietitian (RD). The RD documented the resident was independent with eating, consuming ,[DATE]% of estimated nutritional needs, had experienced unintended weight loss prior to admission, had a chronic illness but appeared to be eating better. The RD also documented the resident had significant nutrition concerns and weighed 130.5 pounds. The RD made recommendations to monitor the resident's intake, weight and appetite. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact, required limited assistance with activities of daily living and weighed 130 pounds had no significant weight loss or gain and received a regular diet. Resident #126 did not have a Care Area Assessment (CAA) for nutritional status because the resident did not trigger for concern. An Adult Nutrition Reassessment was completed on [DATE] by the RD. The RD documented Resident #126's weight was 130 pounds and his intake had decreased to 30 - 100%. The RD recommended to encourage intake of meals, honor food preferences and monitor weight. On [DATE] Resident #126 was discharged home with his family and died on [DATE]. On [DATE] at 9:10 AM a family member was interviewed on the telephone and reported the facility did nothing to address Resident #126's weight loss. The family member stated she was present when the resident was weighed and noted the weight loss. The family member explained she was present when the facility weighed Resident #126 and reported Resident #126 weighed 121 pounds just prior to discharge. Further review of Resident #126's medical record documented one weight of 130.5 pounds. On [DATE] at 10:40 AM the Director of Nursing (DON) was interviewed and explained residents were weighed weekly. She added the weights were documented on a weekly weight worksheet and given to her for review. The DON reported that she reviewed the weights before entering them into the electronic medical record. The DON added that she reviewed the weights for significant changes to determine if a resident needed to be reweighed. The DON stated any significant weight loss would be reported to the RD for review. The DON was able to provide weekly weight worksheets that included weights for Resident #126. The sheets documented Resident #126's weight was: [DATE] 121.4 pounds [DATE] 125.3 pounds The DON stated she was new in her role as of [DATE] and was on a leave of absence in [DATE] and the weights were not entered in Resident #126's medical record because of an oversight. The DON stated Resident #126 was working with speech therapy and felt the resident's decreased intake would improve with speech therapy services. Resident #126's physician was on medical leave and unable to be reached for an interview. On [DATE] at 11:09 AM the RD was interviewed and explained that she noted on [DATE] Resident #126's intake had decreased significantly but since there was no documented weight loss, she felt interventions were not necessary. The RD stated that if she had been notified of Resident #126's weight loss from 130 pounds to 121.4 pounds she would have reassessed the resident and made recommendations. The RD reported that she would review the medical record to look for weights in the electronic chart or be notified by the DON if a resident had weight loss. The RD stated she was unaware Resident #126 had a significant weight loss and was not made aware of the 121.4 pound or 125.3 weights for the resident.

Based on staff interviews and record review the facility failed to document weights in a medical record for a resident with weight loss for 1 of 3 sampled residents (Resident #126). The findings included: Resident #126 was admitted to the facility on [DATE] diagnosed with [REDACTED]. On [DATE] Resident #126 weighed 130.5 pounds. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact, required limited assistance with activities of daily living and weighed 130 pounds had no significant weight loss or gain and received a regular diet. On [DATE] Resident #126 was discharged home with his family and died on [DATE]. Further review of Resident #126's medical record documented one weight of 130.5 pounds. On [DATE] at 10:40 AM the Director of Nursing (DON) was interviewed and explained residents were weighed weekly. She added the weights were documented on a weekly weight sheet and given to her for review. The DON reported that she reviewed the weights before entering them into the electronic medical record. The DON added that she reviewed the weights before entering them into the electronic medical record to look for significant changes to determine if a resident needed to be reweighed. The DON provided weekly weight worksheets that included additional weights for Resident #126. The sheets documented Resident #126's weight was: [DATE] 121.4 pounds [DATE] 125.3 pounds The DON stated she was new in her role as of [DATE] and was on a leave of absence in [DATE] and the weights were not entered in Resident #126's medical record because of an oversight.

Based on record reviews and staff and physician interviews the facility failed to immediately notify the physician and responsible party when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face with a cleansing body lotion for 1 of 1 sampled for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when staff failed to notify the physician and responsible party after a resident had been restrained and abused. The immediate jeopardy is present and ongoing. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited no behaviors. The MDS further indicated Resident #1 required extensive assistance for transfers, bathing and hygiene but was totally dependent on staff for bed mobility and toileting and had upper extremity impairment on one side. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited physical and verbal behaviors directed toward others and was totally dependent on staff for activities of daily living and had upper extremity impairment on one side. A review of a nurse's note dated 03/01/16 at 6:50 AM by Nurse #1 revealed Resident #1 was combative during attempt to give scheduled medications and spit out most of applesauce toward staff. The notes further revealed Resident #1 threatened to go home and get his pistol and shoot staff and attempts to redirect and reason with the resident were unsuccessful. There was no documentation in the nurse's notes that the physician or responsible party were notified. A review of a typed statement dated 03/28/16 by Nurse #1 revealed in part that taking care of Resident #1 was difficult because he was very aggressive and combative. The document further revealed on one night (no date was indicated) while discussing Resident #1 with the night shift nursing supervisor she suggested we might want to secure Resident #1's wrists while cleaning him and release them when we were finished. The document indicated later that night or the next night (no dates indicated) Resident #1 was cursing and combative and Nurse #1 called the supervisor who said to call security but we did not have time for that so in an effort to provide a safe situation for staff and resident she took a soft pillowcase and some tape and secured Resident #1's left wrist to the side rail. The document revealed Resident #1 could still move his arm but he was not able to swing his arm at them. The document indicated they cleaned and repositioned him, then Nurse #1 released the pillowcase, all taking less than 5 minutes. The document indicated Nurse #1 stated she was always in the room during this incident and accepted full responsibility for her judgment. An attempt was made to contact Nurse #1 on 04/19/16 at 2:00 PM by phone but there was no answer and no option to leave a message. During a phone interview on 04/19/16 at 4:36 PM with the night shift Nursing Supervisor she stated she had not instructed Nurse #1 to tie Resident #1's arm to the bed rail. She stated she made rounds during the shift and was available for staff to call her when a resident was out of control and she would have expected Nurse #1 to immediately notify the physician and responsible party after Resident #1's right arm was tied to the bed rail. A review of a facility document completed by the Administrator titled Allegation of Resident Abuse/Restraint dated 03/30/16 revealed a brief summary of interviews of staff. The document indicated on 03/01/16 NA #1 assisted Nurse #1 when they provided morning care to Resident #1. NA #1 assisted with providing peri care then left the room for a short period of time to do other duties. When she finished she noticed the door of Resident #1's room was closed so she went inside the room. When she entered the room she noticed Resident #1's right hand was tied to the bed with a towel and was taped. Nurse #1 was present in the room. NA #1 immediately began to remove the tape and towel to free his hand but Nurse #1 asked what she was doing. Resident #1 had applesauce on his face and a substance on his face that was dripping down the front of him. Nurse #1 stated she was trying to give Resident #1 his meds but he was not listening. On 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16 and reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. On 03/04/16 Nurse #1 and NA #2 were attempting to get Resident #1 up out of bed with a sit to stand lift and over to a chair. Resident #1 became agitated and began hitting and spitting continuously and after he was transferred to his chair NA #2 turned and observed Nurse #1 as she sprayed Resident #1 in the face with cleansing body lotion due to his spitting at her. NA #2 got a wet wash cloth and wiped Resident #1's face to get the lotion off. On 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. On 03/25/16 the DON met with NA #2 and she reported the incident that had occurred on 03/04/16 when Nurse #1 sprayed Resident #1 in the face with cleansing body lotion. On 03/25/16 Resident #1's physician was notified of the incidents. On 03/28/16 at 5:30 PM Resident #1's family was contacted and a meeting was requested to discuss the incident and on 03/29/16 at 10:30 AM administration met with Resident #1's family to inform them of the incidents. A review of facility investigation dated 03/30/16 completed by the Administrator titled Final Summary of Investigation revealed Nurse #1 was consistent with the fact she restrained Resident #1's hand with a pillowcase and tape to avoid being hit. The report also revealed NA #1 provided further clarification and remembered Nurse #1 had spray a bottle of cleansing body lotion in her hand when NA #1 entered Resident #1's room on 03/01/16 and Nurse #1 told NA #1 she had sprayed Resident #1 in the face because he did not listen. The report indicated therefore, it was concluded Nurse #1 intentionally restrained Resident #1 and intentionally sprayed him in or around the face on 03/01/16 and intentionally sprayed Resident #1 in or around the face on 03/04/16 to serve as punishment for hitting, kicking or spitting at her and/or not following her direction during medication administration. During an interview on 04/19/16 at 11:08 AM the Director of Nursing (DON) confirmed NA #1 had witnessed Resident #1's arm tied to the bed rail early in the morning before the end of the shift on 03/01/16. The DON explained on 03/04/16 there was no restraint used but NA #2 observed Nurse #1 spraying a cleansing body lotion in Resident's #1's face. She further verified Nurse #1 was no longer employed by the facility. An attempt was made on 04/20/16 at 11:15 AM to contact Resident #1's physician by phone but was unsuccessful. During an interview on 04/20/16 at 2:24 PM with the facility Medical Director he stated he thought there was a better way to have handled the situation instead of tying the resident's arm to the bed rail. He explained physicians were available and on call 24 hours a day 7 days a week and it was his expectation nursing staff should call the physician if a resident had a change in condition or exhibited behaviors and were out of control. He further stated he would want to be notified about the incidents as soon as possible and why they had occurred. An attempt was made on 04/20/16 at 2:35 PM to contact Resident #1's responsible party but was unsuccessful. During a follow up interview on 04/20/16 at 2:58 PM the DON verified after review of the nurse's notes there was no documentation Resident #1's physician or responsible party were notified after the incidents. She confirmed Resident #1's physician was unaware of the incidents until he was notified during the investigation on 03/25/16 and the family was unaware of the incidents until the administrative staff met with them on 03/29/16. She stated it was her expectation when a resident had a change in status she expected nursing staff to notify the physician and they should notify the responsible party. She stated if she had known the morning of 03/01/16 that Resident #1's arm had been tied to the bed rail and he had been sprayed in the face with the cleansing body lotion she would have notified the physician and responsible party immediately. During an interview on 04/20/16 at 4:23 PM the Administrator stated it was her expectation that nursing staff should have reported immediately to the physician and responsible party when Resident #1's arm was restrained to the bed rail and when Resident #1 was sprayed in the face with the cleansing body lotion. The facility Administrator, DON, hospital Administrator and hospital Vice President were notified of immediate jeopardy on 04/19/16 at 4:02 PM.

Based on observations, staff and physician interviews, police interview and record reviews the facility failed to protect a resident's right to be free of physical restraint when staff restrained a resident without medical symptoms. As a result a nurse restrained the resident's arm to the bed rail with a towel and secured the towel with a plastic medical tape when he became combative during care for 1 of 1 resident sampled for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when Nurse #1 restrained Resident #1's right arm to the side rail with no medical symptoms to warrant the use of restraints. The immediate jeopardy is present and ongoing. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited physical and verbal behaviors directed toward others and was totally dependent on staff for activities of daily living and had upper extremity impairment on one side. The MDS further revealed restraints were not used. A review of a care plan dated 02/15/16 titled [MEDICAL CONDITION]'s revealed Resident #1 was receiving [MEDICATION NAME] and [MEDICATION NAME] for behavior disinhibitions. The goal indicated resident's behavior will be managed by lowest possible dose of medications. The interventions were listed to observe for side effects of [MEDICATION NAME] such as anxiety, somnolence (drowsiness), dizziness or headaches and observe for side effects of [MEDICATION NAME] such as nausea, constipation, sedation and dizziness. A review of a care plan with a revised date of 02/17/16 tiled [MEDICAL CONDITION]'s indicated [MEDICATION NAME] was discontinued and Resident #1 was started on [MEDICATION NAME] and to continue goal that resident's behavior will be managed by lowest possible dose of medications. The interventions were listed to observe for side effects of [MEDICATION NAME] such dry mouth, sedation and somnolence. A review of a care plan with a revised date of 02/22/16 titled [MEDICAL CONDITION]'s indicated [MEDICATION NAME] and [MEDICATION NAME] were discontinued. A review of a care plan with a revised date of 02/29/16 titled [MEDICAL CONDITION]'s indicated [MEDICATION NAME] 25 milligrams was started for [MEDICAL CONDITION] disorder and the goal indicated that resident's behavior will be managed by lowest possible dose of medications. The interventions were listed to observe for side effects of [MEDICATION NAME] such as agitation, dizziness, dry mouth and constipation. A review of a staff schedule for the 11:00 PM - 7:00 AM shift from 02/29/16 through 03/01/16 revealed Nurse #1 and Nurse Aide (NA) #1 were assigned to care for Resident #1. A review of a nurse's note dated 03/01/16 at 4:49 AM by Nurse #1 revealed Resident #1 had slept quietly off and on all night and no complaints or requests were verbalized. A review of a nurse's note dated 03/01/16 at 6:50 AM by Nurse #1 revealed Resident #1 was combative during attempt to give scheduled medications and spit out most of applesauce toward staff. The notes further revealed Resident #1 threatened to go home and get his pistol and shoot staff and attempts to redirect and reason with the resident were unsuccessful. A review of a nurse's notes dated 03/01/16 at 9:57 PM revealed Resident #1 resting in bed with no complaints and took his PM medication with no complications. A review of nursing assessments dated 03/01/16 through 03/31/16 revealed there were no medical symptoms documented for use of restraints. A review of a handwritten statement by NA #1 revealed on Monday night 02/29/16 she worked with Nurse #1 and Resident #1 was very combative. The statement further revealed Nurse #1 helped NA #1 change Resident #1 and after he was changed NA #1 left the room to check on other residents and after she finished with other residents, NA #1 noticed Nurse #1 was still in Resident #1's room so she went to see if Nurse #1 needed any help. The document indicated when NA #1 opened the door she witnessed Nurse #1 fighting with Resident #1 and had his arm tied to the bed with a bath towel and tape wrapped around it. The document further revealed NA #1 immediately removed the tape and towel from Resident #1's arm and straightened him up in bed because he was lying sideways in the bed. During an interview on 04/19/16 at 2:08 PM with NA #1 she confirmed she had written the hand written statement and dated it 02/29/15 because she started her shift at 11:00 PM on that day and worked until the end of her shift at 7:00 AM on 03/01/16. She explained around 6:00 AM on 03/01/16 Nurse #1 helped her change Resident #1. She stated she gathered up the dirty linens and trash and left the room and when she had finished disposing of the linen and trash she noticed Resident #1's door was closed and it concerned her because they did not usually leave his door closed. NA #1 explained when she opened the door Nurse #1 was standing on the left side of the bed and told her to close the door. NA #1 stated she then observed Resident #1's right arm near his wrist was tied to the bed rail with a towel. She explained the towel was wrapped around the bedrail then around Resident #1's wrist and then the ends of the towel were twisted together and plastic medical tape was wrapped multiple times around the towel to secure it. She verified she observed Resident #1's arm was restrained with a white towel and stated she was sure it was a towel and it was not a pillow case. She stated she immediately went to the resident and he was lying across the bed from one side to the other instead of his head toward the head of the bed and his feet toward the foot of the bed. She explained the towel was wrapped pretty tight around his arm and he had limited movement of his right arm. She further explained Resident #1 was unable to use his left arm because of left sided weakness from a stroke so he could not have removed the towel from his right arm. She stated she immediately grabbed the towel and started pulling the tape off and released his arm and she noticed he had applesauce with particles of medication in it and a solution that looked like body cleanser on his face. She explained Nurse #1 told her she had tried to give Resident #1 his morning medications but he was combative and was spitting them at her. NA #1 stated she thought when Nurse #1 tied Resident #1's arm to the bed rail it agitated him more. She described his behaviors as sporadic and she was never sure when he was going to be combative. She explained Resident #1 sometimes made inappropriate verbal remarks and sometimes would hit and kick at staff during care but she redirected him or stopped what she was doing and went back later to provide his care and then he usually was cooperative. During an observation on 04/19/16 at 2:30 PM NA #1 provided a demonstration of how Resident #1's arm was tied to the bedrail in an empty resident room and the DON and Administrator were present for the demonstration. NA #1 turned the bed diagonally so that it was no longer parallel with the wall and the side rails were in the up position on the right side of the bed. NA #1 requested the DON to lie across the bed from side to side with her back resting on the side rail and NA #1 wrapped the towel around the side rail then around the DON's right wrist and twisted the ends of the towel together and taped it to secure it with Transpore medical tape (a latex-free, [MEDICATION NAME], transparent and perforated plastic tape that offers strong adhesion). NA #1 verified the tape was the same plastic medical tape that had been used to tape the towel on Resident #1's arm. A review of a typed statement dated 03/28/16 by Nurse #1 revealed in part that taking care of Resident #1 was difficult because he was very aggressive and combative. The document further revealed on one night (no date was indicated) while discussing Resident #1 with the night shift nursing supervisor she suggested we might want to secure Resident #1's wrists while cleaning him and release them when we were finished. The document indicated later that night or the next night (no dates indicated) Resident #1 was cursing and combative and Nurse #1 called the supervisor who said to call security but we did not have time for that so in an effort to provide a safe situation for staff and resident Nurse #1 took a soft pillowcase and some tape and secured Resident #1's left wrist to the side rail. The document revealed Resident #1 could still move his arm but was not able to swing his arm at them. The document indicated we cleaned and repositioned him, then Nurse #1 released the pillowcase, all taking less than 5 minutes. The document indicated Nurse #1 stated she was always in the room during this incident and accepted full responsibility for her judgment. An attempt was made to contact Nurse #1 on 04/19/16 at 2:00 PM by phone but there was no answer and no option to leave a message. During a phone interview on 04/19/16 at 4:36 PM with the night shift Nursing Supervisor she stated she had not instructed Nurse #1 to tie Resident #1's arm to the bed rail. She stated she made rounds during the shift and was available for staff to call her when a resident was out of control. She further stated it was her expectation Nurse #1 should have called her and should not have tied Resident #1's arm to the bed rail. She explained staff should have attempted to redirect Resident #1 when he was combative or should have stopped what they were doing and went back at a later time to provide care. A review of facility investigation dated 03/30/16 completed by the Administrator titled Final Summary of Investigation revealed it was determined Nurse #1 was unable to provide a consistent story. The report indicated Nurse #1 was inconsistent on the date of the incident, the hand that was restrained, the NA present in the room, when the restraint was actually applied or if a Nurse Supervisor was notified. The report further indicated Nurse #1 was consistent with the fact she restrained Resident #1's hand with a pillowcase and tape to avoid being hit so therefore, it was concluded Nurse #1 intentionally restrained Resident #1. A review of a facility document completed by the Administrator titled Allegation of Resident Abuse/Restraint dated 03/30/16 revealed a brief summary of interviews of staff. The document indicated on 03/01/16 NA #1 assisted Nurse #1 when they provided morning care to Resident #1. NA #1 assisted with providing peri care then left the room for a short period of time to do other duties. When she finished she noticed the door of Resident #1's room was closed so she went inside the room. When she entered the room she noticed Resident #1's right hand was tied to the bed with a towel and was taped. Nurse #1 was present in the room. NA #1 immediately began to remove the tape and towel to free his hand but Nurse #1 asked what she was doing. Nurse #1 stated she was trying to give Resident #1 his medications but he was not listening. On 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. During an interview on 04/19/16 at 11:08 AM with the Director of Nursing (DON) she confirmed Nurse #1 and NA #1 were assigned to care for Resident #1 on the night shift from 02/29/16 through 03/01/16. She also confirmed NA #1 had witnessed Resident #1's arm tied to the bed rail early in the morning before the end of the shift on 03/01/16. She further verified Nurse #1 was no longer employed by the facility. During an observation on 04/19/16 at 1:00 PM the door of Resident #1's room was open and he was sitting calmly in a chair in his room facing the door. An over bed table was in front of him and he was moving items on top of the table around with his right hand and there were no restraints observed. During an observation on 04/20/16 at 10:35 AM the door of Resident #1's room was open and Resident #1 sitting up in a chair in his room with the over bed table in front of him. He was sitting quietly and as staff spoke to him he replied in a calm voice and raised his right hand to wave when staff walked by his door and there were no restraints observed. During an interview on 04/19/16 at 1:15 with the Assistant Chief of Police he verified Resident #1's family reported the incident of tying Resident #1's arm to the bedrail to the police at the police department. He explained they conducted an investigation and issued a warrant for Nurse #1's arrest. He further explained Nurse #1 came to the police station and was taken into custody and she confessed to tying Resident #1's arm to the bed rail. He explained after being processed she was taken to jail on 2 counts of assault on a handicapped person and 1 count of false imprisonment. He further explained she had been released from jail on bond. During an interview on 04/20/16 at 2:24 PM with the facility Medical Director he confirmed the facility was a restraint free facility. He stated he thought there was a better way to have handled the situation instead of tying the resident's arm to the bed rail. He explained usually when a resident exhibited behaviors someone sat with them to monitor them. During a follow up interview on 04/20/16 at 2:58 PM the DON stated they were a restraint-free facility and there should be absolutely no reason for use of physical restraints or restraints used for convenience and there were no medical reasons for restraints to be used for Resident #1. She further stated it was her expectation that staff should have used other least restrictive interventions to handle Resident #1's combative behaviors. She explained Resident #1 should have had a care plan for behaviors with specific interventions for staff to use when he exhibited behaviors. She stated interventions should have included for staff to step away or reach out for help from coworkers or supervisors when a resident exhibited behaviors or redirect residents when they exhibited behaviors or change staff members because sometimes different staff would calm the resident. During an interview on 04/20/16 at 4:23 PM the Administrator stated it was her expectation that no resident in the facility should be restrained because they were a restraint-free facility. She further stated it was her expectation that nursing staff should have reported immediately when Resident #1's arm was restrained to the bed rail. The facility Administrator, DON, hospital Administrator and hospital Vice President were notified of immediate jeopardy on 04/19/16 at 4:02 PM.

Based on observations, staff and physician interviews, police interview and record reviews the facility failed to protect a resident's right to be free from physical abuse when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face on 2 occasions with a cleansing body lotion for 1 of 1 resident sampled for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when NA #1 witnessed Nurse #1 had tied Resident #1's right arm to the bed rail with a towel that was taped with a plastic medical tape and Nurse #1 stated to NA #1 she had sprayed Resident #1 in the face with a cleansing body lotion due to his combative behavior. The immediate jeopardy is present and ongoing. The findings included: A review of a Material Safety Data Sheet (MSDS) dated 02/26/08 indicated the body cleanser used by the facility was labeled Remedy, 4-in-1 body cleanser and described the appearance as a thin yellow liquid. The MSDS sheet further indicated it was not considered to be a skin irritant but with eye contact to flush with adequate amount of cool water for at least 15 minutes and seek medical attention if irritation persists. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited no behaviors. The MDS further indicated Resident #1 required extensive assistance for transfers, bathing and hygiene but was totally dependent on staff for bed mobility and toileting and had upper extremity impairment on one side. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited physical and verbal behaviors directed toward others and was totally dependent on staff for activities of daily living and had upper extremity impairment on one side. The MDS further revealed restraints were not used. A review of a staff schedule for the 11:00 PM - 7:00 AM shift from 02/29/16 through 03/01/16 revealed Nurse #1 and Nurse Aide (NA) #1 were assigned to care for Resident #1. A review of a handwritten statement by NA #1 revealed on Monday night 02/29/16 she worked with Nurse #1 and Resident #1 was very combative. The statement further revealed Nurse #1 helped NA #1 change Resident #1 and after he was changed NA #1 left the room to check on other residents and after she finished with other residents, NA #1 noticed Nurse #1 was still in Resident #1's room so she went to see if Nurse #1 needed any help. The document indicated when NA #1 opened the door she witnessed Nurse #1 fighting with Resident #1 and had his arm tied to the bed with a bath towel and tape wrapped around it. The document further revealed NA #1 immediately removed the tape and towel from Resident #1's arm and straightened him up in bed because he was lying sideways in the bed. During an interview on 04/19/16 at 2:08 PM with NA #1 she confirmed she worked the night shift from 11:00 PM on 02/29/16 until 7:00 AM on 03/01/16. She explained around 6:00 AM on 03/01/16 Nurse #1 helped her change Resident #1. She stated she gathered up the dirty linens and trash and left the room and when she had finished disposing of the linen and trash she noticed Resident #1's door was closed and it concerned her because they did not usually leave his door closed. NA #1 explained when she opened the door Nurse #1 was standing on the left side of the bed and told her to close the door. NA #1 stated she then observed Resident #1's right arm near his wrist was tied to the bed rail with a towel. She explained the towel was wrapped around the bedrail then around Resident #1's wrist and then the ends of the towel were twisted together and plastic medical tape was wrapped multiple times around the towel to secure it. She verified she observed Resident #1's arm was restrained with a white towel and stated she was sure it was a towel and it was not a pillow case. She stated she immediately went to the resident and he was lying across the bed from one side to the other instead of his head toward the head of the bed and his feet toward the foot of the bed. She explained the towel was wrapped pretty tight around his arm and he had limited movement of his right arm. She further explained Resident #1 was unable to use his left arm because of left sided weakness from a stroke so he could not have removed the towel from his right arm. She stated she immediately grabbed the towel and started pulling the tape off and released his arm. She explained after she removed the towel from his arm she noticed he had applesauce with pieces of medication in it and a solution was all over his face and on the front of his gown. She stated the solution on his face was yellow in color and looked like body cleanser they used as a lotion/cleanser during peri care. She explained she did not witness Nurse #1 spray Resident #1 in the face but that Nurse #1 had told her she sprayed him in the face with the body cleanser. She stated Resident #1 was not able to rub the lotion off his face because his right hand was tied to the bed rail. During an observation on 04/19/16 at 2:30 PM NA #1 provided a demonstration of how Resident #1's arm was tied to the bedrail in an empty resident room and the DON and Administrator were present for the demonstration. NA #1 turned the bed diagonally so that it was no longer parallel with the wall and the side rails were in the up position on the right side of the bed. NA #1 requested the DON to lie across the bed from side to side with her back resting on the side rail and NA #1 wrapped the towel around the side rail then around the DON's right wrist and twisted the ends of the towel together and taped it to secure it with Transpore medical tape (a latex-free, [MEDICATION NAME], transparent and perforated plastic tape that offers strong adhesion). NA #1 verified the tape was the same plastic medical tape that had been used to tape the towel on Resident #1's arm. A review of a facility document completed by the Administrator titled Allegation of Resident Abuse/Restraint dated 03/24/16-03/30/16 revealed a brief summary of interviews of staff. The document indicated on 03/01/16 NA #1 assisted Nurse #1 when they provided morning care to Resident #1. NA #1 assisted with providing peri care then left the room for a short period of time to do other duties. When she finished she noticed the door of Resident #1's room was closed so she went inside the room. When she entered the room she noticed Resident #1's right hand was tied to the bed with a towel and was taped and Nurse #1 was present in the room. NA #1 immediately began to remove the tape and towel to free his hand but Nurse #1 asked what she was doing. The document further revealed Resident #1 had applesauce on his face and a substance on his face that was dripping down the front of him. Nurse #1 stated she was trying to give Resident #1 his medications but he was not listening. On 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. The document indicated on 03/04/16 Nurse #1 and NA #2 were attempting to get Resident #1 up out of bed with a sit to stand lift and over to a chair. Resident #1 became agitated and began hitting and spitting continuously and after he was transferred to his chair NA #2 turned and observed Nurse #1 as she sprayed Resident #1 in the face with cleansing lotion due to his spitting at her. NA #2 got a wet wash cloth and wiped Resident #1's face to get the lotion off. On 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. On 03/25/16 the DON met with NA #2 and she reported the incident that had occurred on 03/04/16 when Nurse #1 sprayed Resident #1 in the face with cleansing lotion. A review of a typed statement dated 03/26/16 at 1:15 AM by NA #2 revealed she was in Resident #1's room on 03/04/16 with Nurse #1 to get Resident #1 out of bed. The document indicated Resident #1 was combative (hitting, kicking and trying to spit on staff) and after Resident #1 was transferred to a chair NA #2 asked Nurse #1 several times to assist her to get Resident back in the chair so he wouldn't slide off the edge but instead Nurse #1 proceeded to spray Resident #1 in the face with some lotion base cleansing spray which made Resident #1 more aggressive. The document further indicated NA #2 immediately got a washcloth and washed the resident's face. During a phone interview on 04/19/16 at 3:02 PM with NA #2 she explained Nurse #1 wanted to get Resident #1 up to a chair on 03/04/16 between 6:00 AM and 6:30 AM and they transferred him with a sit to stand lift from his bed to the chair. She stated Resident #1 was trying to hit them and kick them and he was spitting at them. NA #2 stated she kept asking Nurse #1 to help her position Resident #1 in the chair because he was sliding forward but Nurse #1 ignored her and grabbed a spray bottle of cleansing lotion and sprayed him multiple times in the face. She stated the lotion was on his face at his cheekbones and was running down his face so she got a washcloth and wiped the lotion off. She explained when Nurse #1 sprayed him in the face it startled him and made his agitation worse. She stated she felt she had taken care of it by washing the lotion off Resident #1's face and at the time did not think it was abuse. A review of a typed statement dated 03/28/16 by Nurse #1 revealed in part that taking care of Resident #1 was difficult because he was very aggressive and combative. The document further revealed on one night (no date was indicated) while discussing Resident #1 with the night shift nursing supervisor she suggested we might want to secure Resident #1's wrists while cleaning him and release them when we were finished. The document indicated later that night or the next night (no dates indicated) Resident #1 was cursing and combative and Nurse #1 called the supervisor who said to call security but we did not have time for that so in an effort to provide a safe situation for staff and resident, Nurse #1 took a soft pillowcase and some tape and secured Resident #1's left wrist to the side rail. The document revealed Resident #1 could still move his arm but was not able to swing his arm at them. The document indicated we cleaned and repositioned him, then Nurse #1 released the pillowcase, all taking less than 5 minutes. The document indicated Nurse #1 stated she was always in the room during this incident and accepted full responsibility for her judgment. An attempt was made to contact Nurse #1 on 04/19/16 at 2:00 PM by phone but there was no answer and no option to leave a message. During a phone interview on 04/19/16 at 4:36 PM with the night shift Nursing Supervisor she stated she had not instructed Nurse #1 to tie Resident #1's arm to the bed rail. She stated she made rounds during the shift and was available for staff to call her when a resident was out of control. She further stated it was her expectation Nurse #1 should have called her and should not have tied Resident #1's arm to the bed rail and should not have spayed the cleansing body lotion in his face. During an interview on 04/19/16 at 1:15 with the Assistant Chief of Police he verified Resident #1's family reported the incident of tying Resident #1's arm to the bedrail to the police at the police department. He explained they conducted an investigation and issued a warrant for Nurse #1's arrest. He further explained Nurse #1 came to the police station and was taken into custody and she confessed to tying Resident #1's arm to the bed rail. He explained after being processed she was taken to jail on 2 counts of assault on a handicapped person and 1 count of false imprisonment. He further explained she had been released from jail on bond. During an observation on 04/19/16 at 1:00 PM the door of Resident #1's room was open and he was sitting calmly in a chair in his room facing the door. An over bed table was in front of him and he was moving items on top of the table around with his right hand. During an observation on 04/20/16 at 10:35 AM the door of Resident #1's room was open and Resident #1 sitting up in a chair in his room with the over bed table in front of him. He was sitting quietly and as staff spoke to him he replied in a calm voice and raised his right hand to wave when staff walked by his door. During an interview on 04/20/16 at 2:24 PM with the facility Medical Director he confirmed the DON had informed him during the investigation of the incidents that had occurred on 03/01/16 and 03/04/16. He stated he thought there was a better way to have handled the situation instead of tying the resident's arm to the bed rail. During a follow up interview on 04/20/16 at 2:58 PM the DON stated she considered the incidents of tying Resident #1's arm to the bed rail and spraying him in the face with the cleansing lotion as abuse. The DON explained there was a zero tolerance for abuse in the facility. During an interview on 04/20/16 at 4:23 PM the Administrator stated it was her expectation of staff to treat residents respectfully and abuse of residents was not tolerated in the facility. The facility Administrator, DON, hospital Administrator and hospital Vice President were notified of immediate jeopardy on 04/19/16 at 4:02 PM.

Based on staff interviews and record reviews the facility staff failed to immediately report witnessed incidents of physical abuse and the failure to report placed other residents at risk for abuse. The facility staff failed to immediately report when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face with a cleansing body lotion on 2 occasions for 1 of 1 resident sampled for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when NA #1 failed to immediately report to administrative staff when Nurse #1 had tied Resident #1's right arm to the bed rail with a towel that was taped with a plastic medical tape and Nurse #1 stated to NA #1 she had sprayed Resident #1 in the face with a cleansing body lotion due to his combative behavior. The immediate jeopardy is present and ongoing. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited physical and verbal behaviors directed toward others and was totally dependent on staff for activities of daily living and had upper extremity impairment on one side. The MDS further revealed restraints were not used. A review of a staff schedule for the 11:00 PM - 7:00 AM shift from 02/29/16 through 03/01/16 revealed Nurse #1 and Nurse Aide (NA) #1 were assigned to care for Resident #1. A review of a handwritten statement by NA #1 revealed on Monday night 02/29/16 she worked with Nurse #1 and Resident #1 was very combative. The statement further revealed Nurse #1 helped NA #1 change Resident #1 and after he was changed NA #1 left the room to check on other residents and after she finished with other residents, NA #1 noticed Nurse #1 was still in Resident #1's room so she went to see if Nurse #1 needed any help. The document indicated when NA #1 opened the door she witnessed Nurse #1 fighting with Resident #1 and had his arm tied to the bed with a bath towel and tape wrapped around it. The document further revealed NA #1 immediately removed the tape and towel from Resident #1's arm and straightened him up in bed because he was lying sideways in the bed. During an interview on 04/19/16 at 2:08 PM with NA #1 she confirmed she worked the night shift from 11:00 PM on 02/29/16 until 7:00 AM on 03/01/16. She explained around 6:00 AM on 03/01/16 Nurse #1 helped her change Resident #1. She stated she gathered up the dirty linens and trash and left the room and when she had finished disposing of the linen and trash she noticed Resident #1's door was closed and it concerned her because they did not usually leave his door closed. NA #1 explained when she opened the door Nurse #1 was standing on the left side of the bed and Resident #1's right arm near his wrist was tied to the bed rail with a towel. She explained the towel was wrapped around the bedrail then around Resident #1's wrist and then the ends of the towel were twisted together and plastic medical tape was wrapped multiple times around the towel to secure it. She verified she observed Resident #1's arm was restrained with a white towel and stated she was sure it was a towel and it was not a pillow case. She stated she immediately went to the resident and he was lying across the bed from one side to the other instead of his head toward the head of the bed and his feet toward the foot of the bed. She explained the towel was wrapped pretty tight around his arm and he had limited movement of his right arm. She further explained Resident #1 was unable to use his left arm because of left sided weakness from a stroke so he could not have removed the towel from his right arm. She stated she immediately grabbed the towel and started pulling the tape off and released his arm and she noticed he had applesauce with particles of medication in it and a solution that looked like body cleanser on his face. She explained the solution looked like the cleanser they used on a resident's skin while cleaning them and it was all over his face and on the front of his gown and stated the cleanser was yellow in color. She stated Resident #1 was not able to rub the lotion off his face because his right hand was tied to the bed rail. She explained she did not observe Nurse #1 spray the body cleanser on Resident #1's face but Nurse #1 told her she had sprayed Resident #1's face with the cleanser. She confirmed she gave report to the day shift NA on 03/01/16 who was assigned to Resident #1 but she did not report that Resident #1's arm had been tied to the bed rail with a towel. She stated she knew Resident #1's arm should not have been tied to the bed rail but she did not report the incident at the time because she did not want to get anyone in trouble. She further stated she was concerned she would be treated differently by her co-workers if she reported it. She explained she worked with Nurse #1 after the incident on 03/01/16 but they worked on different halls. She explained when the DON called her in on 03/23/16 to talk about some things she saw it as an opportunity to show her the handwritten statement she had written dated 02/29/16. A review of a typed statement dated 03/26/16 at 1:15 AM by NA #2 revealed she was in Resident #1's room on 03/04/16 with Nurse #1 to get Resident #1 out of bed. The document indicated Resident #1 was combative (hitting, kicking and trying to spit on staff) and after Resident #1 was transferred to a chair NA #2 asked Nurse #1 several times to assist her to get Resident #1 back in the chair so he wouldn't slide off the edge but instead Nurse #1 proceeded to spray Resident #1 in the face with some lotion base cleansing spray which made Resident #1 more aggressive. The document further indicated NA #2 immediately got a washcloth and washed the resident's face. During a phone interview on 04/19/16 at 3:02 PM with NA #2 she explained Nurse #1 wanted to get Resident #1 up to a chair on 03/04/16 between 6:00 AM and 6:30 AM and they transferred him with a sit to stand lift from his bed to the chair. She stated Resident #1 was trying to hit them and kick them and he was spitting at them. NA #2 stated she kept asking Nurse #1 to help her position Resident #1 in the chair because he was sliding forward but Nurse #1 ignored her and Nurse #1 grabbed a spray bottle of cleansing lotion and sprayed him multiple times in the face. She stated the lotion was on his face at his cheekbones and was running down his face so she got a washcloth and wiped the lotion off. She explained when Nurse #1 sprayed him in the face it startled him and made his agitation worse. She stated after they got him positioned in his chair she left the room and gave report to the first shift NA but did not report to her that Nurse #1 had sprayed Resident #1 in the face with the body cleansing lotion. She stated she left the facility and didn't report the incident to anyone. She further stated she felt she had taken care of it by washing the lotion off Resident #1's face and at the time did not think it was abuse but now she realized she should have reported the incident immediately. She confirmed she met with the DON on 03/25/16 and reported the incident that had occurred on 03/04/16. She explained the DON requested she write a statement about the incident that occurred on 03/04/16 so that night she wrote the statement that was dated 03/26/16 and emailed it to the DON. A review of a typed statement dated 03/28/16 by Nurse #1 revealed in part that taking care of Resident #1 was difficult because he was very aggressive and combative. The document further revealed on one night (no date was indicated) while discussing Resident #1 with the night shift nursing supervisor she suggested we might want to secure Resident #1's wrists while cleaning him and release them when we were finished. The document indicated later that night or the next night (no dates indicated) Resident #1 was cursing and combative and Nurse #1 called the supervisor who said to call security but we did not have time for that so in an effort to provide a safe situation for staff and resident, Nurse #1 took a soft pillowcase and some tape and secured Resident #1's left wrist to the side rail. The document revealed Resident #1 could still move his arm but was not able to swing his arm at them. The document indicated we cleaned and repositioned him, then Nurse #1 released the pillowcase, all taking less than 5 minutes. The document indicated Nurse #1 stated she was always in the room during this incident and accepted full responsibility for her judgment. An attempt was made to contact Nurse #1 on 04/19/16 at 2:00 PM by phone but there was no answer and no option to leave a message. During a phone interview on 04/19/16 at 4:36 PM with the night shift Nursing Supervisor she stated she had not instructed Nurse #1 to tie Resident #1's arm to the bed rail. She stated she made rounds during the shift and was available for staff to call her when a resident was out of control. She further stated it was her expectation Nurse #1 should have called her and should not have tied Resident #1's arm to the bed rail or sprayed him in the face and Nurse #1, NA #1 and NA #2 should have reported the incidents immediately so an investigation could have been completed. A review of the initial 24 hour report that was sent to the North Carolina Health Care Personnel Registry by facsimile (fax) was dated 03/24/16 at 6:05 PM. The report revealed it was completed by the DON and the allegation description revealed it was reported to the DON on 03/24/16 at 11:00 AM that Nurse #1 had briefly restrained Resident #1's right hand to the bed rail with a pillow case and tape to protect herself and Resident #1 during peri care due to combative behavior. A review of the 5 working day report that was sent to the North Carolina Health Care Personnel Registry by fax was dated 03/30/16 at 1:00 PM. The report revealed it was completed by the DON and the allegation description revealed Nurse #1 restrained Resident #1's right hand to the bottom side rail in order to administer medication and care. The description further revealed Resident #1's hand was restrained with a towel/pillowcase with tape wrapped around the restraint to avoid Resident #1 from hitting Nurse #1. The description indicated NA #1 entered the room, found Resident #1 restrained by Nurse #1 and immediately approached Resident #1 and began removing tape to release restraint. The description also indicated NA #1 noticed Resident #1 had medicine, applesauce and some form of substance on his face and she cleaned it up. The description further indicated NA #1 later stated when she entered the room that Nurse #1 had a spray bottle of cleansing lotion in her hand and admitted she had sprayed it in Resident #1's face when he did not cooperate. A review of a facility document dated 03/30/16 titled Allegation of Resident Abuse/Restraint completed by the Administrator and DON revealed a brief summary of interviews of staff. The document indicated on 03/01/16 NA #1 assisted Nurse #1 when they provided morning care to Resident #1. The document revealed NA #1 assisted with providing peri care then left the room for a short period of time to do other duties and when she finished she noticed the door of Resident #1's room was closed so she went inside the room. The documents further revealed when she entered the room she noticed Resident #1's right hand was tied to the bed with a towel and was taped and Nurse #1 was present in the room. The document indicated NA #1 immediately began to remove the tape and towel to free his hand and Resident #1 had applesauce on his face and a substance on his face that was dripping down from his face onto the front of him. The document revealed Nurse #1 stated she was trying to give Resident #1 his medications but he was not listening. The document further revealed on 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. The document indicated NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. The document further indicated on 03/04/16 Nurse #1 and NA #2 were attempting to get Resident #1 up out of bed with a sit to stand lift and over to a chair. The document revealed Resident #1 became agitated and began hitting and spitting continuously and after he was transferred to his chair NA #2 turned and observed Nurse #1 as she sprayed Resident #1 in the face with cleansing lotion due to his spitting at her. The document indicated NA #2 got a wet wash cloth and wiped Resident #1's face to get the lotion off. The document further indicated on 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. The document revealed NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. The document further indicated on 03/25/16 the DON met with NA #2 and she reported the incident that had occurred on 03/04/16 when Nurse #1 sprayed Resident #1 in the face with cleansing lotion. A review of a facility investigation report dated 03/30/16 completed by the Administrator titled Final Summary of Investigation revealed it was determined Nurse #1 was unable to provide a consistent story. The report indicated Nurse #1 was inconsistent on the date of the incident, the hand that was restrained, the NA present in the room, when the restraint was actually applied or if a Nurse Supervisor was notified. The report further indicated Nurse #1 was consistent with the fact she restrained Resident #1's hand with a pillowcase and tape to avoid being hit. The report also revealed NA #1 provided further clarification and remembered Nurse #1 had spray bottle of cleansing lotion in her hand when NA #1 entered Resident #1's room on 03/01/16 and Nurse #1 told NA #1 she had sprayed Resident #1 in the face because he did not listen. The report indicated therefore, it was concluded Nurse #1 intentionally restrained Resident #1 and intentionally sprayed him in or around the face on 03/01/16 and intentionally sprayed Resident #1 in or around the face on 03/04/16 to serve as punishment for hitting, kicking or spitting at her and/or not following her direction during medication administration. During an interview on 04/19/16 at 11:08 AM with the Director of Nursing (DON) she confirmed Nurse #1 and NA #1 were assigned to care for Resident #1 on the night shift from 02/29/16 through 03/01/16. She also confirmed NA #1 had witnessed Resident #1's arm tied to the bed rail early in the morning before the end of the shift on 03/01/16 but NA #1 did not immediately report the incident. She explained the handwritten document by NA #1 dated 02/29/16 was given to her on 03/24/16 when she had called NA #1 to come in and meet with her and at the end of the meeting NA #1 showed her the handwritten document and stated she needed to discuss it. The DON stated she asked NA #1 why she had not reported the incident immediately after she observed Nurse #1 had tied Resident #1's arm to the bed rail and NA #1 stated she had not reported the incident to anyone because of personal reasons and she had been processing what she was going to do about it. The DON explained on 03/04/16 NA #2 observed Nurse #1 spraying a cleansing lotion in Resident's #1's face but did not report the incident immediately. She stated she met with NA #2 on 03/25/16 and asked her why she had not reported it immediately and NA #2 stated at the time she didn't think it was something that should be reported. The DON verified Resident #1 was still present in the facility. She further verified Nurse #1 was no longer employed by the facility. During an interview on 04/19/16 at 3:00 PM the Adminsitrator explained Nurse #1 had requested to meet with her on the morning of 03/04/16 after she had finished working the night shift. She explained she came in and met with Nurse #1 and she was crying and upset and told her Resident #1 had been hitting, kicking and spitting at her. She stated she asked Nurse #1 numerous times if anything else had happened and Nurse #1 told her nothing else had happened. The Administrator stated she felt Nurse #1 was experiencing burnout and but was completely unaware at that point the incidents of abuse had occurred on 03/01/16 and 03/04/16. During a follow up interview on 04/20/16 at 2:58 PM the DON stated it was her expectation that Nurse #1 and NA #1 should have immediately reported the incident on 03/01/16 so an investigation could have been started immediately. The DON further stated it was her expectation NA #2 should have immediately reported the incident on 03/04/16 when NA #2 witnessed Nurse #1 spray the body cleansing lotion in Resident #1's face. During a follow up interview on 04/20/16 at 4:23 PM the Administrator stated it was her expectation that nursing staff should have reported immediately when Resident #1's arm was restrained to the bed rail and when Resident #1 was sprayed in the face with the body cleansing lotion. The facility Administrator, DON, hospital Administrator and hospital Vice President were notified of immediate jeopardy on 04/19/16 at 4:02 PM.

Based on staff interviews and record reviews the facility staff failed to operationalize policy and procedure when staff failed to immediately notify administrative staff of 2 witnessed incidents of physical abuse when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face with a cleansing body lotion on 2 occasions. The facility staff also failed to assess the resident for physical injury after both of these instances of staff abuse for 1 of 1 resident sampled for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when NA #1 failed to immediately report when Nurse #1 had tied Resident #1's right arm to the bed rail with a towel that was taped with a plastic medical tape and Nurse #1 stated to NA #1 she had sprayed Resident #1 in the face with a cleansing body lotion due to his combative behavior. The immediate jeopardy is present and ongoing. The findings included: A review of a facility policy titled Abuse Prohibition Policy with a reviewed date of October 2014 revealed neglect or abuse of residents will not be tolerated. Any employee who willfully or unintentionally abuses or neglects a resident will be suspended immediately and ultimately terminated after completion of investigation. Residents shall be examined by the Director of Nursing (DON) or by supervisory personnel as designated by the DON to determine if evidence of abuse or neglect exists. Any incident which appears to have resulted from abuse shall be thoroughly investigated and reported to the appropriate authorities, including but not limited to, the police, the Division of Facility Services, the Nurse Aide Registry and the Board of Nursing. The Director of Nursing and/or Administrator shall investigate all complaints of abuse immediately by speaking with the resident and/or complainant and any staff member involved or having knowledge of the occurrence. Any staff member suspected of being abusive shall be suspended from work until the investigation is complete. Residents are assessed, care planned and monitored to identify needs and behaviors that might lead to abuse, neglect or misappropriation. This may include those with dementia, abnormal behavior, aggressiveness, mental illness etc. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited physical and verbal behaviors directed toward others and was totally dependent on staff for activities of daily living and had upper extremity impairment on one side. The MDS further revealed restraints were not used. A review of a staff schedule for the 11:00 PM - 7:00 AM shift from 02/29/16 through 03/01/16 revealed Nurse #1 and Nurse Aide (NA) #1 were assigned to care for Resident #1. A review of a handwritten statement by NA #1 revealed on Monday night 02/29/16 she worked with Nurse #1 and Resident #1 was very combative. The statement further revealed Nurse #1 helped NA #1 change Resident #1 and after he was changed NA #1 left the room to check on other residents and after she finished with other residents, NA #1 noticed Nurse #1 was still in Resident #1's room so she went to see if Nurse #1 needed any help. The document indicated when NA #1 opened the door she witnessed Nurse #1 fighting with Resident #1 and had his arm tied to the bed with a bath towel and tape wrapped around it. The document further revealed NA #1 immediately removed the tape and towel from Resident #1's arm and straightened him up in bed because he was lying sideways in the bed. During an interview on 04/19/16 at 2:08 PM with NA #1 she confirmed she worked the night shift from 11:00 PM on 02/29/16 until 7:00 AM on 03/01/16 and wrote the hand written statement. She explained around 6:00 AM on 03/01/16 Nurse #1 helped her change Resident #1. She stated she gathered up the dirty linens and trash and left the room and when she had finished disposing of the linen and trash she noticed Resident #1's door was closed and it concerned her because they did not usually leave his door closed. NA #1 explained when she opened the door Nurse #1 was standing on the left side of the bed and Resident #1's right arm near his wrist was tied to the bed rail with a towel. She explained the towel was wrapped around the bedrail then around Resident #1's wrist and then the ends of the towel were twisted together and plastic medical tape was wrapped multiple times around the towel to secure it. She verified she observed Resident #1's arm was restrained with a white towel and stated she was sure it was a towel and it was not a pillow case. She stated she immediately went to the resident and he was lying across the bed from one side to the other instead of his head toward the head of the bed and his feet toward the foot of the bed. She explained the towel was wrapped pretty tight around his arm and he had limited movement of his right arm. She further explained Resident #1 was unable to use his left arm because of left sided weakness from a stroke so he could not have removed the towel from his right arm. She stated she immediately grabbed the towel and started pulling the tape off and released his arm and she noticed he had applesauce with particles of medication in it and a solution that looked like body cleanser on his face. She explained the solution looked like the cleanser they used on a resident skin while cleaning them and it was all over his face and on the front of his gown and stated the cleanser was yellow in color. She stated Resident #1 was not able to rub the lotion off his face because his right hand was tied to the bed rail. She explained she did not observe Nurse #1 spray the body cleanser on Resident #1's face but Nurse #1 told her she had sprayed Resident #1's face with the cleanser. She confirmed she gave report to the day shift NA on 03/01/16 who was assigned to Resident #1 but she did not report that Resident #1's arm had been tied to the bed rail with a towel. She stated she knew Resident #1's arm should not have been tied to the bed rail but she did not report the incident at the time because she did not want to get anyone in trouble. She further stated she was concerned she would be treated differently by her co-workers if she reported it. She explained she worked with Nurse #1 after the incident on 03/01/16 but they worked on different halls. She explained when the DON called her in on 03/23/16 to talk about some things she saw it as an opportunity to show her the handwritten statement she had written dated 02/29/16. A review of a typed statement dated 03/26/16 at 1:15 AM by NA #2 revealed she was in Resident #1's room on 03/04/16 with Nurse #1 to get Resident #1 out of bed. The document indicated Resident #1 was combative (hitting, kicking and trying to spit on staff) and after Resident #1 was transferred to a chair NA #2 asked Nurse #1 several times to assist her to get Resident #1 back in the chair so he wouldn't slide off the edge but instead Nurse #1 proceeded to spray Resident #1 in the face with some lotion base cleansing spray which made Resident #1 more aggressive. The document further indicated NA #2 immediately got a washcloth and washed the resident's face. During a phone interview on 04/19/16 at 3:02 PM with NA #2 she explained Nurse #1 wanted to get Resident #1 up to a chair on 03/04/16 between 6:00 AM and 6:30 AM and they transferred him with a sit to stand lift from his bed to the chair. She stated Resident #1 was trying to hit them and kick them and he was spitting at them. NA #2 stated she kept asking Nurse #1 to help her position Resident #1 in the chair because he was sliding forward but Nurse #1 ignored her and Nurse #1 grabbed a spray bottle of cleansing lotion and sprayed him multiple times in the face. She stated the lotion was on his face at his cheekbones and was running down his face so she got a washcloth and wiped the lotion off. She explained when Nurse #1 sprayed him in the face it startled him and made his agitation worse. She stated after they got him positioned in his chair she left the room and gave report to the first shift NA but did not report to her that Nurse #1 had sprayed Resident in the face with the body cleansing lotion. She stated she left the facility and didn't report the incident to anyone. She further stated she felt she had taken care of it by washing the lotion off Resident #1's face and at the time did not think it was abuse but now she realized she should have reported the incident immediately. She confirmed she met with the DON on 03/25/16 and reported the incident that had occurred on 03/04/16. She explained the DON requested she write a statement about the incident that occurred on 03/04/16 so that night she wrote the statement that was dated 03/26/16 and emailed it to the DON. A review of a typed statement dated 03/28/16 by Nurse #1 revealed in part that taking care of Resident #1 was difficult because he was very aggressive and combative. The document further revealed on one night (no date was indicated) while discussing Resident #1 with the night shift nursing supervisor she suggested we might want to secure Resident #1's wrists while cleaning him and release them when we were finished. The document indicated later that night or the next night (no dates indicated) Resident #1 was cursing and combative and Nurse #1 called the supervisor who said to call security but we did not have time for that so in an effort to provide a safe situation for staff and resident, Nurse #1 took a soft pillowcase and some tape and secured Resident #1's left wrist to the side rail. The document revealed Resident #1 could still move his arm but was not able to swing his arm at them. The document indicated we cleaned and repositioned him, then Nurse #1 released the pillowcase, all taking less than 5 minutes. The document indicated Nurse #1 stated she was always in the room during this incident and accepted full responsibility for her judgment. An attempt was made to contact Nurse #1 on 04/19/16 at 2:00 PM by phone but there was no answer and no option to leave a message. During a phone interview on 04/19/16 at 4:36 PM with the night shift Nursing Supervisor she stated she had not instructed Nurse #1 to tie Resident #1's arm to the bed rail. She stated she made rounds during the shift and was available for staff to call her when a resident was out of control. She further stated it was her expectation Nurse #1 should have called her and should not have tied Resident #1's arm to the bed rail or sprayed him in the face and Nurse #1, NA #1 and NA #2 should have reported the incidents immediately. The initial 24 hour report that was sent to the North Carolina Health Care Personnel Registry by facsimile (fax) was dated 03/24/16 at 6:05 PM. The report revealed it was completed by the DON and the allegation description revealed it was reported to the DON on 03/24/16 at 11:00 AM that Nurse #1 had briefly restrained Resident #1's right hand to the bed rail with a pillow case and tape to protect herself and Resident #1 during peri care due to combative behavior. A review of the 5 working day report that was sent to the North Carolina Health Care Personnel Registry by fax was dated 03/30/16 at 1:00 PM. The report revealed it was completed by the DON and the allegation description revealed Nurse #1 restrained Resident #1's right hand to the bottom side rail in order to administer medication and care. The description further revealed Resident #1's hand was restrained with a towel/pillowcase with tape wrapped around the restraint to avoid Resident #1 from hitting Nurse #1. The description indicated NA #1 entered the room, found Resident #1 restrained by Nurse #1 and immediately approached Resident #1 and began removing tape to release restraint. The description also indicated NA #1 noticed Resident #1 had medicine, applesauce and some form of substance on his face and she cleaned it up. The description further indicated NA #1 later stated when she entered the room that Nurse #1 had a spray bottle of cleansing lotion in her hand and admitted she had sprayed it in Resident #1's face when he did not cooperate. A review of a facility document dated 03/30/16 titled Allegation of Resident Abuse/Restraint completed by the Administrator and DON revealed a brief summary of interviews of staff. The document indicated on 03/01/16 NA #1 assisted Nurse #1 when they provided morning care to Resident #1. The document revealed NA #1 assisted with providing peri care then left the room for a short period of time to do other duties and when she finished she noticed the door of Resident #1's room was closed so she went inside the room. The documents further revealed when she entered the room she noticed Resident #1's right hand was tied to the bed with a towel and was taped and Nurse #1 was present in the room. The document indicated NA #1 immediately began to remove the tape and towel to free his hand and Resident #1 had applesauce on his face and a substance on his face that was dripping down from his face onto the front of him. The document revealed Nurse #1 stated she was trying to give Resident #1 his medications but he was not listening. The document further revealed on 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. The document indicated NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. The document further indicated on 03/04/16 Nurse #1 and NA #2 were attempting to get Resident #1 up out of bed with a sit to stand lift and over to a chair. The document revealed Resident #1 became agitated and began hitting and spitting continuously and after he was transferred to his chair NA #2 turned and observed Nurse #1 as she sprayed Resident #1 in the face with cleansing lotion due to his spitting at her. The document indicated NA #2 got a wet wash cloth and wiped Resident #1's face to get the lotion off. The document further indicated on 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. The document revealed NA #1 reported Nurse #1 briefly restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident while providing peri care due to combative behavior. The document further indicated on 03/25/16 the DON met with NA #2 and she reported the incident that had occurred on 03/04/16 when Nurse #1 sprayed Resident #1 in the face with cleansing lotion. A review of a fax documents revealed a report of the investigation was submitted to the North Carolina Board of Nursing on 03/31/16. A review of facility investigation dated 03/30/16 completed by the Administrator titled Final Summary of Investigation revealed it was determined Nurse #1 was unable to provide a consistent story. The report indicated Nurse #1 was inconsistent on the date of the incident, the hand that was restrained, the NA present in the room, when the restraint was actually applied or if a Nurse Supervisor was notified. The report further indicated Nurse #1 was consistent with the fact she restrained Resident #1's hand with a pillowcase and tape to avoid being hit. The report also revealed NA #1 provided further clarification and remembered Nurse #1 had spray bottle of cleansing lotion in her hand when NA #1 entered Resident #1's room on 03/01/16 and Nurse #1 told NA #1 she had sprayed Resident #1 in the face because he did not listen. The report indicated therefore, it was concluded Nurse #1 intentionally restrained Resident #1 and intentionally sprayed him in or around the face on 03/01/16 and intentionally sprayed Resident #1 in or around the face on 03/04/16 to serve as punishment for hitting, kicking or spitting at her and/or not following her direction during medication administration. During an interview on 04/19/16 at 11:08 AM with the Director of Nursing (DON) she confirmed Nurse #1 and NA #1 were assigned to care for Resident #1 on the night shift from 02/29/16 through 03/01/16. She also confirmed NA #1 had witnessed Resident #1's arm tied to the bed rail early in the morning before the end of the shift on 03/01/16 but NA #1 did not immediately report the incident. She explained the handwritten document by NA #1 dated 02/29/16 was given to her on 03/24/16 when she had called NA #1 to come in and meet with her and at the end of the meeting NA #1 showed her the handwritten document and stated she needed to discuss it. The DON stated she asked NA #1 why she had not reported the incident immediately after she observed Nurse #1 had tied Resident #1's arm to the bed rail and NA #1 stated she had not reported the incident to anyone because of personal reasons and she had been processing what she was going to do about it. The DON explained on 03/04/16 NA #2 observed Nurse #1 spraying a cleansing lotion in Resident #1's face but did not report the incident immediately. She stated she met with NA #2 on 03/25/16 and asked her why she had not reported it immediately and NA #2 stated at the time she didn't think it was something that should be reported. The DON verified Resident #1 was still present in the facility. She further verified Nurse #1 was no longer employed by the facility. During an interview on 04/19/16 at 3:00 PM the Administrator explained Nurse #1 had requested to meet with her on the morning of 03/04/16 after she had finished working the night shift. She explained she came in and met with Nurse #1 and she was crying and upset and told her Resident #1 had been hitting, kicking and spitting at her. She stated she asked Nurse #1 numerous times if anything else had happened and Nurse #1 told her nothing else had happened. The Administrator stated she felt Nurse #1 was experiencing burnout and but was completely unaware at that point the incidents of abuse had occurred on 03/01/16 and 03/04/16. During a follow up interview on 04/20/16 at 2:58 PM the DON stated facility staff received training regarding abuse and neglect when hired at the facility during orientation and it was repeated annually and more often as needed. She further stated during the training the facility policies for abuse and neglect were reviewed with staff. She stated it was her expectation for all staff to abide by the facility policies to prevent abuse and neglect and Nurse #1 and NA #1 should have immediately reported the incident on 03/01/16 so an investigation could have been started immediately. The DON further stated Nurse #1 and NA #2 should have reported the incident on 03/04/16 immediately and an investigation would have been done. The DON explained she did not have any evidence Nurse #1 had assessed Resident #1 after the incidents because there was no documentation in Resident #1's medical record that he was assessed for injuries after his arm was tied to the bed rail on 03/01/16 or was assessed for any irritation on his face or in his eyes when the body lotion was sprayed in his face on 03/01/16 or 03/04/16. She stated she would have expected for Nurse #1 to have assessed Resident #1 immediately after the incidents and should have documented her assessments in the nurse's notes. The DON explained she was notified on 03/24/16 of the incidents that had occurred on 03/01/16 and 03/04/16 and assessed Resident #1 on 03/25/16 as part of her investigation and did not see any physical signs of injury to Resident #1's right arm or irritation to his eyes. During a follow up interview on 04/20/16 at 4:23 PM the Administrator stated it was her expectation that all staff would be knowledgeable of the abuse and neglect policies in the facility and abide by them. She further stated nursing staff should have reported immediately when Resident #1's arm was restrained to the bed rail and when Resident #1 was sprayed in the face with the cleansing body lotion so it could have been investigated immediately. The facility Administrator, DON, hospital Administrator and hospital Vice President were notified of immediate jeopardy on 04/19/16 at 4:02 PM.

Based on record reviews and staff interviews the facility failed to develop a care plan with interventions to guide staff for handling a resident with inappropriate and combative behaviors during nursing care. As a result of the lack of care plan interventions the resident's arm was tied to the bed rail with a towel and secured with a plastic medical tape and he was sprayed in the face with a cleansing body lotion on 2 occasions for 1 of 1 resident sampled for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when Nurse #1 tied Resident #1's right arm to the bed rail with a towel and taped it with a plastic medical tape to secure it and Nurse #1 stated to NA #1 she had sprayed Resident #1 in the face with a cleansing body lotion due to his combative behavior during nursing care. The immediate jeopardy is present and ongoing. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited no behaviors. The MDS further indicated Resident #1 required extensive assistance for transfers, bathing and hygiene but was totally dependent on staff for bed mobility and toileting and had upper extremity impairment on one side. A review of the Care Area Assessments revealed behaviors did not trigger. A review of a quarterly MDS dated [DATE] indicated Resident #1 was severely impaired in cognition and exhibited no behaviors. The MDS further indicated Resident #1 was totally dependent on staff for activities of daily living and had upper extremity impairment on one side. A review of a care plan dated 02/15/15 titled [MEDICAL CONDITION]'s revealed Resident #1 was receiving [MEDICATION NAME] and [MEDICATION NAME] for behavior disinhibitions. The goal indicated resident's behavior will be managed by lowest possible dose of medications. The interventions were listed to observe for side effects of [MEDICATION NAME] such as anxiety, somnolence (drowsiness), dizziness or headaches and observe for side effects of [MEDICATION NAME] such as nausea, constipation, sedation and dizziness. The resident's care plan did not contain any interventions on what staff should do if the resident exhibited inappropriate or combative behaviors. A review of a care plan with a revised date of 02/17/16 tiled [MEDICAL CONDITION]'s indicated [MEDICATION NAME] was discontinued and Resident #1 was started on [MEDICATION NAME] and to continue goal that resident's behavior will be managed by lowest possible dose of medications. The interventions were listed to observe for side effects of [MEDICATION NAME] such dry mouth, sedation and somnolence. The resident's care plan did not contain any interventions on what staff should do if the resident exhibited inappropriate or combative behaviors. A review of a care plan with a revised date of 02/22/16 titled [MEDICAL CONDITION]'s indicated [MEDICATION NAME] and [MEDICATION NAME] were discontinued. A review of a care plan with a revised date of 02/29/16 titled [MEDICAL CONDITION]'s indicated [MEDICATION NAME] 25 milligrams was started for [MEDICAL CONDITION] disorder and the goal indicated that resident's behavior will be managed by lowest possible dose of medications. The interventions were listed to observe for side effects of [MEDICATION NAME] such as agitation, dizziness, dry mouth and constipation. The resident's care plan did not contain any interventions on what staff should do if the resident exhibited inappropriate or combative behaviors. A review of a facility document dated 03/30/16 titled Allegation of Resident Abuse/Restraint by the Administrator revealed a brief summary of interviews of staff. The document indicated on 03/01/16 NA #1 assisted Nurse #1 when they provided morning care to Resident #1. NA #1 assisted with providing peri care then left the room for a short period of time to do other duties. When she finished she noticed the door of Resident #1's room was closed so she went inside the room. When she entered the room she noticed Resident #1's right hand was tied to the bed with a towel and was taped and Nurse #1 was present in the room. NA #1 immediately began to remove the tape and towel to free his hand but Nurse #1 asked what she was doing. The document further revealed Resident #1 had applesauce on his face and a substance on his face that was dripping down the front of him. Nurse #1 stated she was trying to give Resident #1 his medications but he was not listening and restrained Resident #1's right hand to his bed rail with a pillowcase/towel and tape to protect herself and resident due to combative behavior. On 03/24/16 the DON met with NA #1 and she reported the incident that had occurred on 03/01/16. The document indicated on 03/04/16 Nurse #1 and NA #2 were attempting to get Resident #1 up out of bed with a sit to stand lift and over to a chair. Resident #1 became agitated and began hitting and spitting continuously and after he was transferred to his chair NA #2 turned and observed Nurse #1 as she sprayed Resident #1 in the face with cleansing lotion due to his spitting at her. NA #2 got a wet wash cloth and wiped Resident #1's face to get the lotion off. On 03/25/16 the DON met with NA #2 and she reported the incident that had occurred on 03/04/16 when Nurse #1 sprayed Resident #1 in the face with cleansing lotion. An attempt was made to contact Nurse #1 on 04/19/16 at 2:00 PM by phone but there was no answer and no option to leave a message. During an interview on 04/20/16 at 4:17 PM with the MDS nurse, who developed Resident #1's care plan for [MEDICAL CONDITION] medications on 2/15/16, she described herself as being new to the role of MDS and in the learning process of care plans. She explained she tried to combine care plans to cover individual areas for residents because otherwise a resident might have numerous care plans. The MDS nurse explained when [MEDICAL CONDITION] medications were added for Resident #1 a care plan for the use of [MEDICAL CONDITION] medications was developed on 02/15/16 and her goal with the interventions was to monitor the resident to determine if the medications were effective. She stated she didn't think about implementing interventions for nursing staff to deal with the behaviors and was unable to describe how a staff member would know or be able to handle Resident #1's behaviors from the care plan she had developed. She stated Resident #1 was not coded with behaviors on the admission MDS dated [DATE] and as a result no care plan for behaviors was developed at that time. She explained she developed the care plan on 02/15/16 for [MEDICAL CONDITION] medications when he was started on medications for the behaviors. During an interview on 04/20/16 at 2:58 PM the DON explained the MDS nurse created care plans and Resident #1 should have had a care plan for behaviors with interventions for staff to use when he exhibited behaviors. She stated interventions should have included for staff to step away or reach out for help from coworkers or supervisors when a resident exhibited behaviors or redirect residents when they exhibited behaviors or change staff members because sometimes different staff would calm the resident. The facility Administrator, DON, hospital Administrator and hospital Vice President were notified of immediate jeopardy on 04/20/16 at 5:11 PM.

Based on staff interviews and review of facility records, the facility administrative staff failed to create and impose a culture that all residents would be protected from extreme resident restraint and abuse and that staff would implement the facility's abuse policy and procedures to intervene, protect and immediately report abuse when witnessed. The facility failed to immediately notify the physician and responsible party when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail, failed to protect a resident's right to be free of physical restraint, failed to immediately report witnessed incidents of physical abuse and the failure to report placed other residents at risk for abuse. The facility also failed to operationalize policy and procedure when staff failed to immediately notify administrative staff of 2 witnessed incidents of physical abuse and failed to develop a care plan with interventions to guide staff for handling a resident with inappropriate and combative behaviors during nursing care for a combative resident who experienced 2 episodes of physical abuse without immediate facility intervention, protection and implementation of abuse policies and procedures for 1 of 1 sampled residents reviewed for abuse (Resident #1). Immediate Jeopardy began on 03/01/16 when NA #1 witnessed Nurse #1 had tied Resident #1's right arm to the bed rail with a towel that was taped with a plastic medical tape and Nurse #1 stated to NA #1 she had sprayed Resident #1 in the face with a cleansing body lotion due to his combative behavior and NA #1 failed to immediately report the incident to administrative staff. Immediate jeopardy is present and ongoing. The findings included: Cross refer to F 157 - Based on record reviews and staff and physician interviews the facility failed to immediately notify the physician and responsible party when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face with a cleansing body lotion for 1 of 1 sampled for abuse (Resident #1). Cross refer to F 221 - Based on observations, staff and physician interviews, police interview and record reviews the facility failed to protect a resident's right to be free of physical restraint when staff restrained a resident without medical symptoms. As a result a nurse restrained the resident's arm to the bed rail with a towel and secured the towel with a plastic medical tape when he became combative during care for 1 of 1 resident sampled for abuse (Resident #1). Cross refer to F 223 - Based on observations, staff and physician interviews, police interview and record reviews the facility failed to protect a resident's right to be free from physical abuse when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face on 2 occasions with a cleansing body lotion for 1 of 1 resident sampled for abuse (Resident #1). Cross refer to F 225 - Based on staff interviews and record reviews the facility staff failed to immediately report witnessed incidents of physical abuse and the failure to report placed other residents at risk for abuse. The facility staff failed to immediately report when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face with a cleansing body lotion on 2 occasions for 1 of 1 resident sampled for abuse (Resident #1). Cross refer to F 226 - Based on staff interviews and record reviews the facility staff failed to operationalize policy and procedure when staff failed to immediately notify administrative staff of 2 witnessed incidents of physical abuse when a resident became combative during nursing care and a nurse restrained the resident's arm to the bed rail with a towel and secured it with a plastic tape and sprayed the resident in the face with a cleansing body lotion on 2 occasions. The facility staff also failed to assess the resident for physical injury after both of these instances of staff abuse for 1 of 1 resident sampled for abuse (Resident #1). Cross refer to F 279 - Based on record reviews and staff interviews the facility failed to develop a care plan with interventions to guide staff for handling a resident with inappropriate and combative behaviors during nursing care. As a result of the lack of care plan interventions the resident's arm was tied to the bed rail with a towel and secured with a plastic medical tape and he was sprayed in the face with a cleansing body lotion on 2 occasions for 1 of 1 resident sampled for abuse (Resident #1).

Based on observations and staff interviews the facility failed to repair metal bumpers along the floor with exposed sharp metal edges on 2 of 2 resident wings (2 West Wing and 1 West Wing), repair resident doors with broken and splintered laminate and wood for 22 of 27 resident rooms (Resident room #134, #136, #137, #140, #141, #145, #146, #147, #148, #158, #159, #160, #164, #165, #237, #238, #239, #241, #257, #258, #259 and #260), failed to repair smoke barrier doors with broken and splintered laminate and wood on the edges of smoke barrier doors on 2 of 2 resident wings (2 West Wing and 1 West Wing) and failed to repair doors with broken and splintered laminate and wood for 2 of 2 tub room doors (2 West Wing and 1 West Wing). Findings included: 1. a. Observations during the initial tour of the facility on 2 West Wing on 12/28/15 at 9:30 AM revealed the floor bumper that ran down each hallway above the level of the floor to prevent walls from being damaged from equipment had missing rubber inserts which revealed sharp metal edges located across from elevators and next to resident rooms #237, #239 and #243. Observations on 2 West Wing on 12/29/15 at 10:50 AM revealed the floor bumper that ran down each hallway above the level of the floor to prevent walls from being damaged from equipment had missing rubber inserts which revealed sharp metal edges located across from elevators and next to resident rooms #237, #239 and #243. Observations on 2 West Wing on 12/30/15 at 8:30 AM revealed the floor bumper that ran down each hallway above the level of the floor to prevent walls from being damaged from equipment had missing rubber inserts which revealed sharp metal edges located across from elevators and next to resident rooms #237, #239 and #243. b. Observations during the initial tour of the facility on 1 West Wing on 12/28/15 at 12:18 PM revealed the floor bumper that ran down each hallway above the level of the floor to prevent walls from being damaged from equipment had missing rubber inserts which revealed sharp metal edges located across from elevators and next to resident rooms #135, #140, #143, #146, #147, #159 and #160. Observations on 1 West Wing on 12/29/15 at 11:10 AM revealed the floor bumper that ran down each hallway above the level of the floor to prevent walls from being damaged from equipment had missing rubber inserts which revealed sharp metal edges located across from elevators and next to resident rooms #135, #140, #143, #146, #147, #159 and #160. Observations on 1 West Wing on 12/30/15 at 11:10 AM revealed the floor bumper that ran down each hallway above the level of the floor to prevent walls from being damaged from equipment had missing rubber inserts which revealed sharp metal edges located across from elevators and next to resident rooms #135, #140, #143, #146, #147, #159 and #160. 2. a. Observations of Room #134 on 12/28/15 at 9:38 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:50 AM revealed the door of resident room #134 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:16 AM revealed the door of resident room #134 had broken and splintered laminate on the edges of the bottom half of the door. b. Observations of Room #136 on 12/28/15 at 9:39 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:52 AM revealed the door of resident room #136 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:17 AM revealed the door of resident room #136 had broken and splintered laminate on the edges of the bottom half of the door. c. Observations of Room #137 on 12/28/15 at 9:40 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:53 AM revealed the door of resident room #137 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:18 AM revealed the door of resident room #137 had broken and splintered laminate on the edges of the bottom half of the door. d. Observations of Room #140 on 12/28/15 at 9:41 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:55 AM revealed the door of resident room #140 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:19 AM revealed the door of resident room #140 had broken and splintered laminate on the edges of the bottom half of the door. e. Observations of Room #141 on 12/28/15 at 9:42 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:56 AM revealed the door of resident room #141 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:20 AM revealed the door of resident room #141 had broken and splintered laminate on the edges of the bottom half of the door. f. Observations of Room #145 on 12/28/15 at 9:43 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:57 AM revealed the door of resident room #145 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:23 AM revealed the door of resident room #145 had broken and splintered laminate on the edges of the bottom half of the door. g. Observations of Room #146 on 12/28/15 at 9:44 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:58 AM revealed the door of resident room #146 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:24 AM revealed the door of resident room #146 had broken and splintered laminate on the edges of the bottom half of the door. h. Observations of Room #147 on 12/28/15 at 9:45 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 10:59 AM revealed the door of resident room #147 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:25 AM revealed the door of resident room #147 had broken and splintered laminate on the edges of the bottom half of the door. i. Observations of Room #148 on 12/28/15 at 9:46 AM during the initial tour of the facility revealed the door of the resident's room had splintered laminate broken off on the edges of the bottom half of the door. Observations on 12/29/15 at 11:00 AM revealed the door of resident room #148 had splintered laminate broken off on the edges of the bottom half of the door. Observations on 12/30/15 at 11:26 AM revealed the door of resident room #148 had splintered laminate broken off on the edges of the bottom half of the door. j. Observations of Room #158 on 12/28/15 at 9:52 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:03 AM revealed the door of resident room #158 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:27 AM revealed the door of resident room #158 had broken and splintered laminate broken off on the edges of the bottom half of the door. k. Observations of Room #159 on 12/28/15 at 9:53 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:04 AM revealed the door of resident room #159 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:28 AM revealed the door of resident room #159 had broken and splintered laminate broken off on the edges of the bottom half of the door. l. Observations of Room #160 on 12/28/15 at 9:55 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:05 AM revealed the door of resident room #160 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:29 AM revealed the door of resident room #160 had broken and splintered laminate on the edges of the bottom half of the door. m. Observations of Room #164 on 12/28/15 at 9:56 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door and the door was scraped across the front. Observations on 12/29/15 at 11:06 AM revealed the door of resident room #164 had broken and splintered laminate on the edges of the bottom half of the door and the door was scraped across the front. Observations on 12/30/15 at 11:41 AM revealed the door of resident room #164 had broken and splintered laminate on the edges of the bottom half of the door and the door was scraped across the front. n. Observations of Room #165 on 12/28/15 at 9:58 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door and the door was scraped across the front. Observations on 12/29/15 at 11:07 AM revealed the door of resident room #165 had broken and splintered laminate on the edges of the bottom half of the door and the door was scraped across the front. Observations on 12/30/15 at 11:42 AM revealed the door of resident room #165 had broken and splintered laminate on the edges of the bottom half of the door and the door was scraped across the front. o. Observations of Room #237 on 12/28/15 at 9:30 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:09 AM revealed the door of resident room #237 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:12 AM revealed the door of resident room #237 had broken and splintered laminate on the edges of the bottom half of the door. p. Observations of Room #238 on 12/28/15 at 9:32 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:15 AM revealed the door of resident room #238 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:11 AM revealed the door of resident room #238 had broken and splintered laminate on the edges of the bottom half of the door. q. Observations of Room #239 on 12/28/15 at 9:33 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:17 AM revealed the door of resident room #239 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:10 AM revealed the door of resident room #239 had broken and splintered laminate on the edges of the bottom half of the door. r. Observations of Room #241 on 12/28/15 at 9:33 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:19 AM revealed the door of resident room # 241 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:09 AM revealed the door of resident room #241 had broken and splintered laminate on the edges of the bottom half of the door. s. Observations of Room #257 on 12/28/15 at 9:35 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:20 AM revealed the door of resident room #257 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:08 AM revealed the door of resident room #257 had broken and splintered laminate on the edges of the bottom half of the door. t. Observations of Room #258 on 12/28/15 at 9:36 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:21 AM revealed the door of resident room #258 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:07 AM revealed the door of resident room #258 had broken and splintered laminate on the edges of the bottom half of the door. u. Observations of Room #259 on 12/28/15 at 9:34 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:22 AM revealed the door of resident room #259 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:06 AM revealed the door of resident room #259 had broken and splintered laminate on the edges of the bottom half of the door. v. Observations of Room #260 on 12/28/15 at 9:35 AM during the initial tour of the facility revealed the door of the resident's room had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/29/15 at 11:24 AM revealed the door of resident room #260 had broken and splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:05 AM revealed the door of resident room #260 had broken and splintered laminate on the edges of the bottom half of the door. 3. a. Observations on 2 West Wing on 12/28/15 at 8:34 AM during the initial tour of the facility revealed the smoke barrier doors located on 2 West Wing at resident rooms #240 and #241 had rough and splintered edges with chipped laminate on the lower half of both doors. Observations on 12/29/15 at 11:16 AM revealed the smoke barrier doors located on 2 West Wing at resident rooms #240 and #241 had rough and splintered edges with chipped laminate on the lower half of both doors. Observations on 12/30/15 at 8:34 AM revealed the smoke barrier doors located on 2 West Wing at resident rooms #240 and #241 had rough and splintered edges with chipped laminate on the lower half of both doors. b. Observations on 1 West Wing on 12/28/15 at 9:35 AM during the initial tour of the facility revealed the smoke barrier doors located at room #133 revealed a large piece of splintered laminate which protruded outward on the edge of the lower half of the door. Observations on 12/29/15 at 10:45 AM revealed the smoke barrier doors located on 1 West Wing at room #133 had a large piece of splintered laminate which protruded outward on the edge of the lower half of the door. Observations on 12/30/15 at 8:34 AM revealed the smoke barrier doors located on 1 West Wing at room #133 had a large piece of splintered laminate which protruded outward on the edge of the lower half of the door. 4. a. Observations on 2 West Wing on 12/28/15 at 9:30 AM during the initial tour of the facility revealed the tub room door had splintered laminate on the edges of the bottom half of the door. Observations on 2 West Wing on 12/29/15 at 11:18 AM revealed the tub room door had splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 11:00 AM on 2 West Wing revealed the tub room door had splintered laminate on the edges of the bottom half of the door. b. Observations on 1 West Wing on 12/28/15 at 10:00 AM during the initial tour of the facility revealed the tub room door had splintered laminate on the edges of the bottom half of the door. Observations on 1 West Wing on 12/29/15 at 11:22 AM revealed the tub room door had splintered laminate on the edges of the bottom half of the door. Observations on 12/30/15 at 8:19 AM on 1 West Wing revealed the tub room door had splintered laminate on the edges of the bottom half of the door with a string caught in the splintered laminate. During an environmental tour and interview on 12/30/15 at 4:33 PM with the Director of Engineering and Operations and the Vice President, the Director of Engineering explained he made environmental care rounds in the facility on a routine basis. He stated they had a maintenance request system and staff could generate a request for repairs in the computer system and it was sent to himself and a maintenance supervisor. He explained the request also printed out in the maintenance shop and they prioritized when the repair would be completed. He stated if something needed immediate attention staff paged maintenance staff or called them when they were on call. He stated any staff could access the maintenance request system at any time but if something needed to be repaired on an emergency basis he expected staff to contact their supervisor and notify maintenance staff immediately. He further stated he expected for staff to notify him when they saw damage to doors or splinters on doors. He explained splinters should be removed and the edges of doors sealed when damaged. He confirmed the bumpers along the floors had missing rubber inserts which exposed sharp metal edges and they could not be repaired but would need to be replaced. He further stated he had not noticed or received any requests to repair the bumpers along the floors and had not received requests to repair the splintered laminate on resident doors, smoke prevention doors or tub room doors. During an interview on 12/30/15 at 5:15 PM with the Vice President he stated it was his expectation that the area in need of repair should be reported promptly by staff to the maintenance department. He explained the Director of Engineering and Operations had the authority to fix damaged items unless it involved a large capital expense and then it would be budgeted and prioritized. He stated he had instructed department managers to take ownership of their departments and they were expected to report things that needed repair and to ensure they were fixed. He explained all staff received instruction to report repairs that needed to be made in orientation and at their routine staff meetings. He stated he routinely asked for departments to submit lists of items that needed renovation or repairs and he and the Director of Engineering and Operations and the Environmental Services Director walked through the areas and prioritized lists of repairs. He further stated he was not aware of the sharp metal edges on the floor bumpers or the splintered laminate on resident doors, smoke prevention doors or tub room doors but expected for them to be fixed.

Based on observations, record reviews and staff interviews the facility failed to implement isolation precautions for a resident diagnosed with [REDACTED].#160) and failed to adhere to contact precaution guidelines for disposing of visibly soiled linens for 1 of 3 residents with contact precautions. (Resident #160). Findings included: 1. Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) available for the new admission. A review of a hospital discharge summary dated 12/22/15 indicated septic shock and[DIAGNOSES REDACTED] sepsis. The summary revealed Resident #160 had a series of complications after surgery and developed[DIAGNOSES REDACTED] and developed shock from that which was treated with [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) but was now just treated with [MEDICATION NAME]. A review of physician's orders [REDACTED].#160. A review of a facility document titled Adult Admission assessment dated [DATE] revealed Resident #160 was alert and cooperative. The assessment also indicated Resident #160 had diarrhea and was incontinent of urine. A review of a nurse's progress note dated 12/23/15 at 10:02 PM indicated Resident #160 was alert and oriented. A review of a nurse's note dated 12/25/15 indicated Resident #160 continued on [MEDICATION NAME] due to sepsis (infection throughout the body) from[DIAGNOSES REDACTED]. During an initial tour of the facility on 12/28/15 at 10:00 AM of Resident #160's room revealed there was no isolation precaution sign on the resident's door and there were no isolation supplies visible. A review of a physician's orders [REDACTED]. A review of an interim plan of care with a handwritten note at the bottom of the page dated 12/28/15 indicated[DIAGNOSES REDACTED] contact precautions. During an observation on 12/28/15 at 3:05 PM a contact isolation precaution sign was taped to Resident #160's door and isolation supplies were organized in a rack that hung on the outside of the resident's door. During an interview on 12/30/15 at 2:37 PM with the infection control nurse she explained when residents were admitted from the hospital with isolation precautions in place, the isolation precautions were supposed to be continued when the resident was admitted to the facility. She confirmed[DIAGNOSES REDACTED] had been identified for Resident #160 on 12/07/15 while she was in the hospital and the physician had ordered contact isolation precautions. She stated Resident #160 was discharged from the hospital and admitted to the facility on [DATE] and staff should have put her on contact isolation immediately upon admission. She explained she was unaware the contact isolation precautions had not been implemented because she was off from work for several days and when she returned to work on 12/28/15 she looked into it. She stated when she learned Resident #160 was not on contact isolation precautions she told staff to get her back on contact isolation precautions because Resident #160 was still having loose stools. She explained the hospital nurse who gave report to the nurse in the facility stated Resident #160 had a history of [REDACTED].#160 had an active case of[DIAGNOSES REDACTED]. During an interview on 12/30/15 at 3:47 PM with Nurse #3 who admitted Resident #160 on 12/23/15 she explained a nurse from the hospital called and gave her report on 12/23/15 before Resident #160 arrived. She stated the nurse told her Resident #160 had a history of [REDACTED].#160 was currently having diarrhea so she was not aware Resident #160 had active[DIAGNOSES REDACTED] upon admission to the facility. She explained she looked at Resident #160's admission packet when she arrived around 4:00 PM but didn't see anything in the papers about contact isolation precautions. She stated the nurse aide did not report to her Resident #160 had any diarrhea or loose stools during the shift and she did not question the antibiotics that had been ordered for Resident #160 related to infection. She further stated if the hospital nurse had reported to her Resident #160 was on isolation in the hospital she would have put Resident #160 on contact isolation precautions when she was admitted on [DATE]. During an interview on 12/30/15 at 4:39 PM with the Director of Nursing (DON) she stated it was her expectation for nursing staff to question when a resident was admitted to the facility with a history of[DIAGNOSES REDACTED] to find out if the resident currently had active[DIAGNOSES REDACTED]. She further stated she expected for nursing staff to find out if the resident was on contact precautions in the hospital and if so to put isolation precautions into place upon admission to the facility. During a follow up interview on 12/30/15 with the DON she explained she had identified when Resident #160 was discharged from the hospital the computer system resolved the physician's orders [REDACTED]. She stated if the contact isolation had been identified as active in the computer system instead of resolved, the admitting nurse could have seen the orders for contact isolation precautions when she completed Resident #160's admission orders [REDACTED] 2. Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) information available for the new admission. On 12/29/15 at 2:33 PM nurse #1 was observed exiting Resident #160's room wearing a personal protection gown and gloves; and in her hands she was carrying a towel wadded in a ball covered with light brown smears. Nurse #1 walked from Resident #160's room down the 1 West hall, passing the nurse's station and with her gloved hand punched the combination to the key-pad and enter the soiled linen room. On 12/29/15 at 2:35 PM nurse #1 was interviewed and explained that she had provided care for Resident #160 who was on contact precautions for[DIAGNOSES REDACTED] and had removed the soiled linens by carrying them down the hall to the soiled linen room wearing gloves and gown. The nurse stated the towels were soiled with feces. Nurse #1 added that she was trained to take a soiled linen barrel to a resident's room for disposing of soiled linens but failed to do so because she was in a hurry. Nurse #1 also stated that she should have removed her gloves when in the hallway and pushing the buttons on the key-pad of the soiled linen room. On 12/30/15 at 7:47 AM the Director of Nursing (DON) was interviewed and reported that she expected nurse's to adhere to infection control procedures for disposing contaminated linens by placing a soiled linen barrel outside a resident's room and disposing of the linens by placing them in the barrel. The DON explained that soiled linens should not be transported in the hallway by carrying them and that soiled gloves should not be worn in the hallway.