Every finding on record at Lakeside Health & Rehab Center

Based on observations and interviews, the facility failed to clean a circulatory fan cover in the walk-in refrigerator and prevent condensation from forming and dripping onto stored food, which resulted in water standing on the floor of the walk-in refrigerator. This issue was identified for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect food served to some of the 103 residents residing in the facility. The findings included:On 12/8/25 at 9:48 AM, an observation of the walk-in refrigerator was conducted with the Dietary Manager. The circulatory fan cover contained a thick build-up of gray/brown debris that was crumbly to touch and covered the entire fan cover. Condensation droplets were observed on the bottom of the circulatory fan and drops of condensation had fallen onto a covered container of sliced tomatoes stored directly under the circulatory fan. Additionally, standing water, brown in color, was present on the floor beneath the fan.On 12/8/25 at 9:54 AM the Dietary Manager stated she was not aware of the debris on the fan covers and would report it to maintenance. She also stated the condensation, and dripping water had not occurred prior to this day. She added the floor would be mopped. The Dietary Manager confirmed water should not drip onto stored food, and the affected food container was removed. The Dietary Manager stated she cleaned the walk-in refrigerator after each food delivery on Monday, and it was last cleaned on 12/1/25.On 12/10/25 at 11:55 AM, a follow up observation revealed the walk-in fan cover remained unchanged.On 12/10/25 at 12:38 PM, Dietary Manager reported a refrigerator company had been contacted on 12/8/25. A repair technician inspected the fan the same day and stated the fan cover would be cleaned by the company. The technician also ordered parts to repair the walk-in refrigerator door so it would close automatically, as prolonged door openings caused the condensation issue. The Dietary Manager stated the refrigerator company would clean the fan covers when notified.On 12/11/25 at 1:44 PM, the Administrator stated routine cleaning of the walk-in refrigerator cover should have been done. Additionally, she stated the condensation in the walk-in refrigerator should have been reported for repair to prevent dripping on stored food.

Based on observations, record review, and interviews with resident and staff, the facility failed to maintain a clean shower room for 2 of 3 shower rooms observed. The facility also failed to maintain a wheelchair in good repair for 1 of 4 residents reviewed for mobility devices (Resident #99). The findings included: 1.a. An observation conducted on 12/10/25 at 10:14 AM of the 100-hall shower room with the Environmental Service Manager revealed a black/gray substance covering the tile floor of the resident shower stall. The black/gray substance covered the surface area in the middle of the shower stall near the shower drain and extended up the right side of the shower wall leading to the shower control knobs. The black/gray substance was also observed in the cracks of the shower tile lining the shower stall. b. An observation and interview conducted on 12/10/25 at 10:25 AM of the 300-hall shower room with the Environmental Service Manager revealed a black/gray substance lining the cracks of the shower stall and around the middle shower drain. During an interview conducted at the time of the observation on 12/10/25 at 10:25 AM the Environmental Service Manager stated he had a total of five housekeeping staff members working in the facility from 7:00 AM until 6:30 PM. He stated it was the responsibility of the housekeeping staff member to clean the shower room on the assigned hall. The interview revealed he had experienced a call out and that he was assigned to the 100-hall shower room. He stated Housekeeping Staff Member #1 was assigned to the 300-hall shower room. The housekeeping staff were responsible for mopping the shower rooms daily and wiping down all hardware. The Environmental Service Manager stated he monitored the resident shower rooms daily for cleanliness; however, he had failed to monitor the shower rooms. He stated he had not been in the 100-hall shower room on 12/10/25 but had planned on cleaning it as part of his assignment. On 12/10/25 at 10:30 AM, an interview was conducted with Housekeeping Staff Member #1. During the interview, she stated she was assigned to the 300-hall shower room. She stated she cleaned the shower room daily and knew about the black/gray substance in the shower room; however, she did not have a cleaner that would remove the substance. A second observation was conducted of the 100-hall shower room on 12/10/25 at 10:48 AM. During the observation, the Environmental Service Manager was observed cleaning the 100-hall shower room, and the black/gray substance was easily removed using the daily cleaner located on all housekeeping carts. A follow-up interview was conducted on 12/10/25 at 10:55 AM with the Environmental Service Manager. During the interview, he stated Housekeeping Staff Member #1 was under the impression she could not remove the substance with the standard cleaner located on her housekeeping cart. However, that was what he used to clean the 100-hall shower room and was able to remove all of the substance from the tile. He stated the shower rooms should have been cleaned daily and that if Housekeeping Staff Member #1 had an issue, it should have been reported to him. On 12/10/25 at 1:57 PM, an interview was conducted with the Administrator. During the interview, she stated all shower rooms should be cleaned on a daily basis and inspected as necessary. 2. Resident #99 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #99 with intact cognition and his primary mobility devices were wheelchair and walker. Review of weekly skin assessment from 11/11/25 through 12/09/25 revealed Resident #99's skin was intact. During an observation conducted on 12/08/25 at 11:45 AM, Resident #99 was seen sitting in his wheelchair next to the bed in his room. The plastic vinyl covers of his bilateral armrests for the wheelchair were in disrepair with multiple torn spots, ripped edges, and cracked lines along the edges. Resident #99 was seen wearing a short-sleeved shirt and both of his arms were contacting with the torn and ripped armrests during the observation. An interview was conducted with Resident #99 on 12/08/25 at 11:47 AM. He stated the vinyl cover of his bilateral armrests for the wheelchair had been torn and ripped since he was admitted to the facility around 1.5 months ago. He added it caused itchiness and irritation to his bilateral arms at times. He indicated he used the wheelchair frequently and wanted the torn and ripped armrests to be fixed as soon as possible. During a joint observation conducted on 12/09/25 at 10:54 AM with Nurse #1 and Nurse Aide (NA) #1 in Resident #99's room, the plastic vinyl covers of bilateral armrests for Resident #99's wheelchair remained in disrepair. Nurse #1 assessed the skin condition of Resident #99's bilateral arms immediately and reported his skin was intact without any redness, rashes or open areas. A joint interview was conducted on 12/09/25 at 11:01 AM with Nurse #1 and NA #1. Both nursing staff stated they noticed the torn and ripped armrests of Resident #99's wheelchair but were unable to explain why they did not report the repair need to the maintenance staff. Both nursing staff acknowledged that the bilateral armrests of Resident #99's wheelchair were in disrepair and needed to be fixed immediately. During an interview conducted on 12/10/25 at 1:35 PM, the Assistant Maintenance Manager stated the Maintenance Manager was on leave and he currently oversaw facility maintenance. He identified repair needs mainly by work orders filed by nursing staff or through verbal notification. The Assistant Maintenance Manager indicated he typically did not check repair needs for residents' wheelchairs but expected nursing or rehabilitation staff to file a work order if they identified any repair needs. He acknowledged that Resident #99's torn and ripped armrests needed to be fixed immediately to avoid any skin issues. He further stated he checked work order logs located at each nurse station at least twice daily. He stated it was the responsibility of all staff to remain attentive to residents' mobility devices and report repair needs in a timely manner to ensure they were in good repair all the times. An interview was conducted on 12/10/25 at 3:21 PM with the Director of Nursing. She expected all the staff, including housekeepers and management staff to be more attentive to residents' repair needs and reported the findings to maintenance department in a timely manner. It was her expectation for all the mobility devices including wheelchairs to be in good repair all the time. During an interview conducted on 12/11/25 at 1:24 PM, the Administrator expected all the staff to report repair needs through the work order logs located at each nursing station or by verbal notification to ensure the maintenance staff could address the identified issues in a timely manner. It was her expectation for all the mobility devices to be in good repair all the time.

Based on record reviews and staff interviews, the facility failed to accurately complete a comprehensive assessment in the area of diagnoses for 1 of 22 resident assessments reviewed (Resident #10). The findings included:Resident #10 was admitted to the facility on [DATE]. Resident #10's diagnoses included congestive heart failure, end stage renal disease, atrial fibrillation (an abnormal heart rhythm), and hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease. A review of Resident #10's physician's orders revealed the following orders dated 11/18 25: - Midodrine (a medication used to treat low blood pressure) 5 mg by mouth three times daily.- Metoprolol (a beta blocker medication that treats congestive heart failure and atrial fibrillation) 25 mg by mouth daily. A care plan was initiated 11/18/25 for cardiovascular risk due to diagnosis of congestive heart failure (CHF) and the use of oxygen. The stated goal was Resident #10 would not exhibit respiratory distress through the review period. Interventions included administering medication as ordered, assessment to monitor for edema, elevation of edematous areas, and to monitor weight. An admission Minimum Data Set (MDS) completed on 11/24/25 was reviewed and heart failure was not coded as a diagnosis on the MDS. An interview with the MDS Coordinator was conducted on 12/10/25 at 2:26 PM. The MDS Coordinator stated that Resident #10 had a diagnosis of congestive heart failure. She stated that usually if a resident was not receiving any treatment, medication, or have any major symptoms of a diagnosis, it does not need to be coded on the MDS. The MDS Coordinator reviewed Resident #10's diagnoses and provider notes and stated it had been coded incorrectly. An interview with the Director of Nursing (DON) was conducted on 12/11/2025 at 10:25 AM. The DON stated that all MDS should be coded correctly for relevant diagnoses.

Based on observation, record review, and staff interviews, the facility failed to store ammonium lactate lotion (prescription-strength lotion), antifungal powder, and betadine solution (topical antiseptic solution) in a locked cart. These items were found unsecured on a resident's bedside table. This occurred for 1 of 5 residents reviewed for medication storage (Resident #64). Additionally, the facility failed to date one opened bottle of Latanoprost after it was opened and failed to store one bottle of Latanoprost in accordance with manufacturer's storage guidelines for 1 of 5 medication carts (600 Hall). The findings included: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and hidradenitis suppurativa (skin condition that causes chronic rashes and infections). Resident #64's quarterly Minimum Data Set, dated [DATE] coded Resident #64 with severe cognitive impairment. The MDS did not code the resident for ski problems or rashes. Resident #64's physician orders for December 2025 found no orders for the ammonium lactate lotion, antifungal powder, and betadine solution. Review of Resident #64's Medication Administration Record and Treatment Administration Record for December 2025 revealed the antifungal powder, ammonium lactate lotion, and betadine solution were not listed. On 12/8/25 at 11:10 AM, prescription medications were observed on Resident #64's bedside table. The bedside table contained an opened bottle of ammonium lactate 12% moisturizing lotion prescribed by an outside provider. The lotion contained a discard by date of 3/24/25. The beside table also contained an opened bottle of antifungal powder that was prescribed to another resident and an opened bottle of betadine solution. On 12/8/25 at 11:19 AM, Resident #64's assigned Nurse #2 was interviewed. Nurse #2 confirmed Resident #64 did not have an order for the antifungal powder, prescription-strength lotion, or betadine solution. She said Resident #64 did not have any treatment orders and she did not know why the items were on Resident #64's bedside table. Nurse #2 stated she had not yet given Resident #64 his medications and had not seen the antifungal powder, prescription-strength lotion, or betadine solution at his bedside. The nurse stated Resident #64 could not self-administer the antifungal powder, prescription-strength lotion, or betadine solution and they should be stored in the nurse's cart. Nurse #2 added the prescription lotion was probably brought to the resident from a family member without notifying a nurse. Nurse #2 removed the antifungal powder, prescription-strength lotion, or betadine solution from Resident #64's room. On 12/10/25 at 4:44 PM the Wound Nurse was interviewed. She stated the antifungal powder, prescription-strength lotion, or betadine solution should be kept locked in a cart and not left at bedside. The Wound Nurse stated Resident #64 did not have an active order for wound treatment and did not know why the resident had treatment supplies in his room. On 12/11/25 at 11:43 AM, the Director of Nursing stated the antifungal powder, prescription-strength lotion, or betadine solution should not be left at the bedside unless the resident had an order for self-administration of medications. Resident #64 did not have an order for self-administration, and the antifungal powder, prescription-strength lotion, or betadine solution should have been locked in a nurses or treatment cart. The Director of Nursing did not know why the antifungal powder, prescription-strength lotion, or betadine solution were left at bedside or who had brought them into the room. 2. A review of the manufacturer's package inserts for Latanoprost ophthalmic solution indicated that an unopened bottle must be stored under refrigeration at 36 degrees to 46 degrees Fahrenheit (F). Once a bottle of Latanoprost ophthalmic solution was opened for use, it could be stored at room temperature up to 77 degrees F for up to 6 weeks. During a medication storage audit conducted on 12/09/25 at 4:01 PM in the presence of Nurse #2, one unopened bottle of Latanoprost 0.005% eye drop stored at room temperature was found in the medication cart for 600 Hall. A review of the label on the bottle revealed its manufacturer's expiration date would be 12/2027. At the same time, one bottle of opened Latanoprost 0.005% eye drop was found in the same medication cart without an opened date and was available for use. An interview was conducted with Nurse #2 on 12/09/25 at 4:03 PM. She did not know how long the opened Latanoprost found in the medication cart for 600 Hall had been used and stored at room temperature. She explained that she just took over the medication cart and did not have time to check all the medications in the cart for proper storage yet. In addition, she did not know how long the unopened Latanoprost had been stored in the medication cart at room temperature. She stated that Latanoprost eye drops should be stored in the refrigerator when it was received from the pharmacy. Once it was opened, it should be dated and stored at room temperature for up to 42 days. During an interview conducted on 12/09/25 at 4:09 PM, Nurse #1 stated she was the nurse who worked the previous shift with medication cart for 600 Hall and explained she had just received the unopened Latanoprost from the pharmacy less than 1 hour ago. She stored the eye drop in the medication cart for the time being and planned to place it in the refrigerator later. She did not know who had opened the Latanoprost eye drops without putting an opening date and did not know how long it had been opened and stored at room temperature. She stated the opened Latanoprost should be dated once it was opened and stored in the medication cart at room temperature thereafter. An interview was conducted with the Director of Nursing (DON) on 12/09/25 at 4:14 PM. She stated it was her expectation for nursing staff to follow the facility's medication storage policy and procedure, and manufacturer's guidelines to date Latanoprost eye drops once it was opened and stored the unopened Latanoprost in the refrigerator until it was ready to be used. During an interview conducted on 12/10/25 at 11:24 AM, the Administrator stated it was her expectation for all the nursing staff to follow manufacturer's guidelines and the facility's medication storage policy and procedure when receiving and storing medication, including Latanoprost eye drops.

Based on observation, record review, and interviews with resident and staff, the facility failed to ensure dependent residents could access the light switch located behind the bed for 1 of 1 resident reviewed for accommodation of needs (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's medical record revealed she had stayed in room [ROOM NUMBER] since 08/16/23. The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #2 with a moderately impaired cognition. The MDS indicated walking between locations inside the room for more than 10 feet did not occur for Resident #2 during the assessment period. During an observation conducted on 09/23/24 at 3:44 PM, the switch cord for the light fixture on the wall behind Resident #2's bed was approximately 5 feet from the floor and 6-7 feet from the bed. The switch cord was approximately 4 inches in length. Resident #2 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #2 on 09/23/24 at 3:45 PM. Resident #2 stated she was bedbound and had been in this room for over a year. She could not recall when the switch cord broke. Resident #2 indicated she could not control the light fixture behind her bed as she could hardly stand up to reach the broken switch cord on the wall. She had to rely on nursing staff to control the light fixture and it was very inconvenient to her. Resident #2 wanted the maintenance staff to fix the switch cord to accommodate her needs as soon as possible. During an interview conducted on 09/23/24 at 3:57 PM, Nurse Aide (NA) #1 stated she noticed the switch cord for the light fixture behind Resident #2's bed was broken about 3 months ago. She notified the Maintenance Manager verbally on the same day. She did not know why it had not been fixed so far. Subsequent observations conducted on 09/24/24 at 11:38 AM revealed the switch cord for the light fixture behind Resident #2's bed remained inaccessible. During a joint observation conducted with Nurse #1 on 09/24/24 at 11:45 AM, the switch cord for the light fixture behind Resident #2's bed remained inaccessible from her bed. Nurse #1 acknowledged that the switch cord was broken, and it needed to be fixed immediately. She explained she was assigned to work in 700 halls at times and did not notice the switch cord was broken. An interview was conducted with Unit Manager #1 on 09/24/24 at 11:54 AM. She acknowledged that the switch cord for the light fixture behind Resident #2's bed was broken. It needed to be fixed immediately to ensure Resident #2 had full accessibility to the light fixture. During an interview conducted on 09/24/24 at 12:01 PM, the Maintenance Manager stated he walked through the entire facility at least once daily to identify repair needs. He did not notice the switch cord for Resident #2's light fixture behind her bed was broken and stated it was his oversight. In most cases, he depended on the staff to report repair needs by dropping the work orders in the boxes located in both nurse stations and by verbal notifications. He checked the work order boxes at least twice daily to ensure all repair needs were addressed in a timely manner. During an interview conducted on 09/26/24 at 8:56 AM, the Director of Nursing (DON) expected the staff to be more attentive to residents' living environment, and to report repair needs to the maintenance department in a timely manner to accommodate residents' needs. An interview was conducted with the Administrator on 09/25/24 at 4:33 PM. She expected nursing staff to pay attention to residents' home and report repair needs to the maintenance department in a timely manner. It was her expectation for all the dependent residents to have full accessibility and control of the light fixture behind the bed all the time.

Based on record review, observation and staff interviews the facility failed to follow a physician order to apply a splinting device for 1 of 2 residents (Resident #14) reviewed for range of motion. The findings included: Resident #14 was admitted to the facility on [DATE] with a diagnosis that included contracture to the left hand. Occupational Therapy (OT) discharge summary dated 11/02/2023 indicated recommendations that stated palm guard to left hand 8 hours to facilitate contracture management. On 09/25/2024 at 10:58 AM, an interview with the Director of Rehabilitation revealed on 11/2/2023 Occupational Therapy educated nursing how to don and doff the palm guard to the left hand of Resident #14. A physician order dated 04/04/2024 stated a palm guard should be applied to Resident #14's left hand every day for 8 hours as tolerated. A care plan dated 06/19/2024 revealed Resident #14 had limited physical mobility related to contracture, left-side hemiplegia, and history of stroke. The approaches included first shift Nursing Assistant (NA) to apply left palm guard for wear up to 8 hours as tolerated for contracture management, to monitor skin integrity and to notify nurse of any changes observed. Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment and one upper extremity impairment. Observation of and interview with Resident #14 on 09/23/2024 at 11:08 AM revealed her left hand to be contracted as evidenced by her fingernails touched the palm of her left hand. The left hand was further observed in a tight fixed position. Resident #14 did not have a palm guard to her left hand. At an additional observation at 11:56 AM, the left hand was observed not to have a palm guard. The palm guard was not observed in Resident #14's room. Resident #14 was unable to answer if staff applied the palm guard. Observation of Resident #14 on 09/24/2024 at 9:11 AM revealed her left hand did not have a palm guard. Additional observation on 09/24/2024 at 2:15 PM showed Resident #14 was up in the wheelchair without the palm guard to the left hand. Upon observation on 09/25/2024 at 10:00 am, Resident #14 did not have a left palm guard in place on her left hand when she was lying in bed. At 3:40 PM on 09/25/2024, the resident was up in a wheelchair and was not wearing a left palm guard. During an interview on 09/24/24 at 10:45 AM, Resident #14's Representatives indicated they had not seen the palm guard on Resident #14's left hand for months. During the interview with the Director of Rehabilitation on 09/25/24 at 10:58 AM, she shared a referral for OT was made on 09/18/2024 for self-feeding and increased difficulty with contracture. On 09/25/24 at 11:12 AM, an interview took place with Occupational Therapist #1 who assessed Resident #14 on 09/25/2024. The Occupational Therapist stated the referral had not indicated Resident #14 refused to wear the left palm guard. Occupational Therapist #1 disclosed the palm guard was not on Resident #14 when she entered the room. Occupational Therapist #1 saw the palm guard in a white basket on Resident #14's side table. She stated that the contracture was not worse on 09/25/2024 compared to her 11/02/2023 assessment. Interview with NA #2 on 09/25/2024 at 2:50 PM indicated he was assigned to care for Resident #14 and had never seen Resident #14's left palm guard. NA #2 stated that if he saw a palm guard on the resident that he would ask about it. An interview with Nurse #2 on 09/25/2024 at 11:23 AM revealed NA's were to apply Resident #14's palm guard daily. She further indicated that she had not checked to ensure that NA's applied the palm guard as ordered. Upon interview with the Director of Nursing (DON) on 9/26/2024 at 11:00 AM, the DON revealed the nurse should have visually identified if a resident's contracture device was applied correctly. She further stated Resident #14's palm guard should have been applied according to physician order and OT recommendations.

Based on record reviews and staff interviews, the facility failed to check a finger-stick blood sugar (FSBS) for 1 of 6 residents reviewed for unnecessary medications (Resident #311). The findings included: Review of the hospital discharge summary dated 2/21/2024 revealed Resident #311 had an order for Metformin (anti-diabetic medication) 500 milligrams (mg) twice a day. There were no orders for finger-stick blood sugar (FSBS) checks. Resident #311 was admitted to the facility on [DATE] with multiple diagnoses which included surgical repair of right hip fracture, diabetes, and asthma. Documentation on the care plan initiated 2/21/2024 revealed Resident #311 had diabetes mellitus with interventions to assess, document, and report to physician signs and symptoms of hypoglycemia (low blood sugar) such as sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggered gait. A review of the facility admission orders dated 2/21/2024 revealed Resident #311 had orders for Metformin 500 mg twice a day. There were no orders for FSBS checks. A review of the facility's physician admission history and physical dated 2/23/2024 revealed Resident #311 was admitted to the facility following a fall with a right hip fracture with surgical repair. Resident #311 was noted to be a non-insulin dependent diabetic receiving Metformin twice a day. Review of an additional physician order dated 2/23/2024 revealed Resident #311 had an order to check FSBS every morning and at bedtime starting 2/24/2024 and to notify physician if blood sugar less than 70 or greater than 299 milligrams/deciliter (mg/dl). HgbA1C (blood test that measures person's average blood sugar level over the past 2-3 months) was also ordered for 2/26/2024. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #311 was moderately cognitively impaired, required set up for meals and was totally dependent for toileting, bathing, dressing, and transfers. The MDS also revealed Resident #311 was receiving hypoglycemic medications. A review of the Point-of-Care Blood Sugar Summary report for Resident #311 revealed that no FSBS was obtained on the morning of 2/24/2024. Review of the Medication Administration Record (MAR) on 2/24/2024 revealed Resident #311 took all morning medications including Metformin as ordered by the physician. Review of the Medication Error Report dated 2/25/2024 revealed the physician had ordered FSBS to be obtained every AM and every PM for trending. Unit Manager (UM) #2 confirmed the order and did not add supplementary documentation so the order did not flow to the MAR and alert nursing to obtain the FSBS. An attempt to conduct a phone interview on 9/25/2024 with Nurse #3 was unsuccessful. Nurse #3 was assigned to Resident #311 on 2/24/2024. The phone number was no longer in service. A joint interview was conducted with the Administrator and the DON on 9/25/2024 at 2:34 PM. The DON stated that the order for Resident #311's FSBS did not contain the supplemental documentation so the order did not flow to the MAR which would have alerted the nursing staff to collect the FSBS. The Administrator stated that the facility had developed a robust educational plan which included demonstration of order entry with supplemental documentation that was required for all nursing staff. The facility provided the following corrective action plan with a completion date of 2/28/2024. Address how corrective actions will be accomplished for those residents to have been affected by the deficient practice: On 2/24/2024 the Director of Nursing became aware that the facility had failed to obtain a FSBS on the morning of 2/24/2024 as ordered by the physician for Resident #311. On 2/24/2024 the Director of Nursing audited Resident #311's chart and noted that on 2/23/2024, the physician entered orders for blood sugars to be obtained twice a day for monitoring starting the morning of 2/24/2024. The order was confirmed by UM #2, but she failed to ensure the supplemental documentation was ordered to ensure it fired out to the Medication Administration Record for the nurse to obtain the blood sugar as ordered. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 2/25/2024 the Regional Director of Clinical Services completed an audit of all orders of residents who required blood sugar monitoring to ensure the supplemental documentation was in the order and that the blood sugars were being monitored per orders. One additional order was identified that supplemental documentation was missing for blood sugar and was corrected immediately. Resident noted with no adverse side effects. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? On 2/25/2024 the Director of Nursing educated all Licensed Nurses via demonstration on entering orders requiring supplemental documentation to include blood sugars and when confirming orders to ensure supplementary documentation is in place if indicated. On 2/26/2024 the Regional Director of Clinical Services verbally instructed and demonstrated entering orders requiring supplemental documentation with the Medical Director. This education is already embedded into the Orientation for Licensed Nurses. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? An AD HOC Quality Assurance Performance Improvement Plan meeting was held on 2/27/2024 to determine the root cause analysis of the deficient practice, put a plan of action in place to ensure all orders requiring supplemental documentation are reviewed for accuracy. The monitoring for the plan was initiated on 2/29/2024 and completed on 4/29/2024 with no revision needed and a 100% compliance was achieved. The results of the monitoring will be brought to the Quality Assurance Performance Improvement meeting for the next 3 months, ending May 2024. Quality Improvement Monitoring schedule will be modified based on the findings of monitoring. Alleged Date of Compliance: 2/28/2024. The facility's corrective action plan with correction date of 2/28/2024 was validated onsite by observations, record reviews, and interviews with the Administrator, DON, Medical Director, and nursing staff. An observation was conducted during a medication pass for a FSBS collection on 9/25/2024. The FSBS was collected according to physician's orders at the correct time of day utilizing appropriate infection control measures. The results were documented in the Electronic Medical Record (EMR) correctly and no follow-up action was required by nursing. Interviews with nursing staff including Licensed Practical Nurses, (LPN), and Registered Nurses (RN) confirmed they had received education related to FSBS, order entry including supplemental order documentation, and confirmation of the supplemental documentation. The nurses were able to describe the order entry process including documentation of supplemental orders and verbalized understanding of the education received. Review of audit records revealed all residents receiving FSBS were audited by the DON for 8 weeks beginning 2/25/2024. Then monthly for 1 month to ensure all orders for FSBS had supplemental documentation and were being performed as ordered by the physician. The findings were reported to the Administrator and to the Quality Assurance Performance Improvement Committee monthly for 3 months for suggestions and/or recommendations; the quality improvement monitoring schedule will be modified based on finding of the monitoring. Interviews with the Administrator, Regional Director of Clinical Services, and the DON revealed the facility launched an in-service related to FSBS and supplemental documentation immediately after the incident to re-educate all licensed nurses. The Director of Clinical Services and the DON audited the supplemental orders for FSBS to ensure all orders contained supplemental documentation. The Administrator, Regional Director of Clinical Services, and the DON stated the interventions were successful as the facility did not have any further issues with FSBS and supplemental documentation standards. The corrective action plans completion date of 2/28/24 was validated.

Based on observations, staff interviews and record reviews, the facility failed to date a bottle of eye medication after it was opened and failed to discard 2 bottle of expired eye medications from the medication cart as specified by manufacturer's guidelines for 2 of 5 medication carts observed during medication storage checks (100 hall and 700 hall medication carts). The findings included: a. The manufacturer's package inserts for Latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between the temperature of 36 to 46 Fahrenheit (F) and protected from light. Once it was opened, Latanoprost could be stored at room temperature up to 77 F for up to six weeks. A medication storage audit was conducted on 09/24/24 at 2:46 PM for the 100 hall medication cart in the presence of Nurse #2. One opened bottle of Latanoprost 0.005% eye drops without an opened date was found in the medication cart at room temperature and available for use. An interview was conducted with Nurse #2 on 09/24/24 at 2:47 PM. She acknowledged that the bottle of Latanoprost eye drops was opened but did not know how long it had been stored in the medication cart. She was unsure how long Latanoprost could be stored under room temperature once it was opened. b. During a medication storage audit conducted on 09/24/24 at 3:01 PM for the 700 hall medication cart in the presence of Nurse #1, two opened bottles of Latanoprost 0.005% with opened date of 08/01/24 and 08/03/24 respectively were found in the medication cart and available for use. An interview was conducted with Nurse #1 on 09/24/24 at 3:01 PM. Nurse #1 stated both bottles of latanoprost should be discarded after they were opened and stored under room temperature for over 30 days. Nurse #1 explained she did not work in 700 hall on regular basis and most of her shifts were day shift. Nurse #1 further stated the eye drop was scheduled to be administered by nurses working night shift. During an interview conducted on 09/24/24 at 3:19 AM, Unit Manager #1 stated all 3 bottles of Latanoprost eye drops needed to be discard. She indicated all the nurses were instructed to check each medication for expiration before administration. In addition, as one of the Unit Managers, she checked each medication cart in her area at least once weekly and stated it was her oversight. She added many nursing staff were still unclear about the storage guidelines for Latanoprost, and they needed to be re-educated as soon as possible. During an interview conducted on 09/26/24 at 8:56 AM, the Director of Nursing (DON) stated it was her expectation for the nurses to remove all the expired medications from the medication cart according to manufacturer's expiration date and date the eye drops once it had been opened. An interview was conducted with the Administrator on 09/25/24 at 4:33 PM. She expected nurses to date latanoprost eye drops once it was opened and remove all expired medications from the medication carts. It was her expectation for the Unit Managers to check each medication cart at least once weekly to ensure the facility was free of expired medications.

Based on record review and resident and staff interviews the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested for 1 of 3 residents reviewed for dignity (Resident #1). The Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of hemiplegia and seizure disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact, required extensive assistance with toileting, and was always incontinent of bladder and bowel. No refusal of care was noted during the assessment reference period. Resident #1 was interviewed in his room on 08/08/23 at 10:30 AM. During the interview he stated he often had to wait 40 minutes or longer on staff to answer his call light when he needed to be changed. Resident #1 stated he had just soiled his brief 5 minutes prior to the surveyor speaking with him and proceeded to press his call light to request assistance from staff. The call light was observed on outside of the resident's door at 10:40 AM. An observation was conducted on 08/08/23 at 10:42 AM of Nurse Aide (NA) #1 came into Resident #1's room. She turned off his call light and asked the resident what he needed. Resident #1 stated, I need to be changed. NA #1 then stated to the resident that she would tell his assigned NA that he needed to be changed and exited the room. Resident #1's call light was observed to be off. Resident #1 stated to the surveyor, you see this happens all of the time, they will forget about me. An interview was conducted with Nurse #1 on 08/08/23 at 11:15 AM. He stated the NAs on the hall were good about assisting residents to the restroom. The interview revealed that any NA could assist each resident, it did not have to be the staff member directly assigned to the resident. After stating to Nurse #1 what had been observed and Resident #1 needed to be changed Nurse #1 stated it was typical for a resident to wait on average 30-40 minutes for incontinence care. He stated the NAs on the hall must just be busy. Nurse #1 was then observed pulling medication from the medication cart and proceeding to the other end of the resident hall. An ongoing observation was conducted on 08/08/23 from 10:49 AM until 11:30 AM of NA #1 walking by Resident #1's room but not reentering the room or looking for another NA to provide care for Resident #1. Resident #1 did not place his call light back on. On 08/08/23 at 11:30 AM the surveyor went and informed the Director of Nursing (DON) that Resident #1 had notified NA #1 at 10:40 AM he had soiled his brief and had still not been changed by staff. The DON immediately went to NA #2 who was in a room with another resident and told her that Resident #1 needed assistance. On 08/08/23 at 11:40 AM an observation was conducted of NA #2 providing incontinent care to Resident #1. While NA #2 was completing incontinent care it was noted Resident #1 had a small loose bowel movement and urinated in the brief. Resident #1's clothing was not soiled nor was the bed pad underneath him. No skin breakdown or redness was observed. Resident #1 was observed smiling, laughing, and joking with NA#2 stating, she takes care of me. Resident #1 was not observed in any distress. An interview conducted on 08/08/23 at 11:48 AM with NA #2 revealed NA#1 had never notified her that Resident #1 needed assistance. She stated she was assisting another resident with a shower and did not know until the Director of Nursing came and told her that the resident needed assistance. She stated she was on the split hall meaning she had several residents from 3 different areas in the building and had to rely on assistance from other NAs to let her know if someone needed care. NA #2 stated it was frustrating when other staff members did not tell her when someone needed to be changed and turned off their call light. She stated she had provided Resident #1 with a shower around 8:30 AM and assisted him back to bed. On 08/08/23 at 11:50 AM a follow up interview was conducted with Resident #1. During the interview he stated having to wait on assistance occurred at least once or twice daily in the facility. He stated it made him feel uncomfortable and forgotten about when he had to wait an hour for assistance to be changed. He stated he did not have any burning or pain on his bottom. On 08/08/23 at 12:17 PM an interview was conducted with NA #1. During the interview she stated she was in the middle of assisting a resident when she walked by Resident #1's room and saw the call light on. She stated Resident #1 told her he needed to be changed. NA #1 then stated she left the room and walked past NA #2 and told her the resident needed to be changed. NA #1 stated she never went back into Resident #1's room to check and see if he had received assistance because she was caring for her assigned residents. She stated she couldn't remember if NA #2 had acknowledged her or responded when she told her. NA #1 stated she had been told by the Director of Nursing if she saw a call light on to go into the room and turn off the call light regardless of if you provide the care, and to let the assigned staff member know what the resident needed. She stated she would assist other NAs if they needed a two person assist to get a resident out of bed but otherwise, she would let them know if a resident on their assignment needed incontinence care. On 08/08/23 at 1:30 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated she had told facility staff it was okay to turn the call light off as long as the staff member notified the assigned staff member a resident needed assistance. The DON stated NA #1 should have just changed Resident #1 herself when he told her he had soiled his brief. The interview revealed Nurse #1 could have also assisted Resident #1 with incontinence care. The DON stated Resident #1 should never feel like he had been forgotten about or have to wait an hour to be changed. On 08/08/23 at 1:50 PM an interview was conducted with the Administrator. She stated NA #1 should have provided incontinence care for Resident #1 and not turned off his call light until care had been provided. She stated Resident #1 should not have had to wait an hour on incontinence care and that the facility had just completed an in-service to staff on the days prior discussing the topic.

Based on record review resident interview and staff interviews, the facility failed to provide expedited dental care for a resident with broken dentures for 1 of 1 resident reviewed for dental services (Resident #12). As a result of Resident #1 not having her dentures she was unable to chew her physician ordered diet which resulted in decreased intake and weight loss. Findings included: Review of the facilities Dental Services Policy dated 11/28/17 and revised on 8/11/20 revealed the facility will promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If the referral could not be made within 3 days, the facility would document what was done to ensure the resident could still eat an drink adequately while awaiting dental services. Resident #12 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus, hyperlipidemia and seizure disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact and required extensive assistance of one staff member for most activities of daily living (ADL). The assessment revealed Resident #12 had no dental concerns noted. Review of Resident #12's care plan initiated on 1/13/23 revealed a focus on the activities of daily living (ADL) with no interventions related to dental care or dentures. Review of Resident #12's weight log revealed the following: 03/03/23: 162.8 pounds 03/22/23: 157.6 pounds 04/03/23: 152.0 pounds 05/03/23: 152.0 pounds A dental exam on 03/20/23 revealed Resident #12 had been seen at the facility for a broken lower denture. The recommendation was for impressions of new lower dentures to be made at a facility follow up appointment. A dental exam on 05/08/23 revealed Resident #12 was seen in the facility for upper and lower denture impressions. An interview conducted on 05/23/23 at 1:44 PM with Resident #12 revealed she hadn't had dentures in approximately 3 months. She stated she had previously had no issues with chewing prior to a Nurse Aide breaking her dentures in March 2023. The interview revealed she had upper and lower dentures in her mouth when Nurse Aide (NA) #3 removed the dentures from her mouth and took them into the bathroom to clean them. She stated as NA #3 was coming back into the room from the bathroom she dropped the bottom dentures onto the floor and broke the denture in half. Resident #12 stated she understood that it was an accident but never thought it would take so long to get the dentures fixed. She stated the facility had not provided her with soft food as she was receiving a regular diet and it was sometimes hard to chew what was served on her plate. The resident stated she felt it was ok though because the facility provided her with a supplemental shake with all of her meals. On 05/24/23 at 12:38 PM an observation was conducted of Resident #12 eating her lunch meal. Resident #12 was served a regular diet of smoked sausage, sauerkraut, peach cobbler, potatoes and a roll. Resident #12 was observed to have taken a few bites of the potato and drank a supplemental shake. An interview was conducted on 05/24/23 at 12:38 PM with Resident #12. She stated sauerkraut and smoked sausage was her favorite meal however she could not chew the sausage or sauerkraut. She stated the only thing on her plate she was able to eat was the sliced potatoes. Resident #12 stated, it's okay I have a supplemental shake to drink. On 05/24/23 at 12:47 PM an interview was conducted with NA #3. During the interview she stated on 03/08/23 she was cleaning Resident #12's dentures when she accidentally dropped them onto the floor and the bottom denture broke in half. She stated she told Nurse #6 that she had broken the residents' dentures. NA #3 stated she had since noticed Resident #12 having difficulty chewing her meals and had asked the resident if she would like a substitute meal that she could eat. She stated the resident always declined to have anything else served to her. On 05/24/23 at 12:57 PM an interview was conducted with Nurse #6. During the interview he stated he did not recall NA #3 telling him she had broken the residents' dentures but remembered Resident #12 telling him. He stated he let the Activities Director know of the incident and that the resident needed a dental appointment. Nurse #6 stated the resident could only eat soft food and had complained of dental pain after attempting to chew a piece of bacon which hurt her gums. He stated he knew Resident #12 was on the list to see the dentist and had been seen in May. An interview conducted on 05/23/23 at 3:30 PM with the Activities Director revealed Resident #12's dentures were broken on 03/08/23 by NA #3 while cleaning them. She stated the resident was seen by the dentist when they came into the facility on [DATE] and they recommended new dentures to be made. She stated she had faxed the forms to bill the resident's insurance on 03/28/23 and had been waiting for insurance approval for new dentures. She stated she had placed the resident on the routine dental appointment for the follow up of impressions and she was seen on 05/08/23 when the dentist came to the facility. The interview revealed she knew NA #3 had broken the dentures but didn't know the facility was responsible for replacing the dentures. The interview revealed the Activities Director did not know the resident was experiencing weight loss and did not need an expedited dental appointment for replacement dentures. A Nurse Practitioner (NP) note dated 04/24/23 revealed she had seen Resident #12 for a regulatory visit. In the note she documented Resident #12 had lost some weight due to losing her dentures but had an appointment on 05/08/23 to have the dentures replaced. An interview conducted with the Nurse Practitioner on 05/25/23 at 9:32 AM revealed she was new to the facility and didn't recall Resident #12. After reviewing the NP note she stated the resident must have mentioned something to her during the evaluation about a broken denture. The interview revealed the resident was receiving a supplemental dietary shake and the dentist was going to evaluate the resident on 05/08/23 so she wouldn't have had any further concerns at the time of the assessment. A Registered Dietitian (RD) note dated 05/04/23 revealed the resident had triggered for a weight warning during the monthly report. The note revealed Resident #12 had a regular diet in place and a mighty shake supplement three times a day was initiated. The note did not mention the resident having broken dentures. An interview was conducted with the Administrator on 05/24/23 at 11:21 AM. During the interview she stated the staff meet twice a day to discuss issues in the facility. She stated she did not recall the Activities Director notifying her that a staff member had broken the residents' dentures. The Administrator stated the facility would have been responsible for purchasing new bottom dentures for Resident #12 and would not have waited for insurance approval. The interview revealed she was not aware Resident #12 had experienced weight loss from the time of the dentures being broken and was not aware she was placed on a routine dentist visit list. The Administrator stated the resident should have received an expedited appointment to obtain a new set of dentures. She stated it was her understanding now that the resident was seen on 05/08/23 and the dentures were in the process of being made. The interview revealed Resident #12's weight loss had been discussed and she was evaluated by the Registered Dietitian, but the facility had not correlated the weight loss with her broken dentures. An interview conducted with the Director of Nursing (DON) on 05/25/23 at 4:19 PM revealed she found out on 05/24/23 that the broken dentures were due to a staff member dropping them. She stated she did not know it was a staff member that had broken the dentures prior to the surveyor discussing the situation. The DON stated if administrative staff had known it would have been the facilities responsibility to replace the dentures and would have gotten the resident an appointment at an earlier date. She stated she didn't know why it hadn't been clearly communicated. She stated the Speech therapist had seen the resident on 05/24/23 and downgraded her diet to mechanical soft and the resident stated she was doing better with the texture of the food. The DON stated the facility did track weight loss but what they looked at was the past 6 months and to her knowledge Resident #12 had not triggered on the report.

Based on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 3 of 21 residents reviewed (Resident #20, Resident #21, and Resident #60). The findings include: 1. Resident #20 was admitted to the facility on [DATE]. A review of Resident #20's most recent quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/24/23 revealed it was transmitted to CMS on 5/18/23. 2. Resident #21 was admitted to the facility on [DATE]. A review of Resident #21's most recent quarterly MDS assessment with an ARD of 1/13/23 showed it was transmitted to CMS on 5/18/23. 3. Resident #60 was admitted to the facility on [DATE]. A review of Resident #60's significant change assessment with an ARD of 3/31/23 revealed it was transmitted to CMS on 5/18/23. An interview on 5/24/23 at 3:42 PM with the MDS Coordinator revealed all MDS assessments with an ARD of 12/1/22 or later had been transmitted outside of the regulatory timeframe. The MDS Nurse said the assessments were transmitted late because following the change of ownership on December 1, 2022, she was informed by the Regional Clinical Reimbursement Specialist that there was not a state provider number, and the assessments could not be transmitted without one. The MDS Nurse reported on 5/18/23 she was told by the Regional Clinical Reimbursement Specialist to go ahead and transmit the assessments despite still not having the state provider number. An interview on 5/24/23 at 4:16 PM with the Regional Clinical Reimbursement Specialist revealed she had been informed by the Senior Reimbursement Specialists that the assessments could not be transmitted without the state provider number. She went on to say that she had been in communications with the State (RAI) Coordinator since December of 2022 and on 5/18/23 she was told by the Senior Reimbursement Specialist and the State RAI Coordinator to go ahead and submit the assessments without the state provider number. During an interview with the Senior Reimbursement Specialist on 5/25/23 at 10:33 AM she indicated the company was unaware that the assessments could be transmitted without the state provider number until the [NAME] President of the company was told by the Section Chief for the Nursing Home Licensure and Certification Section that per the RAI manual, they did not need a state provider number to do so. The only number the company needed to transmit assessments was the CMS certification number (CCN) because it did not change with ownership changes. The Senior Reimbursement Specialist went on to say the company would continue to transmit any new assessments and once they received the state provider number the MDS nurses would have to go back and modify those assessments by adding the number. An Interview on 5/25/23 at 5:03 PM with the Administrator revealed the MDS assessments should have been transmitted or at least attempted, even without the state provider number, prior to being told to do so on 5/18/23. The Administrator went on to say she was aware the MDS assessments had not been transmitted since December 2022 because she and the MDS Nurse were told by Corporate to not transmit the assessments without the state provider number.

Based on observations, record review, resident, staff and Nurse Practitioner interviews, the facility failed to apply compression stockings as ordered by the Nurse Practitioner for 18 days. The failure occurred for 1 of 1 resident (Resident #125) reviewed for the provision of care according to professional standards. The findings included: Resident #125 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypertension, protein calorie malnutrition and muscle weakness. Review of Resident #125's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired with no behaviors and could make all his needs known. The assessment also revealed Resident #125 required extensive to total assistance of one staff member with all activities of daily living except eating. Review of a request for treatment note written by Nurse #1 on 05/08/23 revealed Resident #125 had 2+ pitting edema (occurs when excess fluid builds up in body causing swelling; when pressure is applied to the area a pit or indention will remain) to lower extremities and complained of lower leg pain. Review of a progress note written 05/08/2023 by Nurse Practitioner #2 revealed staff and the resident reported increasing bilateral lower extremities edema. Resident #125 reported progressing in physical therapy and reported dyspnea (shortness of breath) with exertion and denied joint pain. The plan as written by Nurse Practitioner #2 was compression stockings for edema control, increase Lasix (medication used to reduce extra fluid in the body such as edema) from 20 to 40 mg daily and add potassium supplementation. The resident was advised to increase his water intake and to change positions slowly. Review of Resident #125's Medication Administration Record (MAR) revealed his Lasix was increased to 40 mg beginning on 05/09/2023 as ordered. Further review of the MAR revealed no order for compression stockings. Review of the Treatment Administration Record (TAR) revealed no order for the compression stockings. Review of the original order revealed it had been confirmed by Unit Manager #1. Observation and interview on 05/22/23 at 12:34 PM with Resident #125 revealed him sitting up in his wheelchair dressed with his legs resting on his bed in low position. The resident stated he was resting his legs up on the bed because of the swelling. He further stated he was supposed to have gotten some compression stockings for his legs to help with the swelling but said he had not seen them yet. He indicated the Nurse Practitioner had seen him and ordered them when she saw the swelling in his legs. Both feet and ankles appeared to be swollen. Observation and 5/24/23 at 2:56 PM with Resident #125 revealed him sitting in his wheelchair dressed with his leg resting on his bed in low position and no stockings on his legs. His feet still appeared to be swollen. Resident #125 stated he was still waiting on his compression stockings. A phone interview on 05/25/23 revealed Nurse Practitioner (NP) #2 was not aware that Resident #125 had not received compression stockings and said no one had reported it to her but it was time for her to see him again. NP #2 stated she was not familiar with the facility's policy with regard to compression stockings and was not sure why he had not received them but said she had not been notified there was an issue with getting him compression stockings. Interview on 05/25/23 at 3:17 PM with Nurse #2 who was assigned to care for Resident #125 on the 7:00 AM to 3:00 PM shift revealed she had never seen the resident with compression stockings on his legs. She stated she was not sure if the stockings were kept in Central Supply because she had not had a need to look for them. Nurse #2 further stated she was not aware he had an order for them and said it had not populated on his MAR or TAR for her to put them on him. She indicated the resident had 2+ pitting edema on his left leg and 3+ pitting edema on his right leg. Nurse #2 further indicated if she received an order for compression stockings, she would go to the Unit Manager for assistance and that was Unit Manager #1. Interview on 05/25/23 at 3:28 PM with Unit Manager #1 revealed when an order for compression stockings was written they make sure they have the right size in stock and if not, they were ordered. Compression stockings were kept in Central Supply in sizes medium, large, extra-large, extra, extra-large (2x) and extra, extra, extra-large (3x). After reviewing the order, Unit Manager #1 stated it had not populated because NP #2 had not scheduled times for the stockings to be placed on and taken off. When pointed out that Unit Manager #1 had confirmed the order, she stated she must have missed confirming the schedule with NP #2 to make the order populate in the electronic medical record (EMR). Unit Manager #1 indicated when the order was written by the provider it should have a specific schedule and the NPs were aware of that process now and said she had just missed correcting it when she confirmed the order. Interview on 05/25/23 at 4:59 PM with the Director of Nursing revealed she would have expected Resident #125 to be provided compression stockings and would have expected Unit Manager #1 to have verified the order with the provider and made sure all the information was there to make the order populate in the EMR so the nurses would put the stockings on and take them off as ordered. Interview on 05/25/23 at 5:02 PM with the Administrator revealed she would have expected Resident #125 to have gotten his stockings on the day they were ordered. She stated Unit Manager #1 should have clarified the order with the provider and provided the needed information for it to populate in the EMR.

Based on observations, record review, staff and Medical Director interviews the facility failed to comply with oxygen orders for 1 of 2 residents reviewed for respiratory care (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, chronic respiratory failure, and dependence on supplemental oxygen. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was not cognitively intact and was coded as receiving oxygen (O2). Review of revised care plan dated 01/13/23 revealed a care plan for oxygen where Resident #43 will not have signs or symptoms of poor oxygen absorption through the review date. Interventions included administer oxygen per orders, assess for signs and symptoms of respiratory distress and reports to physician as needed, monitor oxygen as ordered and/or as needed, monitor tops of ears for redness or breakdown due to use of oxygen tubing, head of bed at least 30 degrees to assist with breathing and for comfort, assist to keep oxygen tubing in place, and position to facilitate breathing. Review of physician order dated 01/11/23 revealed Resident #43 oxygen tubing and humidifier bottle to be changed once weekly every Saturday during night shift for routine monitoring and prevention. Review of May 2023 Medication Administration Record (MAR) revealed task for Resident #43 oxygen tubing and humidifier bottle to be changed every Saturday and signed off when completed. The MAR had been signed off on Saturday 05/06/23, 05/13/23, and 05/20/23 showing task had been completed. Observation on 05/22/23 at 11:48 AM revealed Resident #43's nasal canula and tubing and the humidifier bottle were both dated 05/14/23. Observation on 05/23/23 at 12:00 PM revealed Resident #43's nasal canula and tubing and the humidifier bottle were both dated 05/14/23. Observation on 05/23/23 at 4:20 PM RM revealed Resident #43's nasal canula and tubing and the humidifier bottle were both dated 05/14/23. An observation and interview were conducted with Nurse #3 on 05/23/23 at 4:45 PM revealed she was familiar with Resident #43 and had been responsible for her care on this date. Nurse #3 entered Resident #43 room with surveyor and observed the humidifier bottle was empty and was dated 05/14/23 and nasal canula and tubing connected to humidifier bottle was also dated 05/14/23. She stated Resident #43 humidifier bottle and tubing connected to humidifier bottle was ordered to be changed every Saturday to prevent bacteria from growing and helps to keep from humidifier bottle running out of water. She revealed when nursing staff change out humidifier bottle and tubing, they were supposed to date both and initial task on Resident #43's MAR. Nurse #3 stated Resident #43 humidifier bottle and tubing should have been changed out and dated by nursing staff this past Saturday 05/20/23 and she would change out humidifier bottle immediately. In an interview with the Medical Director (MD) on 05/24/23 at 3:05 PM revealed he was familiar with Resident #43 and that she required 2 liters of humidified oxygen at all times. He stated he had Ordered for Resident #43's humidifier bottle located on top of concentrator and tubing attached to humidifier bottle to be changed weekly because bacteria can develop inside of humidifier bottle and tubing that could cause infection if continuously breathing in. An interview was conducted with Director of Nursing (DON) on 05/25/23 at 4:20 PM revealed she was familiar with Resident #43 and her receiving oxygen. She stated she was not aware Resident #43's humidifier bottle and tubing had not been changed out per physician orders. She revealed nursing staff should be monitoring Resident #43 and making sure physician orders related to her oxygen care are being followed correctly. An interview was conducted with the Administrator on 05/25/23 at 5:05 PM revealed nursing staff should be following and documenting physician orders correctly for all residents related to oxygen.

Based on observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 10 rooms on the 300-hall reviewed for privacy. The findings included: Resident #31 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact for decision making. An observation and interview conducted with Resident #31 on 5/22/23 at 4:20 PM revealed Resident #31 was sitting in her wheelchair in front of the television in her pajamas. Resident #31 indicated she had not had a privacy curtain in a few months and when staff assisted her staff would close the roommates' curtain for privacy. Resident #31 stated she had told nursing staff prior and would prefer to have her own privacy curtain. The interview revealed the resident did not recall what staff member she had told and had not been exposed while getting care due to the lack of having a privacy curtain. An interview and observation conducted with Nurse Aide (NA) #1 on 5/25/23 at 9:55 AM revealed Resident #31 did not have a privacy curtain and she could not recall why. NA #1 further revealed if Resident #31 needs privacy she goes into the bathroom, or they pulled her roommate's privacy curtain. An interview and observation conducted with the Director of Nursing (DON) on 5/25/23 at 10:35 AM revealed Resident #31 did not have a privacy curtain. The DON stated all residents were expected to have a privacy curtain and Resident #31 needed one to ensure privacy when needed. An interview conducted with the Director of Housekeeping on 5/25/23 at 10:55 AM revealed housekeeping was responsible for checking residents' privacy curtains daily. The Housekeeping Director further revealed she was not aware Resident #31 did not have a privacy curtain and should have one. An interview conducted with the Administrator on 5/25/23 at 5:10 PM revealed she expected every resident to have a privacy curtain. The Administrator further revealed housekeeping checked resident rooms daily and should have been aware Resident #31 did not have a privacy curtain.

Based on record review, observation, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident reviewed for dialysis while a resident (Resident #17) and 1 of 3 residents reviewed for discharge status (resident #70). The findings included: 1. Resident #17 was readmitted on [DATE] with a diagnosis of end stage renal disease (ESRD) on hemodialysis 3 days a week on Monday, Wednesday, and Friday. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was marked for ESRD, but no was marked for dialysis while a resident. On the previous Quarterly MDS assessment dated [DATE], ESRD was marked as well as dialysis while a resident. During an interview with Resident #17 on 5/23/23 at 2:02 PM he revealed he attended dialysis and had no issues. He stated he attended dialysis 3 days a week. In an interview with the MDS Coordinator on 5/24/23 at 3:42 PM she reported dialysis while a resident should have been coded on the 4/27/23 MDS assessment. She stated that was something that should be coded and it was missed in error. 2. Resident #70 was admitted [DATE] and discharged from the facility on 4/6/23. Review of the discharge MDS assessment dated [DATE] revealed Resident #70 was marked as a planned discharge to an acute hospital with return not anticipated. Review of Social Worker note dated 4/6/23 indicated Resident #70 was discharged to another Skilled Nursing Facility (SNF) to be closer to family. During an interview with MDS Coordinator on 5/24/23 at 3:42 PM she reported Resident #70 was discharged to another SNF on 4/6/23 and not the hospital. She stated the discharge status on the MDS had been coded in error and discharge to another SNF should have been marked. An interview on 5/25/23 with the Administrator revealed she expected all MDS assessments needed to be coded accurately and reviewed for any errors prior to completion.

Based on observations, record review and interviews with family, residents and staff, the facility imposed a restricted visitation schedule that limited indoor and outdoor visitation of family and friends to 30 minutes per visit for 4 of 4 residents reviewed for visitation (Resident #61, #326, #75, and #10). Findings included: 1. The Resident Council Meeting minutes dated 06/29/21 read in part, visitation remains the same: virtual visits, window visits and indoor visits in the two visitation rooms, and outdoor visitation. All need to be scheduled and must be scheduled 24 to 48 hours in advance. Resident #61 was admitted to the facility 07/05/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] coded Resident #61 with severe impairment in cognition. Review of the Visit Schedule 07/17/21 to 07/27/21 revealed Resident #61's Responsible Party (RP) scheduled an indoor visit on 07/20/21 from 1:00 PM to 1:30 PM. During a telephone interview on 07/27/21 at 10:38 AM, Resident #61's RP voiced concerns regarding the facility's visitation schedule. The RP explained in order to visit with Resident #61, she had to schedule an appointment online and was only allotted 30 minutes to visit. She added, she was used to visiting with Resident #61 daily and it had been difficult not getting to spend more time with her. The RP stated the visitation slots filled up quickly and she had to schedule a visit in advance for next week just to make sure she would be able to visit with Resident #61 on her birthday. During an interview on 07/29/21 at 4:49 PM, the Social Worker (SW) revealed family members had been instructed to go online or call the facility to schedule an appointment for window, outdoor and indoor visits. The SW explained the visits were limited to 30 minutes each and to certain hours of the day and days of the week based on their schedule. She added the facility was aware visitation restrictions had been lifted but stated they had to manage visitation to give all families the opportunity to visit. During an interview on 07/29/21 at 6:04 PM, the Administrator indicated she was aware that visitation restrictions had been lifted; however, scheduling visits was their way of managing visitation capacity for all residents in the facility. 2. The Resident Council Meeting minutes dated 06/29/21 read in part, visitation remains the same: virtual visits, window visits and indoor visits in the two visitation rooms, and outdoor visitation. All need to be scheduled and must be scheduled 24 to 48 hours in advance. Resident #326 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Nursing Evaluation assessment dated [DATE] indicated Resident #326 was alert and oriented to person, place and time with no short or long term memory impairment. Review of the Visit Schedule 07/20/21 to 07/29/21 revealed the following: 07/26/21: Resident #61's Family Member (FM) scheduled an indoor visit from 12:00 PM to 12:30 PM. 07/27/21: Resident #61's FM scheduled an indoor visit from 4:00 PM to 4:30 PM. 07/28/21: Resident #61's FM scheduled an indoor visit from 4:00 PM to 4:30 PM. 07/29/21: Resident #61's FM scheduled an indoor visit from 4:00 PM to 4:30 PM. During an interview on 07/28/21 at 11:24 AM, Resident #326 revealed his family member had signed up for scheduled visitation at 4:00 PM all week and the visits were time-limited to 30 minutes; however, sometimes the visits did go a few minutes longer. Resident #326 stated he enjoyed the daily visits with his family member but they were never long enough. During an interview on 07/29/21 at 4:49 PM, the Social Worker (SW) revealed family members had been instructed to go online or call the facility to schedule an appointment for window, outdoor and indoor visits. The SW explained the visits were limited to 30 minutes each and to certain hours of the day and days of the week based on their schedule. She added the facility was aware visitation restrictions had been lifted but stated they had to manage visitation to give all families the opportunity to visit. During an interview on 07/29/21 at 6:04 PM, the Administrator indicated she was aware that visitation restrictions had been lifted; however, scheduling visits was their way of managing visitation capacity for all residents in the facility. 3. The facility's Visitation Plan updated on 5/2021 indicated: * Visitations will take place from 10 AM to 5 PM, Monday through Sunday, due to staffing needs and resident care. * Routine visits will be 30 minutes in duration to allow for other visits and safe cleaning time * Compassionate visits will be 1 hour in duration and will be scheduled through the Admissions Coordinator. A review of the Resident Council Meeting minutes dated 6/29/21 indicated: * Visitation remains the same: virtual visits, window visits and indoor visits in the visitation rooms (2) and then outdoor visitation. All need to be scheduled and must be scheduled 48 to 24 hours in advance. We also have compassionate visits which are based on an individual need. You may have had a compassionate visit due to health condition and then improved so the need for the compassionate visit is not needed anymore, so the other types of visitation should be scheduled. A review of the Visit Schedule from 7/17/21 to 7/28/21 indicated the following information: 7/17/21 - Resident #75's family member had a scheduled indoor visit from 1:00 PM to 1:30 PM and a window visit from 2:00 PM to 2:30 PM. 7/21/21 - Resident #75's family member had a scheduled indoor visit from 2:00 PM to 2:30 PM. 7/24/21 - Resident #75's family member had a scheduled indoor visit from 1:00 PM to 1:30 PM and a window visit from 2:00 PM to 2:30 PM. 7/28/21 - Resident #75's family member had a scheduled indoor visit from 12:00 PM to 12:30 PM and a window visit from 1:00 PM to 1:30 PM. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 was moderately cognitively impaired. An interview with Resident #75 on 7/28/21 at 10:12 AM revealed Resident #75 had a scheduled visit for 7/28/21 at 12:00 PM and at 1:00 PM. Resident #75 stated her visits from her family member were usually 30 minutes long, but they sometimes let her family member stay over if the next scheduled appointment cancelled. Resident #75 stated they usually do indoor visits in one of the rooms at the front. She added that her family member could only come when she had a day off and she had to set up a schedule before she could come visit. Her family member could not come on the days that she had to work because they did not have visitation after 4:00 PM. An interview with Resident #75's family member on 7/28/21 at 12:46 PM revealed she had concerns regarding visitation because she had to set up a schedule before she could come to the facility to visit Resident #75. Resident #75's family member stated the scheduled visits were only 30 minutes long although there had been times when they let her stay over if the next scheduled appointment had cancelled. She stated that she would like to visit Resident #75 every day but could not because she had to work, and she could only come after 4:00 PM on the days she had to work but the facility restricted visitation to 4:00 PM on weekdays and 2:00 PM on weekends. The facility was also not consistent with getting the visitation schedule posted online and she had to check often to be able to sign up because most slots got filled up quickly. Resident #75's family member also stated she was not sure why the Administrator was limiting visitation because she had read the last guidance regarding visitation and understood from it that family members should be allowed to visit at any time. She also said she did not understand why she couldn't visit Resident #75 in her room since both her and Resident #75 had been fully vaccinated for COVID-19. Resident #75's family member reported the last time she had been able to visit Resident #75 in her room was during a compassionate care visit when Resident #75 had been sick back in December 2020. She added that she had requested the Administrator to allow her to take Resident #75 outside for a walk while she pushed her in her wheelchair, but she was told to notify the Administrator the day before. She was concerned that whenever she called the facility, she might not be able to reach the Administrator and did not understand why she couldn't just let the staff members know when she wanted to take Resident #75 outside. Resident #75's family member further shared that she had been having to schedule both an indoor visit and a window visit on the same day just so she could have more time with Resident #75 rather than just 30 minutes which was not enough to spend quality time with her loved one. An observation was made on 7/28/21 at 2:41 PM of Resident #75 receiving a window visit with her family member at the front lobby. Resident #75 was sitting by the window in her wheelchair inside the facility while her family member sat outside the window. Resident #75 was talking to her family member through a cordless phone on speaker. There were two staff members in the front lobby where Resident #75's conversation with her family member was audible. An interview with the Social Worker (SW) on 7/29/21 at 5:49 PM revealed family members had been instructed to go online or to call the facility to schedule an appointment for window, indoor and outdoor visits. The SW stated the visits were limited to 30 minutes each and to certain hours of the day and days of the week based on their schedule. The SW stated that she had acted as the manager on duty on the weekends and had managed the visitations on Saturdays and Sundays. The SW said she was aware that Resident #75's family member had been scheduling an indoor visit and then a window visit afterwards because she wanted to spend extra time with Resident #75. The SW stated she had to make Resident #75 and her family member move over to the front lobby window after 30 minutes of indoor visitation because another family was scheduled to use the room. The SW agreed that Resident #75 and her family member did not have privacy during their window visit at the front lobby but did not think Resident #75 would go outside because it was hot. An interview with the Administrator on 7/29/21 at 6:04 PM revealed she had not been aware of concerns from Resident #75's daughter regarding the visitation schedule. The Administrator stated she knew that Resident #75's family member liked to spend time with Resident #75, and she would allow her to visit outside or in her room if the facility could prepare for the visit ahead of time. 4. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was severely cognitively impaired. Review of the Visit Schedule from 07/17/21 to 07/28/21 indicated the following information: 07/23/21 - Resident #10's Power of Attorney (POA) had a scheduled outdoor visit from 1:00 PM to 1:30 PM. Telephone interview on 07/26/21 at 11:36 AM with Family Member #1 revealed the visitation restrictions were tough for Resident #10 and for her. Family Member #1 stated Resident #10 was mostly non-verbal and could not use a phone so their only contact with the resident was through visitation. She further stated it had been a while since she had been to visit Resident #10 because she worked, and the visiting hours conflicted with her work schedule. Family Member #1 indicated there were too few slots online to sign up for visiting and outdoor visitation was hard on Resident #10 since it was hot outside. She further indicated she preferred to see the resident in her room so as not to make it so difficult for Resident #10. Family Member #1 said not being able to visit Resident #10 had caused a lot of stress on family members since she could not communicate via phone or virtually. Family Member #1 explained it was difficult for them not being able to see her. Telephone interview on 07/26/21 at 11:54 AM with Resident #10's Power of Attorney (POA) revealed she had only been able to visit the resident once in the last week because there were just too few opportunities online to sign up to visit. Resident #10's POA stated she had to take time off work to visit due to too few time slots for visitation. The POA further stated every time she looked online there were no slots available for visiting inside so she had to schedule visitation with Resident #10 outside. The POA explained she would like to visit Resident #10 in her room because it was hard for her to be taken to another location for the visit but had been told visits were not allowed in the room unless it was a private room with one resident. According to the POA, Resident #10 could not talk and could not use a telephone or tablet without assistance, and these did not provide privacy for them and the resident. An interview with the Social Worker (SW) on 7/29/21 at 5:49 PM revealed family members had been instructed to go online or to call the facility to schedule an appointment for window, indoor and outdoor visits. The SW stated the visits were limited to 30 minutes each and to certain hours of the day and days of the week based on their schedule. The SW further stated the facility was aware restrictions had been lifted but stated they had to manage visitation to give all families the opportunity to visit with their loved one. An interview with the Administrator on 7/29/21 at 6:04 PM revealed she was aware that restrictions on visitation had been lifted but making appointments was their way of managing visitation for all residents in the facility.

Based on observations and staff interviews, the facility failed to date an opened medication vial and discard an expired medication vial in 1 of 2 medication rooms ([MEDICATION(S)] Ridge) and failed to discard a single-dose medication vial and date an opened multi-dose medication vial in 2 of 5 medication carts (300 medication cart and Ashbury medication cart). The findings included: 1. An observation was made on 7/29/21 at 11:35 AM of the [MEDICATION(S)] Ridge medication room with Nurse #3. An opened and undated vial of [MEDICATION(S)], a medication used to aid in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Another opened vial of [MEDICATION(S)] dated 6/2/21 when it was opened was also in the medication refrigerator with half of the vial available for use. An interview with Nurse #3 on 7/29/21 at 11:40 AM revealed she was not sure when an opened vial of [MEDICATION(S)] expired but after inspecting the box of the medication, she read that it expired and should be discarded after 30 days of opening. Nurse #3 stated the opened undated vial of [MEDICATION(S)] should have been dated when it was opened, and the [MEDICATION(S)] vial dated 6/2/21 should have been discarded when it had expired. Nurse #3 stated that she had checked the medication room earlier in the morning for undated and expired medications but failed to notice the two vials of [MEDICATION(S)] in the medication refrigerator that were undated and expired. 2. An observation on 7/29/21 at 11:50 AM of the 300 hall medication cart with Nurse #3 revealed an opened and undated vial of [MEDICATION(S)], a medication used to prevent and treat nausea and vomiting, with one-fourth of the medication available for use in the top drawer of the medication cart. During the observation, an interview with Nurse #3 on 7/29/21 at 11:50 AM revealed the vial of [MEDICATION(S)] was a single-use vial and should have been discarded after use. Nurse #3 stated she had checked the 300 hall medication cart earlier in the morning but did not see the undated and opened vial of [MEDICATION(S)]. 3. An observation was made of the Ashbury medication cart on 7/29/21 at 12:05 PM with Nurse #3 and Nurse #4. An undated opened multi-dose vial of [MEDICATION(S)], an anesthetic use to prevent and to treat pain from some procedures, was observed in the third drawer of the medication cart with half of the medication available for use. An interview with Nurse #3 and Nurse #4 on 7/29/21 at 12:05 PM revealed the [MEDICATION(S)] vial was used to dilute an antibiotic injection for Resident #62 and she had just received 2 out of 7 doses of her antibiotic therapy. Nurse #4 stated she had not given Resident #62 her antibiotic injection because it was scheduled to be given on the evening shift once a day. Nurse #3 stated the [MEDICATION(S)] vial expired after 30 days of opening, but it should have been dated when it was opened. Nurse #3 added she had checked the Ashbury medication cart earlier in the morning for undated medications but failed to notice the undated opened vial of [MEDICATION(S)]. An interview with the Director of Nursing (DON) on 7/29/21 at 5:20 PM revealed all medication vials should be dated when they were opened, and all expired medications should be discarded. The DON stated any unused medication in a single-use medication vial should be discarded as well. The DON shared that Nurse #3 was responsible for checking all the medication rooms and the medication carts and should have observed the undated and expired medications in the medication room refrigerator and the medication carts.

Based on observations, record review, resident and staff interviews, the facility failed to provide nail care for 1 of 2 dependent residents (Resident #64) reviewed for activities of daily living. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #64's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired for daily decision making; however, he was able to make his needs known. The MDS assessment further revealed Resident #64 required extensive assistance of one staff member with personal hygiene and required total assistance of one staff member with bathing. According to the assessment the resident did not refuse any care during the assessment period. Review of Resident #64's care plan dated 07/01/21 revealed he was care planned for needing extensive assistance with personal hygiene and total assistance with bathing. Interventions included resident preferred showers and resident was 2 assists with all activities of daily living. Review of the facility Shower Schedule by Resident Room revealed Resident #64 was scheduled for showers on 1st shift (7:00 AM to 3:00 PM) every Wednesday and Friday. Observation on 07/26/21 at 11:06 AM of Resident #64 revealed he was lying in bed in his room, dressed for the day. Observation of his right hand revealed the hand was contracted inward toward his palm and his thumb, middle, fourth and fifth fingers were noted to have nails extending 1/4 to 1/2 inch beyond the end of his finger. The middle and fourth fingernails were noted to be in touch with the palm of his right hand. Interview with Resident #64 at the time of the observation, revealed he was concerned about the nails digging into his palm and said he preferred for his nails to be short. Observation and interview on 07/27/21 at 10:18 AM with Resident #64 revealed the nails on his right hand remained 1/4 to 1/2 beyond the end of his fingers and resident again stated he preferred for them to be short and not extend beyond the end of his fingers because his hand was contracted. According to Resident #64 no one had offered to cut his nails and stated he had not refused to have them cut. Observation and interview on 07/28/21 at 10:41 AM with Resident #64 revealed the nails on his right hand remained 1/4 to 1/2 inch beyond the end of his fingers and the resident stated he preferred for them to be short. Resident #64 stated no one had offered to cut them but stated maybe they would cut them after his shower today. Observation and interview on 07/29/21 at 11:15 AM with Resident #64 revealed the nails on his right hand remained 1/4 to 1/2 inch beyond the end of his fingers and the resident said no one offered to cut his nails yesterday after his shower. The resident stated he preferred them to be short and no one had offered to cut them for him. Interview on 07/29/21 at 11:32 AM with Nurse Aide (NA) #1 revealed she was taking care of Resident #64 today during the 7:00 AM to 3:00 PM shift. NA #1 described shower days for residents included assisting the resident as needed with washing their body and hair, shaving men and women as requested, drying them off after their shower and applying lotions and creams as needed and requested. NA #1 stated in addition if the resident did not have diabetes and needed their fingernails and toenails clipped, they clipped them while the resident was in the shower. NA #1 further stated if the resident had diabetes and needed their nails clipped, she would report the need to this to the nurse and she would trim the nails for the resident. NA #1 indicated she had not noticed Resident #64's nails being long, but when shown his nails admitted they needed to be cut and said she would notify the nurse to trim them since he had diabetes. Interview on 07/29/21 at 12:17 with the Director of Nursing (DON) in Resident #64's room revealed when she observed the resident's nails on his right hand, agreed they needed to be trimmed. The DON stated she was not sure if someone had offered to trim them and the resident had refused; however, she stated the nails should have been trimmed to avoid them causing pressure to his palm. Interview on 07/29/21 at 12:26 PM with Nurse #1 who had been assigned to Resident #64 all week revealed NA #1 had just told her Resident #64 needed his fingernails trimmed. Nurse #1 stated she had not noticed Resident #64's fingernails needing trimmed this week while caring for him and said no one prior to today had mentioned to her the resident's fingernails were long and needed to be trimmed. Phone interview on 07/29/21 at 1:37 PM with NA #2 who had given Resident #64 his shower on Wednesday 07/28/21 revealed she had not trimmed his nails yesterday after his shower because he had not wanted them to be trimmed. NA #2 stated she could not trim Resident #64's nails without permission from the nurse since he had diabetes and said she had not asked Nurse #1 about trimming his nails after his shower and had not told Nurse #1 Resident #64 had refused to let her trim his nails. A follow up interview on 07/29/21 at 3:00 PM with Nurse #1 revealed NA #2 had not told her Resident #64's nails needed to be trimmed. Nurse #1 further revealed NA #2 had not mentioned to her he had refused to have his nails trimmed. Nurse #1 stated if NA #2 had told her after Resident #64's shower his fingernails needed to be trimmed, she said she would have trimmed them on 07/28/21 after his scheduled shower. The nurse further stated if NA #2 had asked permission to trim the resident's fingernails she would not have given her permission because Resident #64 was diabetic. A follow up interview on 07/29/21 at 3:08 PM with Resident #64 revealed NA #2 had not offered to cut his fingernails after his shower on 07/28/21 and stated he had not refused to have his fingernails cut because he liked for them to be short. Interview on 07/29/21 at 5:25 PM with the Director of Nursing (DON) revealed NAs were not allowed to cut nails for residents with diabetes and said they should all know to notify the resident's nurse the nails needed to be trimmed. The DON further revealed she would have expected the NAs or nurses to have noticed before today Resident #64 needed his nails trimmed especially since his hand was contracted.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and procedures when 2 of 3 staff members (Nurse #4 and Nurse #1) failed to disinfect a glucometer according to manufacturer's recommendations after use on 2 of 3 residents (Resident #62 and Resident #28) reviewed for infection control. The findings included: A review of the facility's policy entitled, Glucometers - Use, Storage and Cleaning of dated 4/2020 indicated: *Glucometers are to be disinfected with an EPA (Environmental Protection Agency) registered Detergent/Germicide after each use whether shared or not. A review of the facility's glucometer (Assure Platinum) manufacturer's instructions indicated the following statements regarding how to clean the meter and how often: *Cleaning can be accomplished by wiping the meter down with soap and water or isopropyl alcohol but will not disinfect a meter. Disinfecting the meter can be accomplished with an EPA registered disinfectant detergent or germicide that is approved for healthcare settings or a solution of 1:10 concentration of sodium hypochlorite (bleach). Do not clean inside the battery compartment or test strip port. In accordance with CDC (Centers for Disease Control and Prevention) guidelines, we recommend that the Assure Platinum meter be cleaned and disinfected after each use for individual resident care. 1. An observation was made on 7/28/21 at 11:35 AM of Nurse #4 while she checked Resident #62's blood sugar. Nurse #4 wiped the glucometer with an alcohol prep pad prior to going into Resident #62's room. Nurse #4 washed both hands, put gloves on and wiped Resident #62's left third finger with an alcohol prep pad prior to sticking it with a lancet. Nurse #4 placed a drop of blood into the strip that was inserted in a glucometer and obtained the blood sugar reading. Nurse #4 went back to the medication cart, placed the glucometer on top of the medication cart and discarded the used lancet in a sharp's container. She pulled out an alcohol prep pad out of the top drawer of the medication cart and wiped the front and back of the glucometer for about five seconds, placed the glucometer into a small plastic bag and locked it in the top drawer of the medication cart. Another observation was made on 7/28/21 at 11:45 AM of Nurse #4 checking Resident #28's blood sugar. Nurse #4 pulled out Resident #28's glucometer from the medication cart and wiped it with an alcohol prep pad. She entered Resident #28's room, washed her hands and put gloves on. Nurse #4 cleaned Resident #28's left thumb with an alcohol wipe and then stuck it with a single use lancet. Nurse #4 applied a drop of blood into the strip that was inserted in a glucometer. After the reading registered in the glucometer, Nurse #4 removed her gloves, washed her hands and started walking towards the medication cart while holding the glucometer and other supplies used to check Resident #28's blood sugar. Nurse #4 discarded her gloves in the trash can and disposed of the lancet in the sharp's container. She then applied another set of gloves and pulled out an alcohol prep pad from the top drawer of the medication cart and started wiping the front and back of the glucometer which took about five seconds. Nurse #4 placed the glucometer which was still wet back into a clear plastic bag and locked it in the medication cart. An interview with Nurse #4 on 7/28/21 at 12:02 PM revealed she had been used to cleaning the glucometer prior to and after use with an alcohol prep pad and that she had not been instructed to disinfect the glucometer with a disinfectant wipe after use. 2. An observation was made on 7/28/21 at 4:10 PM of Nurse #1 while she checked Resident #28's blood sugar. Nurse #1 cleaned Resident #28's left second finger with an alcohol prep pad and stuck it with a lancet. She placed a drop of blood into a strip that was inserted in the glucometer and obtained Resident #28's blood sugar reading. Nurse #1 walked back to the medication cart, placed the glucometer into the top drawer of the medication cart, disposed of her gloves and used a hand sanitizer. When Nurse #1 was asked if she was going to disinfect the glucometer, she stated she was not sure about the facility's glucometer disinfection policy but she was going to ask another nurse. Nurse #1 went back to the nurses' station where she obtained instructions from Nurse #4 on how to clean the glucometer. Nurse #4 instructed Nurse #1 that it was acceptable to use an alcohol prep pad after using the glucometer. Nurse #1 went back to the medication cart, pulled out the glucometer and wiped it front and back with an alcohol prep pad. She then placed it back into the top drawer of the medication cart. An interview with the Assistant Director of Nursing (ADON) on 7/28/21 at 6:10 PM revealed he was currently being trained to take over the facility's infection control program and stated that glucometers could be cleaned and disinfected using alcohol and other EPA-registered disinfectants. The ADON stated that he had read somewhere that alcohol was approved to be used to disinfect glucometers. An interview with the interim Infection Preventionist (IP) on 7/29/21 at 9:21 AM revealed it was acceptable to use alcohol to clean the glucometers because they were not being shared between different residents. The interim IP stated the glucometers should only be cleaned and did not need disinfection unless visibly soiled and had blood on it. She further stated she believed the glucometers did not need disinfection after each use because each resident had their own glucometer. An interview with the Director of Nursing (DON) on 7/29/21 at 5:20 PM revealed the facility assigned single glucometers to each resident and they should be cleaned and disinfected using an EPA-registered disinfectant wipe which should be available in the bottom drawer of each medication cart. The DON stated the nurses should have followed the glucometer's manufacturer's guidelines and used an EPA-registered wipe and not just an alcohol prep pad to disinfect the glucometers after using them.

Based on record reviews, observations, and interviews with staff and a Health Department nurse, the facility failed to implement enhanced droplet contact precautions and require staff to wear all recommended Personal Protective Equipment (PPE) when caring for 8 of 8 newly admitted residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) and cohort and quarantine 3 of 8 newly admitted residents (Resident #2, Resident #3 and Resident #5) on the designated quarantine hall (600 hall) and assign dedicated staff to care for the residents on the quarantine hall (600 hall). The facility also failed to have updated COVID-19 policies and procedures for new admissions current with Centers for Disease Control (CDC) guidance and Centers for Medicare and Medicaid (CMS) requirements. These failures occurred during a COVID-19 pandemic. Immediate Jeopardy began on 09/15/2020 when the facility failed to place newly admitted residents on enhanced droplet contact precautions and failed to cohort and quarantine the newly admitted residents on the designated quarantine hall (600 hall) and failed to have updated COVID-19 policies and procedures in place for new admissions current with CDC guidance and CMS requirements. Immediate jeopardy was removed on 09/26/20 when the facility implemented a credible allegation of compliance for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: The CDC guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes last reviewed and updated on 04/30/20 indicated the following statements: * Place signage at the entrance to the COVID-19 unit that instructs healthcare personnel (HCP) they must wear eye protection and an N95 or higher-level respirator (or facemask if respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. * All recommended COVID-19 PPE should be worn during care of residents under observation which includes use of an N95 or higher-level respirator (or facemask if respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. * A single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted resident should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. * New residents could be transferred out of the observation (quarantine) area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). A review of the facility's COVID-19 Policy and Procedure updated April 2020 for Admission of Residents During Pandemic read in part: A resident admitted without symptoms of and without testing will be considered potentially positive and will be placed on isolation and quarantined in a single room for 5 days. Admissions requiring infection control restrictions will be placed on appropriate isolation precautions based on this facility's policies governing isolation precautions for COVID-19. During the entrance conference on 09/23/20 at 9:30AM, the Administrator indicated the 600 hall was the quarantine hall for COVID-19. A review of the facility's list of Admissions from 09/02/20 to 09/23/20 indicated: 1. Resident #1 was admitted from the hospital on [DATE] to a private room on the 600 hall. A review of her medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative and a COVID-19 test at the facility on 09/21/20 which was negative. There was signage on the door that read 14 Day COVID Watch but no signage regarding enhanced droplet/contact precautions and no PPE available outside the door. Observations of the 600 hall on 09/23/20 at 10:38AM revealed no residents on enhanced droplet/contact precautions and no PPE supplies available for use outside any of the resident doors except Resident #8 who was on contact precautions. NA #1 and NA #2 were observed on 09/23/20 at 10:40AM wearing a mask and gloves while providing care to Resident #1 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. An interview on 09/23/20 at 11:00AM with NA #1 and NA #2 at 10:48 AM revealed their understanding of the 14 Day Watch was the resident was monitored by the nurse for any signs and symptoms of COVID-19. NA #1 and NA #2 further stated they understood they were not required to wear any PPE in the room except their mask and gloves when providing care. They both indicated they had not worn any eye protection or gown while providing care to the residents on the 600 hall. An interview on 09/23/20 at 11:00AM with Nurse #2 on the 100 hall revealed the residents on 14 Day Watch were newly admitted or had gone out for [MEDICAL TREATMENT] or doctor visits and the sign was put up as an extra precautionary measure they provided the residents. She stated it did not require any special equipment other than a mask and gloves when providing care and stated the residents were monitored for respiratory status each day and vitals and temperature at least twice a day. An interview on 09/23/20 at 11:10AM with Nurse #1 on the 600 hall revealed her understanding of the 14 Day Watch was they were to monitor the residents for any signs or symptoms of COVID-19 and report them immediately to the nursing supervisor or Assistant Director of Nursing. The Nurse further stated it was her understanding she only needed to wear a mask and gloves while providing care to the newly admitted residents on the 600 hall because they had a negative COVID-19 test at the hospital prior to their admission. Nurse #1 indicated they were obtaining a respiratory assessment and pulse oximetry daily and temperature twice daily on the new admissions and were not required to use PPE other than a mask and gloves when taking care of the residents. 2. Resident #2 was admitted from home on 09/23/20 to a semi-private room on the 400 hall with a roommate. A review of his medical record revealed the resident had a COVID-19 test upon admission to the facility on [DATE] which was negative. There was no signage on the door and no PPE available outside the door. Observations of the 400 hall on 09/23/19 at 9:40AM revealed Resident #2 in room [ROOM NUMBER]-B and Resident #5 in room [ROOM NUMBER]-A were not quarantined on the 600 hall and were not placed on enhanced droplet/contact precautions with available PPE outside the door. Nurse #3 was observed on 09/23/20 at 9:42AM administering medications with a mask and gloves only to the residents in room [ROOM NUMBER]. An interview on 09/23/20 at 9:50 AM with Nurse #3 revealed Resident #2 and Resident #5 were in a semi-private room on the 400 hall and were recent admissions but were not on the 14 Day COVID Watch. Nurse #3 stated he was not sure why the residents were not on COVID Watch and further stated he had only worn mask and gloves while providing care to the residents. 3. Resident #3 was admitted from the hospital on [DATE] to a semi-private room on the 500 hall with no roommate. A review of her medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative and a COVID-19 test at the facility on 09/22/20 which was negative. There was no signage on the door and there was no PPE available outside the door. Observations of the 500 hall on 09/23/20 at 10:00AM revealed Resident #3 in a semi-private room on the 500 hall without a roommate was not quarantined on the 600 hall and was not placed on enhanced droplet/contact precautions with available PPE outside the door. An interview on 09/23/20 at 10:15AM with Nurse #3 revealed Resident #3 was a recent admission but was not on the 14 Day COVID Watch. Nurse #3 stated he was not sure why the resident was not on COVID Watch and further stated he had only worn mask and gloves while providing care to the resident. 4. Resident #4 was admitted from the hospital on [DATE] to a private room on the 600 hall. A review of her medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative and a COVID-19 test at the facility on 09/21/20 which was negative. There was a sign on the door that read COVID Watch and no PPE available outside the door. Observations of the 600 hall on 09/23/20 at 10:38AM revealed no residents on enhanced droplet/contact precautions and no PPE supplies available for use outside any of the resident doors except Resident #8 who was on contact precautions. NA #1 and NA #2 were observed on 09/23/20 at 10:40AM wearing a mask and gloves while providing care to Resident #1 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. Nurse #1 was observed on 09/23/20 at 10:45AM wearing a mask and gloves while administering medications to Resident #7 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. An interview on 09/23/20 at 11:00AM with NA #1 and NA #2 at 10:48 AM revealed their understanding of the 14 Day Watch was the resident was monitored by the nurse for any signs and symptoms of COVID-19. NA #1 and NA #2 further stated they understood they were not required to wear any PPE in the room except their mask and gloves when providing care. They both indicated they had not worn any eye protection or gown while providing care to the residents on the 600 hall. An interview on 09/23/20 at 11:00AM with Nurse #2 on the 100 hall revealed the residents on 14 Day Watch were newly admitted or had gone out for [MEDICAL TREATMENT] or doctor visits and the sign was put up as an extra precautionary measure they provided the residents. She stated it did not require any special equipment other than a mask and gloves when providing care and stated the residents were monitored for respiratory status each day and vitals and temperature at least twice a day. An interview on 09/23/20 at 11:10AM with Nurse #1 revealed her understanding of the 14 Day Watch was they were to monitor the residents for any signs or symptoms of COVID-19 and report them immediately to the nursing supervisor or Assistant Director of Nursing. The Nurse further stated it was her understanding she only needed to wear a mask and gloves while providing care to the newly admitted residents on the 600 hall because they had a negative COVID-19 test at the hospital prior to their admission. Nurse #1 indicated they were obtaining a respiratory assessment and pulse oximetry daily and temperature twice daily on the new admissions and were not required to use PPE other than a mask and gloves when taking care of the residents. 5. Resident #5 was admitted from the hospital on [DATE] to a semi-private room on the 400 hall without a roommate. A review of his medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative and a COVID-19 test at the facility on 09/22/20 which was negative. There was no signage on the door and no PPE available outside the door. Observations of the 400 hall on 09/23/19 at 9:40AM revealed Resident #2 in room [ROOM NUMBER]-B and Resident #5 in room [ROOM NUMBER]-A were not quarantined on the 600 hall and were not placed on enhanced droplet/contact precautions with available PPE outside the door. Nurse #3 was observed on 09/23/20 at 9:42AM administering medications with a mask and gloves only to the residents in room [ROOM NUMBER]. An interview on 09/23/20 at 9:50 AM with Nurse #3 revealed Resident #2 and Resident #5 were in the semi-private room were recent admissions but were not on the 14 Day COVID Watch. Nurse #3 stated he was not sure why the residents were not on COVID Watch and further stated he had only worn mask and gloves while providing care to the residents. 6. Resident #6 was admitted from the hospital on [DATE] to a private room on the 600 hall. A review of his medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative and a COVID-19 test at the facility on 09/21/20 which was negative. There was no signage on the door and no PPE available outside the door. Observations of the 600 hall on 09/23/20 at 10:38AM revealed no residents on enhanced droplet/contact precautions and no PPE supplies available for use outside any of the resident doors except Resident #8 who was on contact precautions. NA #1 and NA #2 were observed on 09/23/20 at 10:40AM wearing a mask and gloves while providing care to Resident #1 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. Nurse #1 was observed on 09/23/20 at 10:45AM wearing a mask and gloves while administering medications to Resident #7 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. An interview on 09/23/20 at 11:00AM with NA #1 and NA #2 at 10:48 AM revealed their understanding of the 14 Day Watch was the resident was monitored by the nurse for any signs and symptoms of COVID-19. NA #1 and NA #2 further stated they understood they were not required to wear any PPE in the room except their mask and gloves when providing care. They both indicated they had not worn any eye protection or gown while providing care to the residents on the 600 hall. An interview on 09/23/20 at 11:00AM with Nurse #2 on the 100 hall revealed the residents on 14 Day Watch were newly admitted or had gone out for [MEDICAL TREATMENT] or doctor visits and the sign was put up as an extra precautionary measure they provided the residents. She stated it did not require any special equipment other than a mask and gloves when providing care and stated the residents were monitored for respiratory status each day and vitals and temperature at least twice a day. An interview on 09/23/20 at 11:10AM with Nurse #1 revealed her understanding of the 14 Day Watch was they were to monitor the residents for any signs or symptoms of COVID-19 and report them immediately to the nursing supervisor or Assistant Director of Nursing. The Nurse further stated it was her understanding she only needed to wear a mask and gloves while providing care to the newly admitted residents on the 600 hall because they had a negative COVID-19 test at the hospital prior to their admission. Nurse #1 indicated they were obtaining a respiratory assessment and pulse oximetry daily and temperature twice daily on the new admissions and were not required to use PPE other than a mask and gloves when taking care of the residents. 7. Resident #7 was admitted from the hospital on [DATE] to a private room on the 600 hall. A review of her medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative. There was a sign on the door that read 14 Day COVID Watch and no PPE available outside the door. Observations of the 600 hall on 09/23/20 at 10:38AM revealed no residents on enhanced droplet/contact precautions and no PPE supplies available for use outside any of the resident doors except Resident #8 who was on contact precautions. NA #1 and NA #2 were observed on 09/23/20 at 10:40AM wearing a mask and gloves while providing care to Resident #1 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. Nurse #1 was observed on 09/23/20 at 10:45AM wearing a mask and gloves while administering medications to Resident #7 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. An interview on 09/23/20 at 11:00AM with NA #1 and NA #2 at 10:48 AM revealed their understanding of the 14 Day Watch was the resident was monitored by the nurse for any signs and symptoms of COVID-19. NA #1 and NA #2 further stated they understood they were not required to wear any PPE in the room except their mask and gloves when providing care. They both indicated they had not worn any eye protection or gown while providing care to the residents on the 600 hall. An interview on 09/23/20 at 11:00AM with Nurse #2 on the 100 hall revealed the residents on 14 Day Watch were newly admitted or had gone out for [MEDICAL TREATMENT] or doctor visits and the sign was put up as an extra precautionary measure they provided the residents. She stated it did not require any special equipment other than a mask and gloves when providing care and stated the residents were monitored for respiratory status each day and vitals and temperature at least twice a day. An interview on 09/23/20 at 11:10AM with Nurse #1 revealed her understanding of the 14 Day Watch was they were to monitor the residents for any signs or symptoms of COVID-19 and report them immediately to the nursing supervisor or Assistant Director of Nursing. The Nurse further stated it was her understanding she only needed to wear a mask and gloves while providing care to the newly admitted residents on the 600 hall because they had a negative COVID-19 test at the hospital prior to their admission. Nurse #1 indicated they were obtaining a respiratory assessment and pulse oximetry daily and temperature twice daily on the new admissions and were not required to use PPE other than a mask and gloves when taking care of the residents. 8. Resident #8 was admitted from the hospital on [DATE] to a private room on the 600 hall. A review of his medical record revealed the resident had a COVID-19 test at the hospital on [DATE] which was negative. There was a sign on the door that read Contact Precautions and there was available PPE, but the resident was not on enhanced droplet precautions. Observations of the 600 hall on 09/23/20 at 10:38AM revealed no residents on enhanced droplet/contact precautions and no PPE supplies available for use outside any of the resident doors except Resident #8 who was on contact precautions. NA #1 and NA #2 were observed on 09/23/20 at 10:40AM wearing a mask and gloves while providing care to Resident #1 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. Nurse #1 was observed on 09/23/20 at 10:45AM wearing a mask and gloves while administering medications to Resident #7 on the 600 hall. There was a sign on the door that read 14 Day COVID Watch but no PPE available outside the door. An interview on 09/23/20 at 11:00AM with NA #1 and NA #2 at 10:48 AM revealed their understanding of the 14 Day Watch was the resident was monitored by the nurse for any signs and symptoms of COVID-19. NA #1 and NA #2 further stated they understood they were not required to wear any PPE in the room except their mask and gloves when providing care. They both indicated they had not worn any eye protection or gown while providing care to the residents on the 600 hall. An interview on 09/23/20 at 11:00AM with Nurse #2 on the 100 hall revealed the residents on 14 Day Watch were newly admitted or had gone out for [MEDICAL TREATMENT] or doctor visits and the sign was put up as an extra precautionary measure they provided the residents. She stated it did not require any special equipment other than a mask and gloves when providing care and stated the residents were monitored for respiratory status each day and vitals and temperature at least twice a day. An interview on 09/23/20 at 11:10AM with Nurse #1 revealed her understanding of the 14 Day Watch was they were to monitor the residents for any signs or symptoms of COVID-19 and report them immediately to the nursing supervisor or Assistant Director of Nursing. The Nurse further stated it was her understanding she only needed to wear a mask and gloves while providing care to the newly admitted residents on the 600 hall because they had a negative COVID-19 test at the hospital prior to their admission. Nurse #1 indicated they were obtaining a respiratory assessment and pulse oximetry daily and temperature twice daily on the new admissions and were not required to use PPE other than a mask and gloves when taking care of the residents. An interview on 09/23/20 at 11:40AM with the Assistant Director of Nursing/Infection Control Preventionist (ICP) revealed their quarantine hall was the 600 hall which was also their rehab unit. She stated they required a COVID-19 test be done on all admissions prior to them being admitted to the facility. The ADON/ICP stated since the new admissions had a negative test prior to admission they were not quarantined but placed on a 14 Day Watch. The ADON/ICP explained the watch meant they would watch the resident for 14 days for any signs or symptoms of COVID-19 including fever, malaise, cough, loss of smell, taste and any other respiratory symptoms. She stated the residents received a respiratory assessment and pulse oximetry daily and temperature check at least twice daily and more often if needed. The ADON/ICP further stated the residents were tested weekly or if they displayed any signs or symptoms of [MEDICAL CONDITION]. She indicated they were not using PPE on the 600 hall for the new admissions unless they showed any signs or symptoms of COVID-19 since their test at the hospital was negative. The ADON/ICP indicated the residents and staff were being tested weekly and currently they had no resident cases of COVID-19 in the facility. She stated her direction for placement of the 14 Day COVID Watch residents had come from the Administrator and stated any resident that displayed sign or symptoms of COVID-19 would automatically be placed under the 14 Day COVID Watch. The ADON/ICP stated she was not sure why this was not included in their policy and procedure and stated that would be a question for the Administrator. She indicated she was not responsible for writing the policies and procedures and was not sure why they would not match the CDC guidance and that too would be a question for the Administrator. She stated again she received her direction from the Administrator. An interview on 09/23/20 at 3:45PM with the Director of Nursing (DON) and ADON/ICP revealed currently they had no resident cases of COVID-19 but had one staff case and considered the facility in outbreak status. The DON stated resident updates were provided at least monthly and more often with any changes in cases. She further stated the families are provided updates by the Admissions Director, Marketing Director and the Social Worker. The DON stated the families were provided information via social media, text, email and phone calls. She explained her understanding of the 14 Day Watch was new admissions were admitted to the 600 hall and placed on the watch and this included a daily respiratory assessment, vital signs including temperature twice daily and continuous monitoring for any signs or symptoms of COVID-19. The DON stated it was her understanding from the Administrator that the newly admitted residents under the 14 Day COVID Watch did not require staff use of PPE due to the resident's negative COVID-19 test at the hospital prior to their admission. She further stated she was not aware that newly admitted residents required quarantine and the use of full PPE including mask, eye protection (goggles and/or face mask), gown and gloves. The DON stated she had been educated by the Administrator. The only equipment required was a mask and gloves if providing resident care. She stated they had considered the new admissions from the hospital with a negative test done at the hospital to be negative and not need full PPE and quarantine. An interview on 09/23/20 at 4:45PM an interview with the DON revealed the facility had not stopped accepting admissions even with the COVID-19 pandemic but required a COVID-19 test 24 to 48 hours prior to admission. She stated they had designated the 600 hall for newly admitted residents when possible but stated some residents had been placed in other rooms due to rehabilitation residents being on the 600 hall as well. The DON stated all the rehab residents that were not newly admitted had been tested this week and all the tests had been negative. An interview on 09/23/20 at 5:00PM with the Administrator revealed new admissions required a COVID-19 test prior to admission and if it was negative, they were placed under a 14 Day COVID Watch. The Administrator explained this meant the resident's received a respiratory assessment every day usually on 1st shift and a temperature and vital sign check at least twice daily. She stated the residents had not been placed on Enhanced precautions with full PPE because the negative test prior to admission indicated their COVID-19 status was known to be negative. The Administrator further explained this had been her interpretation of the guidelines and the reason they had not placed the new admissions on Enhanced precautions and utilized full PPE. She stated otherwise they would utilize their supply of PPE and potentially not have enough should they admit a COVID-19 positive resident. The Administrator further stated all the new admits had a negative test at the hospital prior to being admitted to the facility and the facility had tested the staff and residents on a weekly basis since they were in outbreak status. She stated her interpretation of the guidelines had been the basis for not using full PPE on the 14 Day Watch residents and further stated they had to place some residents out in the general population due to not having adequate space on the 600 hall for all the admitted residents. The Administrator indicated she had worked closely with the facility MD and he was in agreement with the placement of the residents. A phone interview on 09/25/20 at 12:49 PM with a local health department nurse who was the liaison for the facility revealed the local health department expected the facility to quarantine their new admissions and readmissions for 14 days and place them on enhanced precautions. The health department nurse stated she had not been in recent contact with them because they were not in outbreak status but stated she had spoken with them since the start of the pandemic. The Administrator was notified of the immediate jeopardy on 09/26/20 at 12:37PM. On 09/27/20 at 6:57PM, the facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. All residents have the potential to suffer as a result of failure to implement Transmission Based Precautions for COVID 19 by not placing enhanced droplet contact precautions signs up and not requiring staff to wear all recommended Personal Protective Equipment to include gown and eye protection as well as gloves and N95 mask for Residents #1, #2, #3, #4, #5, #6, #7 and #8 when providing care and not cohorting and quarantining residents whose COVID 19 status is unknown as well as not assigning dedicated staff to the designed unit for admission of residents whose COVID 19 status is unknown. The facility's COVID 19 policies were not updated to current Centers for Disease Control guidance and Centers for Medicare and Medicaid requirements. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 1. Residents cited as being in rooms other than the 600-unit rooms whose COVID 19 status is unknown have been moved to the 600 unit (the designated isolation unit) on 09.26.2020. Thus, All residents admitted in the last 14 days whose COVID 19 status is unknown have been cohorted on the 600 unit (the designated isolation Unit). Date of Completion: 09.26.2020 2. Enhanced droplet contact precautions signs have been placed on all resident rooms on the designated quarantine unit (600 unit). Date of Completion: 09.26.2020 3. All Staff assigned to the 600 Unit have been given full PERSONAL PROTECTIVE EQUIPMENT (gowns, gloves, mask, eye protection, face shields) and instructed on use of the PERSONAL PROTECTIVE EQUIPMENT for residents on the isolation unit under 14 day isolation following admission whose COVID 19 status is unknown. The education was provided by the Director of Nursing on 09.24.20 and 09.25.20 as well as the Weekend Nurse Coordinator on 09.26.20. This education included all nursing, dietary, housekeeping, and therapy staff. Date of Completion: 09.26.2020 4. Any staff member not present when the training was provided will be trained by the Director of Nursing, The Infection Control Preventionist or the Weekend Nurse Coordinator before being allowed to return to work as well as any new hires. The use of enhanced precautions will be integrated by the Infection Control Preventions into orientation for all new hires. This training will include all nursing, dietary, housekeeping and therapy staff. Completion Date: 09.26.20. 5. As of 09.26.2020 staff will be designated and dedicated to the 600 unit. The policy of the facility going forward will be that the Director of Nursing and Environmental Services Supervisor will assign dedicated staff to the 600 unit when at all possible based upon current crisis staffing contingencies as relates to industry staffing shortages. Every effort will be made to have assigned and dedicated staff for the 600 unit. Date of Completion: 09.26.20 6. The facility's COVID 19 admissions policies and procedures have been updated to include the current Centers for Disease Control (CDC) guidance and Centers for Medicare and Medicaid (CMS) requirements. The new policy states that for all residents whose COVID 19 status is unknown they will be placed on the isolation unit for a period of 14 days, enhanced droplet precautions and contact isolation will be followed by all staff assigned to the isolation unit and designated staff will be assigned to the unit. Date of Completion: 09.26.2020 7. Beginning on 09.24.2020 all facility staff in all departments have been in-serviced on location of isolation rooms, enhanced droplet precaution and contact isolation signage and its meaning and proper PERSONAL PROTECTIVE EQUIPMENT usage when providing care for residents in rooms with enhanced droplet precautions and contact isolation by the Director of Nursing and the Weekend Coordinator. Date of Completion: 09.26.2020 8. The Admissions Coordinator and Marketing Director have been instructed and educated by the Facility Administrator on the facility policy that ALL admissions whose COVID 19 status is unknown must be admitted to the 600 unit for 14-day isolation period. Date of Completion: 09.26.2020 9. CDC recommended Personal Protective Equipment (gloves, gowns, N95 Mask, eye protection ad face shields) has been placed on the outside of the rooms on 600 unit (the designated isolation unit). Date of Completion: 09.24.2020 10. All residents and staff have been tested weekly since 09.06.2020 as required under the current requirements of the Center for Medicare and Medicaid Services and guidelines of Center for Disease Control (CDC) for current surveillance testing requirements. The next scheduled round of testing starts on 09.27.20 for weekend staff and on 09.28.20 for weekday staff and residents. Date of Completion: 09.28.20 11. Beginning 09.26.20 the Infection Control Preventionist will make daily rounds Monday-Friday and the Week End Nurse Coordinator on Saturday and Sunday to ensure that Enhanced Droplet Precautions and Contact Isolation Signs are posted on the doors of residents that are under a 14 day isolation period and that staff are following enhanced precaution and contact precaution guidelines on the 600 unit. The 3-11 and 11-7 Nurse Coordinators will make rounds each night and ensure that staff are following enhanced precaution and contact isolation guidelines on the 600 unit. (TRUNCATED)

Based on record reviews and staff interviews the facility failed to protect 2 of 3 residents from staff and/or resident physical abuse (Resident #1 and #2). The facility failed to protect Resident #1 from a facility Sitter from forcefully grabbing his left arm which caused a 4-centimeter tunneling skin tear. The facility also failed to protect Resident #1 and #2 from Resident #3 intentionally and deliberately rolling over both residents' feet with his motorized wheelchair. Resident #1's and Resident #2's feet were assessed by the facility's nursing staff and did not experience any physical injuries. Immediate Jeopardy began on 08/18/18 for Resident #1 when a Sitter (who was employed by the facility) grabbed his arm and caused a 4-centimeter (cm) skin tear. Immediate Jeopardy began on 11/25/18 for Resident #1 and Resident #2 when Resident #3 intentionally and deliberately rolled over their feet with his motorized wheelchair. Immediate Jeopardy was removed on 12/07/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment and required extensive 2-person assistance with most of his activities of daily living. The MDS had no behaviors documented during the assessment period. Review of Resident #1's Care Area Assessment (CAA) for Cognition dated 06/01/18 revealed in part that he had a [DIAGNOSES REDACTED]. The CAA also indicated Resident #1 had poor safety awareness and impulsive behaviors. Review of Resident #1's Care Plan dated 06/01/18 stated in part that he had LBD which resulted in his rapid cognitive decline. The established goal was to maintain the ability to follow simple commands by utilizing interventions which included facing him while speaking to him, speaking slowly and distinctly to him and maintain eye contact during interaction with him. Review of a Nurses Note, written by Nurse #2, dated 08/18/18 at 10:22 AM indicated in part that Resident #1 was alert and verbal with confusion. Resident #1 received a skin tear to the top of left forearm which measured 4 cm long by 1.5 cm wide with a flap of skin tunneling 0.5 cm to the left side of the skin tear. Resident #1 was calm and in good a mood while treatment was being given. Resident #1 stated the Sitter and he were scuffling, and she tore a chunk of meat from his arm then he punched her. The note specified, Resident #1 also stated that the Sitter said ha, ha, ha I won. Resident #1 stated he felt some soreness in his left arm. Review of Employee's Accident/Incident Report dated 08/18/18 at 10:00 AM written by Nurse Supervisor (NS) #3 stated Resident Companion (Sitter) came up to her and stated Resident #1 punched her in the face and she scratched him accidentally as she was moving his arms out of her face. The Sitter then began to cry and the NS #3 told her to remove herself from Resident #1's room. Review of the Sitter's statement dated 08/18/18 (untimed) revealed Resident #1 was trying to stand and she tried to get him to sit back down in his chair for his safety. Resident #1 then got very agitated and punched the Sitter in the jaw with his left arm. In response, the Sitter shoved his arm away in an urgent manner accidentally digging her nails into his arm in the process. The Sitter immediately went to NS #3 and told her what happened. When the Sitter went back to the room, Resident #1 had his left sleeve rolled up revealing a skin tear that she had unintentionally caused. Telephone interview with Resident Companion (Sitter) on 12/03/18 at 3:05 PM she stated Resident #1 had started to stand up and she told him to sit back down then he reached up with his hand and hit her in the face. The Sitter stated out of instinct she grabbed Resident #1's left hand to keep him from hitting her again. By this time Resident #1 was sitting down so she immediately went to the nurses' station to report what had happened. The Sitter stated while she was holding an ice pack to her right jaw they brought Resident #1 to the desk and when he saw her he said Oh, you did this while pointing to his skin tear. The Sitter stated Resident #1 was not bleeding a lot. On 12/03/18 at 4:30 PM the interview with the Sitter continued in person with demonstration of incident. The Sitter stated she and Resident #1 were watching television when he started to stand up and she stood up in front of him and leaned down to him and said (Resident #1) you need to sit down and at that time he had already sat back down then he hit me on the right side of my face with his left hand and out of instinct I grabbed his arm to keep him from hitting me again and in doing so my fingernails caused a skin tear on his arm. The Sitter stated she did not know she caused the skin tear to Resident #1's arm until he came to the nurses' station later and showed the nurse and me his arm. The Sitter stated, It (the resident 's arm) clearly had the imprints of my fingernails and it was open with small drops of blood. The Sitter explained that she had not received training on what to do when a resident became agitated. Review of NS #3's written statement (undated) and timed 10:00 AM revealed the Sitter approached her and stated Resident #1 needed an [MEDICATION NAME]. NS #3 asked the Sitter what Resident #1 was doing and the Sitter stated that he kept trying to get up and that he punched her in the jaw. NS #3 stated she wanted to assess Resident #1 before she gave him an [MEDICATION NAME] and observed him from his doorway smiling and seemed okay. A minute later the Sitter approached NS #3 and said Resident #1 had a skin tear that he had punched her and she grabbed his arm to push him away and (caused a) skin tear. On 12/04/18 at 10:04 AM during an interview with NS #3, she stated that on 08/18/18 the Sitter came up to her (NS) and told her (NS) that Resident #1 was trying to stand up and she (Sitter) tried to restrain him and he punched her (Sitter) in the face. NS #3 stated she called the Interim Director of Nursing (IDON) and was instructed to get a statement from the Sitter then send the Sitter home. Review of Nurse #2's written statement (undated and untimed) revealed in part that while she was treating Resident #1's skin tear he stated that she (Sitter) grabbed his arm with her nails then he punched her. Resident #1 continued to state the Sitter tempted him to hit her saying hit me, hit me so Resident #1 said he hit her. Resident #1 said they were initially scuffling and that she always does this with him. On 12/03/18 at 5:31 PM during a telephone interview with Nurse #2 she stated she was asked by NS #3 to come and note a skin tear on Resident #1. Nurse #2 stated that it didn't look like a normal skin tear and described it as deep, tunneling, and had a crescent shaped skin flap. The Nurse also stated there was a moderate amount of bleeding. After NS #2 treated the skin tear, she documented the measurements and what Resident #1 stated happened in her nurses' notes and reported it to NS #3 and called the IDON. Review of the Investigation Timeline written by IDON and dated 08/24/18 and signed by Administrator on 08/24/18 revealed the IDON was called on 08/18/18 at approximately 10:45 AM and informed that Resident #1 had swung at his Sitter while being redirected to sit down. While attempting to sit Resident #1 down he swung at the Sitter striking her in the right side of her face/jaw and that while the Sitter was trying to move his hands away a skin tear was caused on the left forearm of Resident #1. The IDON told NS #3 to assess both Resident #1 and the Sitter for injuries and get a written statement from the Sitter then send her home. The Sitter was noted with red mark on the right side of her face/jaw. Resident #1 had a skin tear on his left forearm. The skin tear was treated with normal saline and dressed with a xeroform gauze and dry dressing. The Physician's On-Call was notified of the situation and the family was notified via message. The IDON completed a 24-Hour Initial Report and faxed it to the state agency. The IDON also spoke with Resident #1 and asked him how he hurt his arm in which he replied I punched her. however Resident #1 was not a reliable source due to the [DIAGNOSES REDACTED]. The Sitter reported she was attempting to redirect Resident #1 to sit back down and he began to get agitated with her and swung at her hitting her in the right side of her face/jaw. In response to him swinging at her she reacted by forcefully pushing his arm away from her face. She left the room to notify the nurse of the increase in agitation. Upon returning to the room with the nurse she and the nurse noted blood on the sleeve of his left forearm. When the sleeve was rolled up a skin tear was observed. The Sitter was asked to demonstrate how she reacted when he hit her since she used the word forcefully. Both the IDON and the Administrator witnessed her reaction and felt that it was a reaction to being hit and she did not mean to cause a skin tear to his arm. The Sitter was told by the Administrator that she was being suspended until Monday, (MONTH) 27th at which time they would call her and let her know about returning to work once the facility's investigation was complete. At that time they felt it was not appropriate for her to work as a Resident Companion. The Timeline stated, we did not feel this was abuse and therefore were not able to substantiate abuse since there were no witnesses and the resident was not a reliable source due to the [DIAGNOSES REDACTED]. During an interview with the IDON on 12/04/18 at 11:47 AM she reported that she was notified of the incident between Resident #1 and the Sitter in the morning of 08/18/18 and arrived at the facility in the early afternoon. The IDON stated she was told by NS #3 that Resident #1 became combative with the Sitter and punched her in the face after they got into a scuffle. The IDON stated she instructed NS #3 to get a statement from the Sitter then send her home. The IDON stated that when she got to the facility Resident #1's skin tear was already dressed and she did not remove the dressing to assess his skin tear. The IDON stated she interviewed Resident #1 but because of his progressive LBD he could not remember the incident. The IDON stated she reviewed the Sitter's statement and read it as when Resident #1 went up to hit her she pushed his hand out of the way and caused the skin tear. The IDON continued to state that they (Administration) brought the Sitter in to act out of incident and they did not feel the act was intentional or abusive. During an interview with the Administrator on 12/04/18 at 3:45 PM she stated the Sitter received the same training on residents with agitation as the other direct care staff and she did what she should have done by reporting the incident which she did right away. The Administrator stated she did not consider the incident between the Sitter and Resident #1 abuse. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #3's most recent MDS Assessment revealed Resident #3 was moderately cognitively impaired with no noted behaviors during the look back period. A. Review of Resident #3's nurse's notes revealed a noted dated 11/25/18 at 1:25PM that was written by Nurse #1. The note specified Resident #3 was leaving the dining room and had an altercation with Resident #1 in which Resident #3 utilized his motorized wheelchair to roll over Resident #1's feet. Per the nurse's note, the altercation was a result of Resident #1 being in the way of Resident #3 and not moving out of the way as fast as Resident #3 wanted. The nurse's note revealed Resident #3 reported that he rolled over Resident #1's feet because Resident #1 did not move out of his way so he had to teach him a lesson. Further review of the progress note revealed Resident #3 appeared to have no remorse and stated again that he had to teach him a lesson. Review of the nurse note revealed Nurse #1 spoke with Resident #3 after the incident and noted telling him that type of behavior would not be accepted. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) Assessment revealed Resident #1 was cognitively impaired with no noted behaviors. Resident #1 was coded as requiring extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 was coded as requiring limited assistance with locomotion on & off the unit. A review of Resident #1's medical record revealed no documented skin assessment of Resident #1's feet when Resident #3 ran over his feet on 11/25/18. An interview with Medication Aide #1 on 12/04/18 at 3:41 PM revealed on 11/25/18 she was out in the hall and heard Resident #3 state get out of my way angrily. She reported she noted Resident #3 had the control stick to his motorized wheelchair pushed as far to the left as it would go towards Resident #1. She stated Resident #3 reported to her that Resident #1 should have moved out of his way. She reported Resident #1 appeared frightened and scared, staring off into space. She stated Resident #3's motorized wheelchair to be off balance at times due to Resident #3 continuing to try and traverse up and over Resident #1's feet. She stated she was surprised Resident #3 did not tip the motorized wheelchair over. She stated she separated the residents she immediately reported the incident to her supervisor and that she had not been asked by administration to provide a statement in regards to what she witnessed. During an interview with Nurse #1 on 12/04/18 at 10:12 AM she revealed that she did not witness Resident #3 running over Resident #1's feet first hand on 11/25/18 and that it was reported to her by Nurse Aide #1. She continued, reporting that she documented the incident in the nurse's notes as Nurse Aide #1 reported it to her. She stated after the incident was reported to her, she completed only a visual assessment of Resident #1's feet and noted no injuries and she observed no broken skin or bruising with no complaints of pain from Resident #1. She reported notifying the DON through a text message and received a response of OK, thanks in a return text message. The Nurse stated she did not set up any monitoring systems for Resident #3 to prevent him from exhibiting this inappropriate behavior again. An interview with Nurse Supervisor #1 on 12/04/18 at 10:45AM revealed she was informed of the incident by Nurse #1. She stated she reported the incident to Nurse Supervisor #2 on 11/26/18 who reported she would notify the Director of Nursing. The NS indicated she was not aware of any monitoring systems that were put into place to prevent Resident #3's behavior from happening again. An interview with Nurse Supervisor #2 on 12/04/18 at 1:35PM revealed she was notified of the incident on 11/26/18 during her morning report that Resident #3 had run over two different resident's feet the day before. She stated she instructed Nurse #1 to complete an incident report and document the incident and pass the information on during her report. She stated she spoke with the Director of Nursing (DON) that morning and asked the DON about the incidents. She reported the DON informed her that she was already aware of the incident and the facility was ordering a urinalysis for Resident #3. During an interview with the Director of Nursing (DON) on 12/04/18 it was revealed she had been made aware of the incident on the morning of 11/26/18 and reported she was scheduled to monitor the hall where Resident #1 and Resident #3 for other quality assurance measures that the facility was currently monitoring. She reported she received a text message the morning of 11/26/18 from Nurse #1 and reported she had already been informed by Nurse Supervisor #2 by the time she had received the text message. She reported she spoke to both residents involved in the incident about their general wellbeing but denied specifically asking about the incident with the motorized wheelchair. The DON stated both residents denied having any issues or complaints at that time. She reported she observed and visually assessed Resident #1's feet and found them to have no issues or problems with redness, bruising, swelling, skin tears or other injuries. The DON reported she informed the Administrator about the incident involving Resident #1 and Resident #3. An interview with the Administrator on 12/04/18 in the morning revealed she had been made aware of the incident on 11/26/18 and reported she re-educated Nurse #1 on making sure she contacted administrative staff until someone was reached. She stated she did not start an abuse investigation, contact local law enforcement, local adult protective services or the state agency due to her belief that the incident was not abuse. She reported not completing an internal investigation due to her belief that the incident was not abuse, stating it was a resident to resident incident and that is was not reportable. She denied implementing any interventions to attempt to prevent similar incidents from happening again. B. Review of Resident #3's nurse's notes revealed a nurse's note dated 11/25/18 at 7:18 PM, written by Nurse #1, stated Resident #3 had an incident with Resident #2 while leaving the dining room. Further review of the nurse's note revealed Resident #3 ran over Resident #2's feet with his motorized wheelchair reportedly because Resident #2 was in his way. Additional review of the nurse's note indicated this was the 2nd incident of Resident #3 running over another resident's feet due to the other residents reportedly being in Resident #3's way. The nurse's note also revealed the nurse stated she would continue to monitor Resident #3's behavior, told Resident #3 that behavior would not be tolerated and passed the information of the incident onto the 3rd shift Nurse Supervisor. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's most recent MDS assessment dated [DATE] and coded as a quarterly assessment revealed Resident #2 to be cognitively impaired with noted physical and verbal behaviors directed towards others occurring 1-3 days during the look back period. Resident #2 was coded as requiring extensive assistance with bed mobility, locomotion on the unit and dressing. Resident #2 was coded as being totally dependent with transfer. A review of Resident #2's medical record revealed no documented skin assessment of Resident #2's feet after Resident #3 ran over his feet with a motorized wheelchair. An interview on 12/04/18 at 10:12 AM with Nurse #1 who completed the nurse's note on 11/25/18 revealed she did not witness Resident #3 running over Resident #2's feet with his motorized wheelchair first hand. She reported Dietary Aide #1 reported the incident to her and she wrote her nurse's note as a reflection of the incident as it was reported to her. She stated she visually assessed Resident #2's feet and noted there to be no injuries and reported no lingering pain. She stated she reported the incident to the Director of Nursing after the incident by text message and reportedly received a response of OK, thanks by text. An interview with Dietary Aide #1 on 12/04/18 at 11:15 AM revealed she was in the dining room assisting residents when she heard Resident #2 yell out oh, oh, he ran over my foot. She stated she turned around and observed Resident #3 continuing to try and engage his wheelchair over Resident #2's feet. She reported observing Resident #2 attempt to grab Resident #3 but by that time Resident #3 had already run over Resident #2's foot. She reportedly ran over to the two residents to separate them and informed a nurse, whom she could not identify, walking down the hall with whom she asked for help. Dietary Aide #1 reported she was asked to write a statement about the incident but reported she had forgotten and did not complete it until 12/04/18. An interview with Nurse Supervisor #1 on 12/04/18 at 10:45 AM revealed she was informed of the incident by Nurse #1. She stated she reported the incident to Nurse Supervisor #2 on 11/26/18 who reported she would notify the Director of Nursing. An interview with Nurse Supervisor #2 on 12/04/18 at 1:35 PM revealed she was notified of the incident on 11/26/18 during her report that Resident #3 had run over two different resident's feet. She stated she instructed Nurse #1 to complete an incident report and document the incident and pass the information on during her report. She stated she spoke with the Director of Nursing (DON) that morning and asked the DON about the incidents. She reported the DON informed her that she was already aware of the incident and the facility was ordering a urinalysis for Resident #3. During an interview with the Director of Nursing (DON) on 12/04/18 at 11:45 AM it was revealed she had been made aware of the incident on the morning of 11/26/18 and reported she was scheduled to monitor the hall where Resident #2 and Resident #3 for other quality assurance measures that the facility was currently monitoring. She reported she spoke to both residents involved in the incident about their general well being but denied specifically asking about the incident with the motorized wheelchair. The DON stated that both residents reported no current issues or complaints. She stated she observed and visually assessed Resident #1's feet on the morning of 11/26/18 and found them to have no issues or problems with redness, bruising, swelling, skin tears or other injuries and had no complaints of pain. The DON reported she informed the Administrator on 11/26/18 about the incident involving Resident #2 and Resident #3. An interview with the Administrator on 12/04/18 11:45 AM revealed she had been made aware of the incident regarding Resident #3 running his motorized wheelchair over the feet of Resident #1 and Resident #2 on 11/26/18 and reported she re-educated Nurse #1 on making sure she contacted administrative staff until someone was reached. She stated she did not start an abuse investigation, contact local law enforcement, local adult protective services or the state agency due to her belief that the incident was not abuse. She reported not completing an internal investigation due to her belief that the incident was not abuse, stating it was a resident to resident incident and that is was not reportable. She reported there was no further follow-up was completed based on her determination that the incident of Resident #3 running over Resident #2's feet with his motorized wheelchair was not abuse. The Administrator was informed of Immediate Jeopardy on 12/05/18 at 11:00 am. The facility's provided an acceptable Credible Allegation of Immediate Jeopardy removal on 12/07/18 at 10:50 AM which specified the following: Credible Allegation of Immediate Jeopardy removal F-600 FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION Resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Address How Corrective Action (S) Will Be Accomplished For Those Residents Found To Have Been Affected By The Deficient Practice: The following interventions were put into place by the facility: 08/18/2018 Incident: 1. The facility did not substantiate the abuse of Resident #1 on 08/18/2018 when Resident Companion was struck by Resident #1 and Resident Companion grabbed his arm resulting in a skin tear, based on the witness statement and the facilities' investigation at that time. Based on the Resident Companion's statement we immediately removed the employee and suspended her until the investigation was complete. Based on our investigation and interview with the employee the decision was made to move the employee to the Dietary department as a Dietary Aide where she will not be able to provide care with the residents. Thus we were in compliance as of the 08/18/2018 date. 2. However due to the complaint survey citing the facility for failure to prevent abuse due to the employee's statement on 12/03/2018 the facility has decided to re-open the investigation. 3. The Police were notified on 12/05/2018 at 10:00 am and they came to the facility around 10:30 am at which time we made a report. 4. The facility sent in a 24 Hour Report to NCDHSR to indicate that they had re-opened the investigation. 5. The employee in question was notified of the need to come in for another interview on 12/05/2018 and she arrived at 12:30 pm at which time an interview was conducted. Per our policy the employee is suspended now pending another investigation. If the investigation supports bringing her back to work she will have go through another orientation at which time she will receive training on Abuse, How to react to combative behavior from residents, and Dementia Training. Therefore the facility has provided an environment free from abuse. 11/25/2018 Incident: 1. (MONTH) 25, (YEAR) there was an incident where Resident #3 ran over the feet of Resident #1 and Resident #2. The staff intervened with Resident #1 and Resident #3 by removing Resident #1 from the area and monitoring Resident #3, per #1 Nurse LPN witness statement and nurse's note. After the incident with Resident #2 and #3 the staff in the dining room intervened by assisting Resident #3 from the dining room which was his intent when running over resident #2's feet. The #1 Nurse LPN evaluated the resident #1 and #2's feet at the time and there were no injuries or complaints from the residents per the nurse's notes. The facility did not identify the root cause of the incident as an abusive act. At the time of incident, the resident's intent was not clear. Though Resident #3 stated he meant to run over the resident's feet when asked by staff, upon further consideration by administration, this admission could be erroneous due to resident's acute mental status related to Urinary Tract Infection. Resident #3 does not have a history of aggression or altercation and was being treated for [REDACTED].#1 or Resident #2. The facility did not submit report, as per resident to resident abuse. 2. On (MONTH) 26, (YEAR) the DON completed a thorough skin assessment on Resident # 1 and Resident #2 involved in the 11/25/2018 incidents and there were no noted areas of bruising, discoloration, scratches and or injury. The residents did not appear to have any mental or emotional distress as a result of the incident as they mentally appeared to be at their baseline and did not express any signs of physical or mental distress. 3. The Resident #3 was evaluated by Physical Therapy on 12/03/2018 to determine if the resident has the capability of maneuvering a motorized chair independently. It was determined that resident has great difficulty when decreased space is available. He is unable to see his feet or immediately by his sides due to decreased visual field. He tends to use the wheelchair to increase his visual field as opposed to turning his head. Required cues to turn his head instead, he would turn the chair. Due to the safety needs of the residents the Interdisciplinary Care Team and Physician has decided the resident will be evaluated on 12/06/2018 for a traditional wheelchair and placed in chair after the evaluation. Address How Corrective Action Will Be Accomplished For Those Residents Having Potential To Be Affected By The Same Deficient Practice: 1. All interview able residents were interviewed by the facility Social Worker and Director of Nursing to determine if they had been a recipient of, or witnessed abuse by a staff member, family member, visitor or another resident. The interviews were conducted on 12/05/2018 and there were no residents who had experienced or witnessed any abuse. 2. The facility performed ongoing audits of Incident reports, since October, (YEAR). However, this process was escalated further to include 24 hour nursing shift reports as well, which are reviewed for incidents involving possible resident to resident altercations, and or abuse. This new process was initiated by Administrator following the resident to resident altercation on 11/28/2018. To date, there have been no injuries of unknown origin to investigate. The Morning Meeting Signature Agenda reflects the Administrative and the Clinical Team attendance. Thus all non-interview able residents have not had any noted incidents 3. The Administrator, Director of Nursing and Corporate Nurse Consultant conducted In-services with all staff beginning on 12/05/2018 and completed on 12/07/2018 which is required to be completed prior to returning to work; and all new hires will be required to complete the following training in orientation prior to working with the resident; a. ABUSE - Resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. b. Types of abuse, i.e., (physical, verbal, chemical, sexual, and resident to resident abuse. c. What to do if abuse is witnessed, who to report the abuse to, d. How to react to combative behavior from residents; how to provide care and services to combative residents to prevent abuse to resident(s) or harm to the care giver; and e. Dementia training. f. Reporting of ANY SUSPICION of abuse of any type, neglect, exploitation and misappropriation of resident property. g. Notification of the incident to the Administrator and the Director of Nursing IMMEDIATELY. Failure to notify will result in disciplinary action. 4. The Administrator and the Director of Nursing received additional training on the Abuse policy and regulations, the investigation process and the regulations regarding timely notification by staff, and then timely reporting of the abuse to the required agencies and Dementia Training. This was completed on 12/06/2018 by the Corporate Nurse Consultant. Address What Measures Will Be Put Into Place Or Systemic Changes Made To Ensure That The Deficient Practice Will Not Recur: 1. Due to the safety needs of the all residents the Interdisciplinary Care Team and Physician has decided the Resident #3 will be evaluated on 12/06/2018 for a traditional wheelchair and placed in chair after the evaluation. 2. The Nursing Staff were informed by the Nurse Manager of the incident and instructed them to be hyper vigilant with observation of Resident #3) on 11/25/2018. All staff has been made aware of the Resident ' s behavior and the need to be hyper vigilant with observation by 12/07/2018. The Director of Nursing has completed QA rounds ensure resident does not exhibit any further behaviors/abuse. I

Based on record reviews and staff interviews the facility failed to implement their Abuse policy in the areas of Identifying, Investigating and Reporting for 2 of 3 Residents reviewed for abuse. The facility failed to identity, investigate and report to law enforcement an incident of physical abuse when a Sitter forcefully grabbed Resident #1 and caused a 4-centimeter skin tear to his arm. The facility also failed to identify, investigate and report an incident of resident to resident abuse to law enforcement and the state survey agency when Resident #3 intentionally and deliberately rolled over Resident #1 and Resident #2's feet with his motorized wheelchair. Resident #1 and Resident #2's feet were assessed by the facility's nursing staff to have no physical injuries. Immediate Jeopardy began on 08/18/18 for Resident #1 when a Sitter (who was employed by the facility) grabbed his arm and caused a 4-centimeter (cm) skin tear. Immediate Jeopardy began on 11/25/18 for Resident #1 and Resident #2 when Resident #3 intentionally and deliberately rolled over their feet with his motorized wheelchair. Immediate Jeopardy was removed on 12/07/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. The finding included: Review of the facility's Abuse Policy and Procedure dated 04/05/05 revealed in part, area of Identification stated (Facility) will follow up with accidents or incident that occur to ensure that abuse and/or neglect have not occurred. In Investigating/Protection, the facility will review all incidents to determine, if possible, the cause of the incident and injury that may have occurred. 1) A complete and thorough follow up will be completed to identify the cause of all injuries. 2) Needed investigations will be conducted with the resident's safety as the foremost concern in order to protect the resident from future harm. In further review, the area of Reporting/Response read in part, 3) For all incidents/accidents that are suspected abuse, neglect, or misappropriation, the following agencies may be contacted: A) North Carolina Division of Facility Services (state survey agency) and F) Police Department. A review of the facility's policy (dated 04/05/05) entitled Abuse Policy and Procedures revealed a section entitled Resident to Resident Abuse and Family to Resident Abuse. Review of this section revealed subsection #4 that stated investigations would be conducted of all reports of resident to resident and/or family to resident abuse and that the investigation will be conducted with the resident's safety as the foremost concern in order to protect the resident or residents from future harm. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment and required extensive 2-person assistance with most of his activities of daily living. The MDS had no behaviors documented during the assessment period. Review of Resident #1's Care Area Assessment (CAA) for Cognition dated 06/01/18 revealed in part that he had a [DIAGNOSES REDACTED]. The CAA also indicated Resident #1 had poor safety awareness and impulsive behaviors. Review of Resident #1's Care Plan dated 06/01/18 stated in part that he had LBD which resulted in his rapid cognitive decline. The established goal was to maintain the ability to follow simple commands by utilizing interventions which included facing him while speaking to him, speaking slowly and distinctly to him and maintain eye contact during interaction with him. Review of a Nurses Note, written by Nurse #2, dated 08/18/18 at 10:22 AM indicated in part that Resident #1 was alert and verbal with confusion. Resident #1 received a skin tear to the top of left forearm which measured 4 cm long by 1.5 cm wide with a flap of skin tunneling 0.5 cm to the left side of the skin tear. Resident #1 was calm and in good a mood while treatment was being given. Resident #1 stated the Sitter and he were scuffling, and she tore a chunk of meat from his arm then he punched her. The note specified, Resident #1 also stated that the Sitter said ha, ha, ha I won. Resident #1 stated he felt some soreness in his left arm. Review of the Sitter's statement dated 08/18/18 (untimed) revealed Resident #1 was trying to stand and she tried to get him to sit back down in his chair for his safety. Resident #1 then got very agitated and punched the Sitter in the jaw with his left arm. In response, the Sitter shoved his arm away in an urgent manner accidentally digging her nails into his arm in the process. The Sitter immediately went to NS #3 and told her what happened. When the Sitter went back to the room, Resident #1 had his left sleeve rolled up revealing a skin tear that she had unintentionally caused. Review of Employee's Accident/Incident Report dated 08/18/18 at 10:00 AM written by Nurse Supervisor (NS) #3 stated Resident Companion (Sitter) came up to her and stated Resident #1 punched her in the face and she scratched him accidentally as she was moving his arms out of her face. The Sitter then began to cry and the NS #3 told her to remove herself from Resident #1's room. Telephone interview with Resident Companion (Sitter) on 12/03/18 at 3:05 PM she stated Resident #1 had started to stand up and she told him to sit back down then he reached up with his hand and hit her in the face. The Sitter stated out of instinct she grabbed Resident #1's left hand to keep him from hitting her again. By this time Resident #1 was sitting down so she immediately went to the nurses' station to report what had happened. The Sitter stated while she was holding an ice pack to her right jaw they brought Resident #1 to the desk and when he saw her he said Oh, you did this while pointing to his skin tear. The Sitter stated Resident #1 was not bleeding a lot. On 12/03/18 at 4:30 PM the interview with the Sitter continued in person with demonstration of incident. The Sitter stated she and Resident #1 were watching television when he started to stand up and she stood up in front of him and leaned down to him and said (Resident #1) you need to sit down and at that time he had already sat back down then he hit me on the right side of my face with his left hand and out of instinct I grabbed his arm to keep him from hitting me again and in doing so my fingernails caused a skin tear on his arm. The Sitter stated she did not know she caused the skin tear to Resident #1's arm until he came to the nurses' station later and showed the nurse and me his arm. The Sitter stated, It (the resident's arm) clearly had the imprints of my fingernails and it was open with small drops of blood. The Sitter explained that she had not received training on what to do when a resident became agitated. Review of NS #3's written statement (undated) and timed 10:00 AM revealed the Sitter approached her and stated Resident #1 needed an [MEDICATION NAME]. NS #3 asked the Sitter what Resident #1 was doing and the Sitter stated that he kept trying to get up and that he punched her in the jaw. NS #3 stated she wanted to assess Resident #1 before she gave him an [MEDICATION NAME] and observed him from his doorway smiling and seemed okay. A minute later the Sitter approached NS #3 and said Resident #1 had a skin tear that he had punched her and she grabbed his arm to push him away and (caused a) skin tear. On 12/04/18 at 10:04 AM during an interview with NS #3, she stated that on 08/18/18 the Sitter came up to her (NS) and told her (NS) that Resident #1 was trying to stand up and she (Sitter) tried to restrain him and he punched her (Sitter) in the face. NS #3 stated she called the Interim Director of Nursing (IDON) and was instructed to get a statement from the Sitter then send the Sitter home. Review of Nurse #2's written statement (undated and untimed) revealed in part that while she was treating Resident #1's skin tear he stated that she (Sitter) grabbed his arm with her nails then he punched her. Resident #1 continued to state the Sitter tempted him to hit her saying hit me, hit me so Resident #1 said he hit her. Resident #1 said they were initially scuffling and that she always does this with him. On 12/03/18 at 5:31 PM during a telephone interview with Nurse #2 she stated she was asked by NS #3 to come and note a skin tear on Resident #1. Nurse #2 stated that it didn't look like a normal skin tear and described it as deep, tunneling, and had a crescent shaped skin flap. The Nurse also stated there was a moderate amount of bleeding. After NS #2 treated the skin tear, she documented the measurements and what Resident #1 stated happened in her nurses' notes and reported it to NS #3 and called the IDON. Review of the Investigation Timeline written by IDON and dated 08/24/18 and signed by Administrator on 08/24/18 revealed the IDON was called on 08/18/18 at approximately 10:45 AM and informed that Resident #1 had swung at his Sitter while being redirected to sit down. While attempting to sit Resident #1 down he swung at the Sitter striking her in the right side of her face/jaw and that while the Sitter was trying to move his hands away a skin tear was caused on the left forearm of Resident #1. The IDON told NS #3 to assess both Resident #1 and the Sitter for injuries and get a written statement from the Sitter then send her home. The Sitter was noted with red mark on the right side of her face/jaw. Resident #1 had a skin tear on his left forearm. The skin tear was treated with normal saline and dressed with an occlusive gauze and dry dressing. The Physician's On-Call was notified of the situation and the family was notified via message. The IDON completed a 24-Hour Initial Report and faxed it to the state agency. The IDON also spoke with Resident #1 and asked him how he hurt his arm in which he replied I punched her. however Resident #1 was not a reliable source due to the [DIAGNOSES REDACTED]. The Sitter reported she was attempting to redirect Resident #1 to sit back down and he began to get agitated with her and swung at her hitting her in the right side of her face/jaw. In response to him swinging at her she reacted by forcefully pushing his arm away from her face. She left the room to notify the nurse of the increase in agitation. Upon returning to the room with the nurse she and the nurse noted blood on the sleeve of his left forearm. When the sleeve was rolled up a skin tear was observed. The Sitter was asked to demonstrate how she reacted when he hit her since she used the word forcefully. Both the IDON and the Administrator witnessed her reaction and felt that it was a reaction to being hit and she did not mean to cause a skin tear to his arm. The Sitter was told by the Administrator that she was being suspended until Monday, (MONTH) 27th at which time they would call her and let her know about returning to work once the facility's investigation was complete. At that time they felt it was not appropriate for her to work as a Resident Companion. The Timeline stated, we did not feel this was abuse and therefore were not able to substantiate abuse since there were no witnesses and the resident was not a reliable source due to the [DIAGNOSES REDACTED]. During an interview with the IDON on 12/04/18 at 11:47 AM she reported that she was notified of the incident between Resident #1 and the Sitter in the morning of 08/18/18 and arrived at the facility in the early afternoon. The IDON stated she was told by NS #3 that Resident #1 became combative with the Sitter and punched her in the face after they got into a scuffle. The IDON stated she instructed NS #3 to get a statement from the Sitter then send her home. The IDON stated that when she got to the facility Resident #1's skin tear was already dressed and she did not remove the dressing to assess his skin tear. The IDON stated she interviewed Resident #1 but because of his progressive LBD he could not remember the incident. The IDON stated she reviewed the Sitter's statement and read it as when Resident #1 went up to hit her she pushed his hand out of the way and caused the skin tear. She added she did not consider the incident as abuse which was why it was not reported to the police. The IDON continued to state that they (Administration) brought the Sitter in to act out of incident and they did not feel the act was intentional or abusive. During an interview with the Administrator on 12/04/18 at 3:45 PM she stated the Sitter received the same training on residents with agitation as the other direct care staff and she (Sitter) did what she should have done by reporting the incident which she did right away. The Administrator stated the facility informed the state abuse the incident but did not inform law enforcement about the incident because she did not see it as abuse. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #3's most recent MDS Assessment revealed Resident #3 was moderately cognitively impaired with no noted behaviors during the look back period. A. Review of Resident #3's nurse's notes revealed a noted dated 11/25/18 at 1:25 PM that reported Resident #3 was leaving the dining room and had an altercation with Resident #1 in which Resident #3 utilized his motorized wheelchair to roll over Resident #1's feet. Per the nurse's note, the altercation was a result of Resident #1 being in the way of Resident #3 and not moving out of the way as fast as Resident #3 wanted. The nurse's note revealed Resident #3 reported that he rolled over Resident #1's feet because Resident #1 did not move out of his way so he had to teach him a lesson. Further review of the progress note revealed Resident #3 appeared to have no remorse and stated again that he had to teach him a lesson. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) Assessment revealed Resident #1 to be cognitively impaired with no noted behaviors. Resident #1 was coded as requiring extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 was coded as requiring limited assistance with locomotion on & off the unit and he was totally dependent of others in bathing. A review of Resident #3's nurse's notes revealed a noted dated 11/25/18 at 1:25PM that reported Resident #3 was leaving the dining room and had an altercation with Resident #1 in which Resident #3 utilized his motorized wheelchair to roll over Resident #1's feet. Per the nurse's note, the altercation was a result of Resident #1 being in the way of Resident #3 and not moving out of the way as fast as Resident #3 wanted. The nurse's note revealed Resident #3 reported that he rolled over Resident #1's feet because Resident #1 did not move out of his way so he had to teach him a lesson. Further review of the progress note revealed Resident #3 appeared to have no remorse and stated again that he had to teach him a lesson. A review of facility provided incident logs revealed no filed reported/documented incidents regarding Resident #1 or Resident #3. An interview with Medication Aide #1 on 12/04/18 at 3:41 PM revealed on 11/25/18 she was out in the hall and heard Resident #3 state get out of my way angrily. She reported she noted Resident #3 had the control stick to his motorized wheelchair pushed as far to the left as it would go towards Resident #1. She stated Resident #3 reported to her that Resident #1 should have moved out of his way. She reported Resident #1 appeared frightened and scared, staring off into space. She stated Resident #3's motorized wheelchair to be off balance at times due to Resident #3 continuing to try and traverse up and over Resident #1's feet. She stated she was surprised Resident #3 did not tip the motorized wheelchair over. She stated she separated the residents she immediately reported the incident to her supervisor and that she had not been asked by administration to provide a statement in regards to what she witnessed. During an interview with Nurse #1 on 12/04/18 at 10:12 AM she revealed that she did not witness Resident #3 running over Resident #1's feet first hand on 11/25/18 and that it was reported to her by Nurse Aide #1. She continued, reporting that she documented the incident in the nurse's notes as Nurse Aide #1 reported it to her. She stated after the incident was reported to her, she completed only a visual assessment of Resident #1's feet and noted no injuries and she observed no broken skin or bruising with no complaints of pain from Resident #1. She reported notifying the DON through a text message and received a response of OK, thanks in a return text message. The Nurse stated she did not set up any monitoring systems for Resident #3 to prevent him from exhibiting this inappropriate behavior again. An interview with Nurse Supervisor #1 on 12/04/18 at 10:45AM revealed she was informed of the incident by Nurse #1. She stated she reported the incident to Nurse Supervisor #2 on 11/26/18 who reported she would notify the Director of Nursing. The NS indicated she was not aware of any monitoring systems that were put into place to prevent Resident #3's behavior from happening again. An interview with Nurse Supervisor #2 on 12/04/18 at 1:35PM revealed she was notified of the incident on 11/26/18 during her morning report that Resident #3 had run over two different resident's feet the day before. She stated she instructed Nurse #1 to complete an incident report and document the incident and pass the information on during her report. She stated she spoke with the Director of Nursing (DON) that morning and asked the DON about the incidents. She reported the DON informed her that she was already aware of the incident and the facility was ordering a urinalysis for Resident #3. During an interview with the Director of Nursing (DON) on 12/04/18 at 11:45 am it was revealed she had been made aware of Resident #3 running over Resident #1's feet on the morning of 11/26/18 and reported she was scheduled to monitor the hall where Resident #1 and Resident #3 for other quality assurance measures that the facility was currently monitoring. She reported she spoke to both residents involved in the incident about their general wellbeing but denied specifically asking about the incident with the motorized wheelchair. The DON stated both resident denied having any issues or complaints at that time and Resident #1 voiced no complaints of lingering pain. She reported informing the Administrator of Resident #3 running over Resident #1's feet on 11/26/18. An interview with the Administrator on 12/04/18 at 11:45 am revealed she had been made aware of the incident involving Resident #3 running over Resident #1's feet with his motorized wheelchair on 11/26/18 and reported she re-educated Nurse #1 on making sure she contacted administrative staff until someone was reached. She stated she did not start an abuse investigation, contact local law enforcement, local adult protective services or the state agency due to her belief that the incident was not abuse. She reported not completing an internal investigation due to her belief that the incident was not abuse, stating it was a resident to resident incident and that it was not reportable. B. Review of Resident #3's nurse's notes revealed a note dated 11/25/18 at 7:18PM, written by Nurse #1, stated Resident #3 had an incident with Resident #2 while leaving the dining room. Further review of the nurse's note revealed Resident #3 ran over Resident #2's feet with his motorized wheelchair reportedly because Resident #2 was in his way. Additional review of the nurse's note indicated this was the 2nd incident of Resident #3 running over another resident's feet due to the other residents reportedly being in Resident #3's way. The nurse's note also revealed the nurse stated she would continue to monitor Resident #3's behavior and passed the information of the incident onto the 3rd shift Nurse Supervisor. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's most recent MDS assessment dated [DATE] and coded as a quarterly assessment revealed Resident #2 to be cognitively impaired with noted physical and verbal behaviors directed towards others occurring 1-3 days during the look back period. Resident #2 was coded as requiring extensive assistance with bed mobility, locomotion on the unit, dressing and was coded as being totally dependent with transfers. A review of facility provided incident logs revealed no filed reported/documented incidents regarding Resident #2 or Resident #3. An interview on 12/04/18 at 10:12 am with Nurse #1 who completed the nurse's note on 11/25/18 revealed she did not witness Resident #3 running over Resident #2's feet with his motorized wheelchair first hand. She reported Dietary Aide #1 reported the incident to her and she wrote her nurse's note as a reflection of the incident as it was reported to her. She stated she visually assessed Resident #2's feet and noted there to be no injuries and reported no lingering pain. She stated she reported the incident to the Director of Nursing after the incident by text message and reportedly received a response of OK, thanks by text. An interview with Dietary Aide #1 on 12/04/18 at 11:15 AM revealed she was in the dining room assisting residents when she heard Resident #2 yell out oh, oh, he ran over my foot. She stated she turned around and observed Resident #3 continuing to try and engage his wheelchair over Resident #2's feet. She reported observing Resident #2 attempt to grab Resident #3 but by that time Resident #3 had already run over Resident #2's foot. She reportedly ran over to the two residents to separate them and informed a nurse, whom she could not identify, walking down the hall with whom she asked for help. Dietary Aide #1 reported she was asked to write a statement about the incident but reported she had forgotten and did not complete it until 12/04/18. An interview with Nurse Supervisor #1 on 12/04/18 at 10:45AM revealed she was informed of the incident by Nurse #1. She stated she reported the incident to Nurse Supervisor #2 on 11/26/18 who reported she would notify the Director of Nursing. An interview with Nurse Supervisor #2 on 12/04/18 at 1:35PM revealed she was notified of the incident on 11/26/18 during her report that Resident #3 had run over two different resident's feet. She stated she instructed Nurse #1 to complete an incident report and document the incident and pass the information on during her report. She stated she spoke with the Director of Nursing (DON) that morning and asked the DON about the incidents. She reported the DON informed her that she was already aware of the incident and the facility was ordering a urinalysis for Resident #3. During an interview with the Director of Nursing (DON) on 12/04/18 at 11:45 am it was revealed she had been made aware of Resident #3 running over Resident #1's feet on the morning of 11/26/18 and reported she was scheduled to monitor the hall where Resident #2 and Resident #3 for other quality assurance measures that the facility was currently monitoring. She reported she spoke to both residents involved in the incident about their general wellbeing but denied specifically asking about the incident with the motorized wheelchair. The DON stated Resident #2 voiced no complaints of pain or injury. She reported informing the Administrator of Resident #3 running over Resident #2's feet on 11/26/18. An interview with the Administrator on 12/04/18 at 11:45 am revealed she had been made aware of the incident involving Resident #3 running over Resident #2's feet with his motorized wheelchair on 11/26/18 and reported she re-educated Nurse #1 on making sure she contacted administrative staff until someone was reached. She stated she did not start an abuse investigation, contact local law enforcement, local adult protective services or the state agency due to her belief that the incident was not abuse. She reported not completing an internal investigation due to her belief that the incident was not abuse, stating it was a resident to resident incident and that it was not reportable. The Administrator was informed of Immediate Jeopardy on 12/05/18 at 11:00 am. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 12/06/18 at 11:41 am which specified the following: CORRECTIVE ACTION PLAN F- 607 Facility must develop and implement written policies and procedures that; Prohibit and prevent abuse, neglect and exploitations of residents and misappropriation of resident property, Establish policies and procedures to investigate any such allegations, and Include training as required. Address How Corrective Action (S) Will Be Accomplished For Those Residents Found To Have Been Affected By The Deficient Practice: 08/18/2018 INCIDENT 1. The facility did not substantiate the abuse of Resident #1 on 08/18/2018 when Resident Companion was struck by Resident #1 and Resident Companion grabbed his arm resulting in a skin tear, based on the witness statement and the facilities' investigation at that time. Based on the Resident Companion's statement we immediately removed the employee and suspended her until the investigation was complete. Based on our investigation and interview with the employee the decision was made to move the employee to the Dietary department as a Dietary Aide where she will not be able to provide care with the residents. Thus we were in compliance as of the 08/18/2018 date. 2. However due to the complaint survey citing the facility for failure to prevent abuse due to the employee's statement on 12/03/2018 the facility has decided to re-open the investigation. 3. The Police were notified on 12/05/2018 at 10:00 am and they came to the facility around 10:30 am at which time we made a report. 4. The facility sent in a 24 Hour Report to NCDHSR to indicate that they had re-opened the investigation. 5. The employee in question was notified of the need to come in for another interview on 12/05/2018 and she arrived at 12:30 pm at which time an interview was conducted. Per our policy the employee is suspended now pending another investigation. If the investigation supports bringing her back to work she will have go through another orientation at which time she will receive training on Abuse, How to react to combative behavior from residents, and Dementia Training. Therefore the facility has provided an environment free from abuse. 6. For Resident #1 his care plan was updated on 08/30/2018 by the MDS Nurse to reflect how to approach him when providing care and services to minimize his behaviors and to gain his cooperation; to always have two staff members when providing his care; to explain in a calm voice what is going to be done to the resident before starting care and to stop care if resident becomes combative and to re-approach after he has become calm and cooperative to finish care. 11/25/2018 INCIDENT 1. (MONTH) 25, (YEAR) there was an incident where Resident #3 ran over the feet of Resident #1 and Resident #2. The staff intervened with Resident #1 and Resident #3 by removing Resident #1 from the area and monitoring Resident #3, per #1 Nurse LPN witness statement and nurse's note. After the incident with Resident #2 and #3 the staff in the dining room intervened by assisting Resident #3 from the dining room which was his intent when running over resident #2's feet. The #1 Nurse LPN evaluated the resident #1 and #2's feet at the time and there were no injuries or complaints from the residents per the nurse's notes. The facility did not identify the root cause of the incident as an abusive act. At the time of incident, the resident's intent was not clear. Though Resident #3 stated he meant to run over the resident's feet when asked by staff, upon further consideration by administration, this admission could be erroneous due to resident's acute mental status related to Urinary Tract Infection. Resident #3 does not have a history of aggression or altercation and was being treated for [REDACTED].#1 and #2. The facility did not submit report, as per resident to resident abuse. 2. On (MONTH) 26, (YEAR) the DON completed a thorough skin assessment on Resident # 1 and Resident #2 involved in the 11/25/2018 incident and there were no noted areas of bruising, discoloration, scratches and or injury. Resident #1 and #2 did not appear to have any mental or emotional distress as a result of the incident as they mentally appeared to be at their baseline and did not express any signs of physical or mental distress. 3. Resident #3 was evaluated by Physical Therapy on 12/03/2018 to determine if the resident has the capability of maneuvering a motorized chair independently. It was determined that resident has great difficulty when decreased space is available. He is unable to see his feet or immediately by his sides due to decreased visual field. He tends to use the wheelchair to increase his visual field as opposed to turning his head. Required cues to turn his head instead, he would turn the chair. Due to the safety needs of the residents the Interdisciplinary Care Team and Physician has decided the resident will be evaluated on 12/06/2018 for a traditional wheelchair and placed in chair after the evaluation. Address How Corrective Action Will Be Accomplished For Those Residents Having Potential To Be Affected By The Same Deficient Practice: 1. All interview able residents were interviewed by the facility Social Worker and Director of Nursing to determine if they had been a recipient of, or witnessed abuse by a staff member, family member, visitor or another resident. The interviews were conducted on 12/05/2018 and there were no residents who had experienced or witnessed any abuse. 2. The facility performed ongoing audits of Incident reports, since October, (YEAR). However, this process was escalated further to include 24 hour nursing shift reports as well, which are reviewed for incidents involving possible resident to resident altercations, and or abuse. This new process was initiated by Administrator following the resident to resident altercation on 11/28/2018. To date, there have been no injuries of unknown origin or resident to resident abuse to investigate. The Morning Meeting Signature Agenda reflects the Administrative and the Clinical Team attendance. Thus all non-interview able residents have not had any noted incidents. a. The Administrator, Director of Nursing and Corporate Nurse Consultant conducted In-services with all staff beginning on 12/05/2018 and completed on 12/07/2018 which is required to be completed prior to returning to work; on the following; and all new hires will be required to complete the following training in orientation prior to working with the resident. b. ABUSE - Resident has the right to be free from abuse, neglect, misappropriation of re

Based on record review and staff interviews it was determined that the facility failed to protect a resident's right to be free of physical abuse for 1 of 1 (Resident #1) residents reviewed for abuse. Resident #1, a cognitively impaired resident was slapped by a nursing assistant during the provision of care. Resident #1 was assessed at the facility and found to have no physical injuries from being slapped by the staff member. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his 14 Day Minimum Data Set (MDS) assessment dated [DATE] revealed the residents' speech was unclear. He scored a zero on the brief interview of mental status indicating that he had poor cognition and memory. No behaviors were documented during the assessment period. He required extensive, two-person assistance for bed mobility and was totally dependent for toileting with 2 persons assist. The resident was also dependent on staff for eating, dressing, bathing and personal hygiene. He had no limits with range of motion per the assessment. Review of the medical record revealed a general note dated 10/16/18 6:49 AM which stated, Res (Resident) was very combative while doing care, he punched CNA (certified nursing assistant) in the jaw and kicked her, was combative during the entire care. Review of the medical record revealed a general note dated 10/16/18 10:37 PM written by Nurse #1 which stated Resident combative during care. This nurse called into room assisted CNAs with changing brief. CNAs stated that resident was hitting and kicking. Review of a Daily Skilled Nursing Evaluation dated 10/16/18 (untimed) stated, alert not oriented, memory problem, unclear speech, barely never understands. Behavior hitting others, grabbing other, behaviors unchanged. Review of the Facility Investigation Time Line of an incident that involved Resident #1 being slapped by nursing assistant (NA) #1 on 10/16/18 that was signed by the Administrator 10/22/18 revealed the following: At approximately 7:15PM- NA #1 went to supervisor and floor nurse and informed them that resident #1 was being combative by way of hitting, kicking, and punching while providing personal care (changing brief and peri-care). Floor nurse then went into room and assisted with personal care until task was completed. Supervisor requested staff statements on the resident being combative from both CNAs present in the room. Statements were turned into the nurse manager approximately 10:45 PM while CNAs were leaving. Upon reviewing the statement, it was noted that in the statement from NA #1, she stated that the resident became very violent and punched the other CNA (NA#2) and herself in the chest and slapped NA #1 in the face, and because it caught her off guard I slapped him back, not hard enough to leave a mark. After turning her statement in, she left the facility. Review of an Investigation-employee statement written by NA #2 date signed 10/16/18 7:00PM stated, I (NA#2) went in Room # with (NA #1) to help her put the brief on (Resident #1) in room #. While we were trying to put the brief on he started kicking, hitting and punching both of us. I tried to hold his hands and feet but was unable to. And then (NA #1) slapped him because he hit her and he started kicking and hitting her so she slapped him again. I then told her to go get the nurse and she did. During interview on 11/4/18 at 3:20 PM with NA #2 she stated that NA #1 needed someone to help (with Resident #1), someone to hold him while we changed him. She was changing him, I was trying to hold his hands, so he wouldn't hit us. He punched me in my breast. He was hitting us and kicking us. He slapped her in the face. She was on the side closest to the window. She had already put the pad underneath him, but she needed help to get the diaper on him. NA #2 stated she then let go of his hand and told NA #1 to go get the nurse. NA #1 went to get the nurse. Resident #1 hit NA #1 before the nurse came in. She slapped him open handed on the face on the left side. He didn't say anything, he was still trying to fight us. She hit him hard, it was more of a reflex. NA #2 stated they got the brief on and that NA #1 hit the resident twice. She slapped him again. That one was not as bad as the first one. NA #2 reported that she went out and told another NA (NA #3), who told her to tell the Assistant Director of Nurses (ADON). The ADON came and talked to her (NA#2) after the incident and told her to slip a note under the door if she could not talk about it. NA #2 stated that she received abuse training after the date of the incident. Review of an Investigation-Employee Statement date signed 10/16/18 9:00PM written by NA #1 stated, At 7 PM after I had cleaned the resident and dressed him for bed. The resident wouldn't allow me to put his brief on so I went to get help from another CNA (Certified Nursing Assistant) NA #2 and when we tried to continue care, (Resident #1) became very violent he punched (NA#2) and myself in chest, and slapped me in the face, because it caught me off guard I slapped him back, not hard enough to leave a mark, but I immediately contacted the nurse and informed her of what happened. Interview with a nursing assistant #1 (NA) at 12:43 PM on 11/4/18 revealed that it was a normal day. She was not told that the resident was taken off all his medication. The resident had a bowel movement and she entered the room to clean him up. She stated that she got another NA to help her because the resident was a tall man, who spoke no English, he weighed 200 pounds and was a 2 person assist. The NA reported that the resident was agitated, and they tried talking to him when he started fighting and kicking he hit her and the other NA in the chest. She stated they stopped providing care and went to the nurse supervisor who told her to get her nurse. The nurse came into the room and was talking to him, she and the other NA were holding him down still trying to clean him up. I turned my head and he socked me, I mean slapped the fire out of me. I slapped his hand on instinct. I told the nurse supervisor I hit him, and I apologized. She stated that she probably did slap his face, but it wasn't a slap, it was a pop like don't hit me. She reported that she only hit Resident #1 once. She stated that she did not hurt him. He had no bruises and that she did not intend to hurt him. She stated that the resident was calm when the nurse was talking to him and she told them to go ahead and clean him up. He snapped again so the nurse told them (NAs) to leave him alone. NA #1 stated that she had worked with the resident previously and he was calm when he was on medication. Review of an Investigation-employee statement written by Nurse #1 dated and signed 10/16/18 at 9:00PM stated, I was called into the room. (NA #1) told me that resident was being combative and hitting them and they couldn't change him. I went into the room. Res. (Resident) was laying in the bed on his side. I held resident's hands and told him to let them change him. Res. Held legs together at first but did let them change his brief. Did not try to hit or kick. Telephone interview with Nurse #1 at 2:23 PM on 11/4/18 revealed that the NA #1 came and got her because Resident #1 was being combative, and they needed help. She stated that she held his hands and talked to him and he was calm for her. The resident let them change him. Supervisor said she wanted them to do a witness statement. At the end of the shift I was going over the witness statements and saw what was written. NA #1 did leave early that day. She looked like she was upset. This was not the first time the resident was combative when being changed. The resident was observed at 4:39 PM on 11/4/18 laid back in his wheelchair with his feet off the ground. During interview with the Administrator and Clinical Nurse Consultant on 11/4/18; they reported completing a plan of correction. The Administrator stated the following corrective action had been completed as of 10/25/18: · CORRECTIVE ACTION PLAN F-600 FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION Resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Address How Corrective Action (S) Will Be Accomplished For Those Residents Found To Have Been Affected By The Deficient Practice: Immediately after learning of the incident the following interventions were put into place by the Administrator and Director of Nursing: 1. The employee who admitted to abusing the resident was suspended pending the investigation and then terminated once the investigation was completed. 2. On (MONTH) 17, (YEAR) the ADON completed a thorough skin assessment on the resident and there were no noted areas of bruising, discoloration, scratches and or injury. The resident did not appear to have any mental or emotional distress as a result of the incident as he mentally appeared to be at his baseline and did not show any nonverbal signs of mental distress such as crying out or being scared of care givers. 3. The Assistant Director of Nursing/Staff Development conducted In-services with all nurses and CNAs beginning on 10/17/2018 and completed on 10/24/2018 on the following; a. Abuse, what is it; b. Types of abuse; c. What to do if abuse is witnessed; d. How to react to combative behavior from residents; how to provide care and services to combative residents to prevent abuse to resident(s) or harm to the care giver; 4. Beginning 10-17-2018 an intervention of two CNAs (and/or one CNA and one nurse) are to always provide care together for this resident due to his history of combative behavior. Address How Corrective Action Will Be Accomplished For Those Residents Having Potential To Be Affected By The Same Deficient Practice: Immediately after learning of the incident the following interventions and corrective actions were put into place by the Administrator and Director of Nursing for residents having the potential to be affected by the alleged deficient practice: 1. Following the incident on (MONTH) 16, (YEAR), the Administrator and Director of Nursing reviewed all incident reports for the past three (3) months to determine if there were any bruises or injuries of unknown origin as a sign of a systemic issue with resident abuse. The review of the incident reports completed on 10-18-2018 did not reveal any injuries or bruises of unknown origin for any resident. 2. On (MONTH) 25, (YEAR) alert and oriented resident were interviewed by the facility activity director concerning resident abuse as well as violation of any resident rights. A Resident Council Meeting was held on 10/25/18 and further discussion of resident abuse and violation of resident rights took place. No report from alert and oriented residents was lodged concerning any incident of resident abuse or violation of resident rights. 3. Between the dates of 10/17/2018 and 10/25/18 a Body Audit was completed on all residents by the CNA's and given to the Staff Nurses who in turn reviewed for any signs or symptoms of bruises, impairment of skin or signs of injury of unknown origin. There were no injuries of unknown origin detected. Address What Measures Will Be Put Into Place Or Systemic Changes Made To Ensure That The Deficient Practice Will Not Recur: 1. For any resident with combative behaviors, only CNAs who have been employed by the facility for greater than three (3) months and have demonstrated the ability to work with combative residents to de-escalate the behaviors and provide care in a manner and way that protects the resident from abuse will be assigned to these residents. The decision to implement this procedure was made on (MONTH) 17, (YEAR) by the Director of Nursing who then educated the supervisory nurses, (who make the CNA assignments), about this procedure . The CNA's and Staff Nurses were then educated on this protocol on (MONTH) 17, (YEAR) by the DON. 2. All staff nurses and supervisory nurses were informed of the incident and instructed to be hyper vigilant with observation of CNAs to ensure abuse does not occur and to report immediately any concerning CNA behaviors to the Director of Nursing. The decision to implement this procedure was made on (MONTH) 17, (YEAR) by the Director of Nursing who then educated the supervisory nurses, (who make the CNA assignments), about this procedure. The CNA's and Staff Nurses were then educated on this protocol on (MONTH) 17, (YEAR) by the DON. 3. Administrative Staff, following the incident, rounded on the resident care units six (6) times the first week (entering rooms and showers where care was being provided) and four (4) times the following week to ensure that care delivery was being conducted in a way that preserved the resident's privacy, dignity and freedom from abuse. These rounds will continue at four (4) per week (including at least one (1) on the 11-7 shift for the next six (6) months and then two (2) per week for the following six (6) months to ensure that the deficient practice does not reoccur. The Administrative Staff were notified (MONTH) 17, (YEAR) by the Administrator who makes the assignments. Indicate How The Facility Plans To Monitor It's Performance To Make Sure That Solutions Are Sustained. The Facility Must Develop A Plan For Ensuring That Correction Is Achieved And Sustained: 1. The QA Committee, QAPI Committee and the Medical Director have been apprised of this plan and commit their support to assisting the facility with achieving and sustaining compliance with this alleged citation. The QAPI Committee was notified on 10/18/2018. 2. The resident care unit rounds will be presented at weekly QA meetings and monthly to the QAPI Committee for evaluation to determine if the system is adequate and if not to devise and re-implement a system to ensure that the alleged deficient practice does not occur again. 3. Incident Reports will be reviewed Monday through Friday in morning meetings for any unusual incident to include bruises, skin tears and injuries of unknown origin. An immediate investigation will be started for all bruises or unknown origin, skin tears of unknown origin or any other incident or injury of unknown origin and any occurrence that is suspected abuse will be reported immediately to the Huntersville Police Department and the North Carolina Health Care Personnel Registry. 4. The incident reports are completed electronically by the staff nurses and the nurse supervisors are responsible to print the incident report(s) for their unit before the morning meeting and are responsible to bring them to the morning meeting. In the event the nursing supervisor is absent the responsibility of printing the incident reports is assigned to the ADON and then to the DON. 5. All incident reports will be reviewed monthly at the QAPI Committee Meeting for any bruises, skin tears and injury of unknown origin and investigations of incidents of unknown origin to determine if any patterns or practices exist that may be considered abuse. If any patterns or practices are noted, the QAPI Committee will begin an immediate investigation to ensure that solutions are put into place to ensure corrective action is achieved and sustained. · Date of Compliance: 10-25-2018 Validation Information: An interview with the Administrator and Director of Nursing on 11/8/18 at 4:14 PM revealed they expected the nursing staff to follow the facility's abuse policy and to immediately report to administration any concerns with abuse. The Administrator stated the following corrective action had been completed as of 10/25/18. · Quality Assurance Performance Improvement (QAPI) Committee met and developed a plan · All staff were in-serviced on identifying and reporting abuse; any prn (as needed) staff could not work until they were re-educated and only trained nurse aides employed at least 3 months would be assigned to work with residents identified with aggressive behaviors. · Body audits were completed on 100% of the residents, residents were interviewed regarding abuse and a Resident Council meeting was held to discuss any concerns related to abuse that residents had · Resident care plans were audited/updated regarding residents with aggressive behaviors · Incident reports for the prior 3 months were reviewed to identify any concerns related to injuries of unknown origin · Administrative staff monitored resident: staff interactions during nursing care and were currently monitoring 4 residents each week to ensure staff/residents were aware of the procedure for reporting abuse, and that abuse was not occurring · Staff reviewed orientation packets to make sure it contained up-to-date information regarding identifying/reporting abuse · The facility continued to monitor/audit for ongoing compliance The facility provided documentation of training for all staff regarding abuse, documentation of all body audits, revised care plans, minutes from Resident Council, resident interviews and QAPI monitoring for corrective action as of 10/25/18. At the time of the survey, sampled residents were observed to receive nursing care without concerns related to abuse. Interviews with alert/oriented residents revealed they were they felt safe. Interviews with staff revealed they were aware of the facility's revised policy/procedures for preventing/reporting abuse. The facility's date of compliance was validated as 10/25/18.

Based on record review and staff interviews the facility to implement their policy and procedure in the areas of reporting and protection by not immediately reporting staff to resident abuse to administration for 1 of 1 Residents (Resident #1) reviewed for abuse. Facility staff failed to immediately report staff to resident abuse for 1 of 1 cognitively impaired residents (Resident #1) who was slapped by a nursing assistant. Findings included: Review of the facility Abuse Policy and Procedures Reporting/Response on 11/4/18 revealed the following, Any suspected incident of abuse, neglect or misappropriation of resident property is to be reported immediately to a supervisor or a member of administration. The facility Investigation/Protection Policy stated, (Facility) will review all incidents to determine, if possible, the cause of the incident and injury that may have been inflicted. 1) a complete and through follow up will be conducted to identify the cause of all injuries. 2) Needed investigations will be conducted with the resident's safety as the foremost concern in order to protect the resident from future harm. 3) If abuse or neglect is suspected, the individual suspected of abusing or neglecting the resident will be placed on suspension pending the outcome of the investigation. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his 14 day Minimum Data Set Assessment ((MDS) dated [DATE] revealed the residents' speech was unclear. He scored a zero on the brief interview of mental status indicating that he had poor cognition and memory. No behaviors were documented during the assessment period. He required extensive, two-person assistance for bed mobility and was totally dependent for toileting with 2 persons assist. The resident was also dependent on staff for eating, dressing, bathing and personal hygiene. He had no limits with range of motion per the assessment. Review of the medical record revealed a general note dated 10/16/18 at 10:37 PM which stated Resident combative during care. This nurse called into room assisted CNAs (certified nursing assistants) with changing brief. CNAs stated that resident was hitting and kicking. Review of an Investigation-employee statement written by Nursing Assistant (NA) #2 dated and signed 10/16/18 at 7:00 PM stated, I (NA#2) went in Room # with (NA #1) to help her put the brief on (Resident #1) in room #. While we were trying to put the brief on he started kicking, hitting and punching both of us. I tried to hold his hands and feet but was unable to. And then (NA #1) slapped him because he hit her and he started kicking and hitting her so she slapped him again. I then told her to go get the nurse and she did. During interview on 11/4/18 at 3:20 PM with NA #2 she stated that NA #1 needed someone to help (with resident #1), someone to hold him while we changed him. She was changing him, I was trying to hold his hands, so he wouldn't hit us. He punched me in my breast. He was hitting us and kicking us. He slapped her in the face. She was on the side closest to the window. She had already put the pad underneath him, but she needed help to get the diaper on him. NA #2 stated she then let go of his hand and told NA #1 to go get the nurse. NA #1 went to get the nurse. Resident #1 hit NA #1 before the nurse came in. She slapped him open hand on the face on the left side. He didn't say anything, he was still trying to fight us. She hit him hard, it was more of a reflex. NA #2 stated they got the brief on and that NA #1 hit the resident twice. She slapped him again. That one was not as bad as the first one. NA #2 reported that she went out and told another NA (NA #3), who told her to tell the Assistant Director of Nurses (ADON). The ADON came and talked to her (NA#2) to her after the incident and told her to slip a note under the door if she could not talk about it. Interview with the ADON on 11/4/18 at approximately 5:40 PM revealed that she was present in the facility on 11/16/18. She told NA #2 to put a note under her door because NA#2 was visibly upset and crying. Review of an Investigation-Employee Statement dated and signed 10/16/18 at 9:00 PM written by NA #1 stated, At 7 PM after I had cleaned the resident and dressed him for bed. The resident wouldn't allow me to put his brief on so I went to get help from another CNA (Certified Nursing Assistant) NA #2 and when we tried to continue care, (Resident #1) became very violent he punched (NA#2) and myself in chest, and slapped me in the face, because it caught me off guard I slapped him back, not hard enough to leave a mark, but I immediately contacted the nurse and informed her of what happened. Interview with NA #1 at 12:43 PM on 11/4/18 revealed that it was a normal day. She was not told that the resident was taken off of all his medication. The resident had a bowel movement and she entered the room to clean him up. She stated that she got another NA to help her because the resident was a tall man, who spoke no English, he weighed 200 pounds and was a 2 person assist. The NA reported that the resident was agitated, and they tried talking to him when he started fighting and kicking he hit her and the other NA in the chest. She stated they stopped providing care and went to the nurse supervisor who told her to get her nurse. The nurse came into the room and was talking to him, she and the other NA were holding him down still trying to clean him up. I turned my head and he socked me, I mean slapped the fire out of me. I slapped his hand on instinct. I told the nurse supervisor I hit him, and I apologized. She stated that she probably did slap his face, but it wasn't a slap slap, it was a pop like don't hit me. She reported that she only hit Resident #1 once. She stated that she did not hurt him. He had no bruises and that she did not intend to hurt him. She stated that the resident was calm when the nurse was talking to him and she told them to go ahead and clean him up. He snapped (became combative) again so the nurse told them (NAs) to leave him alone. NA #1 stated that she had worked with the resident previously and he was calm when he was on medication. NA #1 stated that she followed protocol to the letter. Review of an Investigation-employee statement written by Nurse #1 dated and signed 10/16/18 at 9:00 PM stated, I was called into the room. (NA #1) told me that resident was being combative and hitting them and they couldn't change him. I went into the room. Res. (Resident) was laying in the bed on his side. I held resident's hands and told him to let them change him. Res. Held legs together at first but did let them change his brief. Did not try to hit or kick. Telephone interview with Nurse #1 at 2:23 PM on 11/4/18 revealed that the NA came and got her because Resident #1 was being combative, and they needed help. She stated that she held his hands and talked to him and he was calm for her. The resident let them change him. Supervisor said she wanted them to do a witness statement. At the end of the shift I was going over the witness statements and saw what was written. NA#1 did leave early that day. She looked like she was upset. This was not the first time the resident was combative when being changed. Review of the Facility Investigation Time Line signed by the Administrator on 10/22/18 revealed the following: · 10/16/18, At approximately 7:15PM- NA #1 went to supervisor and floor nurse and informed them that resident #1 was being combative by way of hitting, kicking, and punching while providing personal care (changing brief and peri-care). Floor nurse then went into room and assisted with personal care until task was completed. Supervisor requested staff statements on the resident being combative from both CNAs present in the room. Statements were turned into the nurse manager approximately 10:45 PM while CNAs were leaving. Upon reviewing the statement, it was noted that in the statement from NA #1, she stated that the resident became very violent and punched the other CNA (NA#2) and herself in the chest and slapped NA #1 in the face, and because it caught her off guard I slapped him back, not hard enough to leave a mark. After turning her statement in, she left the facility. · ·10/17/18 11:20 AM- Received call back from 3-11 supervisor (Name), questioned her in regards to the situation the previous evening. She stated that she was informed around 8:00 PM in regards to the resident becoming combative and the CNA (NA#1) responding to the resident with a slap. Supervisor stated that she informed the CNAs to let their charge nurse (Nurse #1) know about what happened and to write statements. This writer then spoke to Nurse #1, floor nurse and was informed that she did not find out about the slapping of the resident until the end of the shift as the CNA was leaving and turned in her statement. It was confirmed by supervisor and CNA, that from time of incident to the end of shift the CNA #1, did not attend to Resident #1; the floor nurse, nurse #1 took over care for him due to his aggression towards the CNAs. Interview with the Clinical Nurse Consultant at 4:01 PM on 11/4/18 revealed that the nurse supervisor on duty told her that she was informed that Resident #1 was combative, and that NA #1 had responded with a slap back around 8 PM on the day of the incident. The nurse supervisor said she did not make a report because she was busy. The Clinical Nurse Consultant stated she and facility management had a phone interview with the nurse supervisor (10/17/18) and met with her in person. The resident was observed at 4:39 PM on 11/4/18 laid back in his wheelchair He did not appear to be in distress. During interview with the Director of Nurses (DON) during the evening of 11/4/18, the DON stated that she was informed of the incident the following day by the Clinical Nurse Consultant. She stated we all (referring to management) found out that morning that the resident was aggressive, and staff slapped the resident. The DON reported that the statements were already written and that interviews were continued. She further stated that per the nurse supervisor on duty she was in the middle of handling another emergency and that's why she did not report the incident immediately. The DON stated the staff were properly in-serviced after the incident regarding immediate notification. The DON said she would have expected to be notified by the supervisor. An interview with the Administrator and Director of Nursing on 11/8/18 at 4:14 PM revealed they expected the nursing staff to follow the facility's abuse policy and to immediately report to administration any concerns with abuse. The administrator stated the following corrective action had been completed as of 10/25/18: CORRECTIVE ACTION PLAN F- 607 Facility must develop and implement written policies and procedures that; Prohibit and prevent abuse, neglect and exploitations of residents and misappropriation of resident property, Establish policies and procedures to investigate any such allegations, and Include training as required. Address How Corrective Action (S) Will Be Accomplished For Those Residents Found To Have Been Affected By The Deficient Practice: 1. For Resident MR# 2129 the CNA having committed the abuse was suspended during the investigation and then terminated. 2. All staff was in-serviced by the ADON/Staff Development on the facilities abuse, neglect, exploitation and misappropriation policies, procedures and protocols including the facilities zero tolerance of abuse, how to provide care for dementia residents, and reporting any abuse, neglect, exploitation and/or misappropriation IMMEDIATELY to the facility Director of Nursing and Administrator. The in-services concluded on 10-24-2018. 3. For Resident MR# 2129, his care plan has been updated on 10/18/2018 by the MOS Nurse to reflect how to approach him when providing care and services to minimize his behaviors and to gain his cooperation; to always have two staff members when providing his care; to explain in a calm voice what is going to be done to the resident before starting care (Resident #2129 spoke English, German and Dutch before his onset of [MEDICAL CONDITION] but now does not respond to either of the languages, even to his wife/partner) and to stop care if resident becomes combative and to re-approach after he has become calm and cooperative to finish care. 4. For Resident MR# 2129, only CNAs that have been with the facility for greater than three (3) months and have demonstrated ability to provide care to combative residents with appropriate responses to their combativeness (how to calm and soothe combative residents) will be assigned to him. The Director of Nursing educated the supervisory nurses, (who make the CNA assignments,)about his procedure and implemented it on (MONTH) 17, (YEAR). The CNA's and Staff Nurses were then educated on this protocol on (MONTH) 17, (YEAR) by the DON. 5. For Resident MR# 2129 a full investigation was completed and a report was made to the North Carolina Health Care Personnel Registry and the Police Department on 10-17-2018. (24 hour report filed on 10/17/2018 by DON and 5 day report filed on 10/22/2018 by DON) and to the police department on 10/17/2018 by Corporate Compliance Nurse. 6. On (MONTH) 17, (YEAR) the ADON completed a thorough skin assessment on the resident and there were no noted areas of bruising, discoloration, scratches and or injury. The resident did not appear to have any mental or emotional distress as a result of the incident as he mentally appeared to be at his baseline and did not show any nonverbal signs of mental distress such as crying out or being scared of care givers. Address How Corrective Action Will Be Accomplished For Those Residents Having Potential To Be Affected By The Same Deficient Practice: 1. The facility already has developed and implemented written policies and procedures that prohibit and prevent abuse, neglect and exploitations of residents and misappropriation of resident property. The facility also has established policies and procedures to investigate any such allegations, and include training as required. All employees are screened upon employment for any history of abuse, neglect, exploitations of residents and misappropriation of resident property. This includes criminal background check, contacting previous employers and checking the licensing boards and registries. 2. Between the dates of 10/17/2018 and 10/25/18 a Body Audit was completed on all residents by the CNA's and given to the Staff Nurses who in turn reviewed for any signs or symptoms of bruises, impairment of skin or signs of injury of unknown origin. There were no injuries of unknown origin detected. 3. This is a one (1) time incident that occurred by a newly hired employee, who readily admitted that she reflectively struck back at the resident after being hit by the combative resident. The breakdown in employees not following the abuse policy occurred when supervisory staff did not immediately remove the CNA from all care giving duties and sent home pending the investigation. As well as supervisory staff did not immediately notify the DON and the Administrator of the occurrence. 4. The CNA committing the abuse was suspended on 10-17-2018 and terminated on 10- 22-2018. The CNA and the Nurses aware of the abuse that occurred were disciplined because they failed to report the abuse immediately to the Administrator and Director of Nursing. 5. The facility has always provided and continues to provide supervision of staff to assure that its policies and procedures are followed. Immediately after learning of the incident the following interventions were put into place by the Administrator and Director of Nursing: A. The employee who admitted to abusing the resident was suspended pending the investigation and then terminated once the investigation was completed. She was reported on 10-17-2018 to the Health Care Personnel Registry and the Huntersville Police Department. B. The staff involved in the incident who did not report the incident to the Director of Nursing and/or Administrator timely were re-educated on Abuse, Proper Reporting to include timing of the report and prevention. They also received disciplinary actions by the Director of Nursing. This was completed on (MONTH) 17, (YEAR). C. The Assistant Director of Nursing/Staff Development conducted In-services with all staff beginning on 10/17/2018 and completed on 10/24/2018 on the following; 1. Abuse, what is it; 2. Types of abuse; 3. What to do if abuse is witnessed; 4. How to react to combative behavior from residents. 5. Reporting abuse timely and how to report abuse Address What Measures Will Be Put Into Place Or Systemic Changes Made To Ensure That The Deficient Practice Will Not Recur: 1. All abuse policies, practices, procedures and protocols were reviewed with all staff by (MONTH) 24, (YEAR) to ensure that residents are free from abuse, neglect and exploitations or misappropriation of their property. 2. Administrative Staff will round on the resident care units six (6) times a week the week following the incident entering rooms and showers were resident care is being provided, then four (4) times a week for the next six (6) months and two (2) times a week for the following six (6) months with at least one (1) round per week occurring on the 11-7 shift to ensure that care is being provided in a way that protects residents from abuse. The Administrative Staff were notified 10/17/2018 by the Administrator who makes the assignments. Indicate How The Facility Plans To Monitor It's Performance To Make Sure That Solutions Are Sustained. The Facility Must Develop A Plan For Ensuring That Correction Is Achieved And Sustained: 1. Administrative Rounds will be presented to the QAPI Committee monthly to review and evaluate that solutions are achieved and sustained to prevent reoccurrence. 2. All incident reports will be reviewed by the QAPI Committee monthly to evaluate any patterns or practices that may potentially be indicative of abuse or abusive patterns. Any patterns or practices identified by the QAPI Committee will immediately be investigated by the QAPI Committee to determine if abuse is an issue and to ensure that solutions are achieved and sustained to prevent reoccurrence. 3. All policies, procedures, protocols and practices pertaining to abuse will be reviewed quarterly by the QAPI Committee for the next two quarters and annually thereafter for appropriateness in preventing abuse as outlined in the facilities policies. 4. The QA Committee, QAPI Committee and the Medical Director were apprised of the problem and corrective action plan on 10-18-2018 and commit their support to assisting the facility with achieving and sustaining compliance. Date of Compliance: 10-25-2018 Validation Information: An interview with the Administrator and Director of Nursing on 11/8/18 at 4:14 PM revealed they expected the nursing staff to follow the facility's abuse policy and to immediately report to administration any concerns with abuse. The administrator stated the following corrective action had been completed as of 10/25/18. · Quality Assurance Performance Improvement (QAPI) Committee met and developed a plan · All staff were in-serviced on identifying and reporting abuse; any prn (as needed) staff could not work until they were re-educated and only trained nurse aides employed at least 3 months would be assigned to work with residents identified with aggressive behaviors. · Body audits were completed on 100% of the residents, residents were interviewed regarding abuse and a Resident Council meeting was held to discuss any concerns related to abuse that residents had · Resident care plans were audited/updated regarding residents with aggressive behaviors · Incident reports for the prior 3 months were reviewed to identify any concerns related to injuries of unknown origin · Administrative staff monitored resident: staff interactions during nursing care and were currently monitoring 4 residents each week to ensure staff/residents were aware of the procedure for reporting abuse, and that abuse was not occurring · Staff reviewed orientation packets to make sure it contained up-to-date information regarding identifying/reporting abuse · The facility continued to monitor/audit for ongoing compliance The facility provided documentation of training for all staff regarding abuse, documentation of all body audits, revised care plans, minutes from Resident Council, resident interviews and QAPI monitoring for corrective action as of 10/25/18. At the time of the survey, sampled residents were observed to receive nursing care without concerns related to abuse. Interviews with alert/oriented residents revealed they were they felt safe. Interviews with staff revealed they were aware of the facility's revised policy/procedures for preventing/reporting abuse. The facility's date of compliance was validated as 10/25/18.

Based on staff interviews and record review the facility failed to implement fall precautions for a resident at risk for falls that fell and sustained a fractured femur for 1 of 3 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's fall care plan updated on 11/11/14 specified the resident was at risk for falls related to history of falls with a fracture and poor safety awareness due to dementia. The care plan specified interventions to prevent a major injury included: - monitor resident for attempts to get out of bed or wheelchair unassisted - bed and chair alarms in place to alert staff of unassisted transfers The Minimum Data Set ((MDS) dated [DATE] specified the resident had severely impaired cognition, required extensive assistance with activities of daily living (ADL) including transfers, but had not fallen since the last review. A fall risk assessment dated [DATE] specified the resident was a high risk for falls. Review of Resident #1's medical record revealed a nurse's entry dated 02/18/15 made by Nurse #1 that she responded to the Nurse Supervisor's call for help around 9:15 PM that Resident #1 fell . Nurse #1 documented that it appeared Resident #1 fell out of her wheelchair and that her left leg was twisted at the knee and the lower leg was turned outward. The entry specified that Resident #1's personal alarm was not sounding at the time of the fall. Further review of Resident #1's medical record revealed that on 02/18/15 she was transported to the Emergency Department and diagnosed with [REDACTED]. On 03/10/15 at 10:10 AM nurse aide (NA) #1 was interviewed and reported she was assigned to care for Resident #1 on 02/18/15. She explained that she did not routinely care for the resident but was aware that the resident at times resisted care, was at risk for falls and required a personal alarm at all times. NA #1 reported that she had placed Resident #1's personal alarm on the resident's wheelchair prior to the evening meal. The NA could not recall if she checked that the alarm was functioning. The NA explained that on 02/18/15 she attempted to put Resident #1 to bed but the resident was combative. NA #1 added that she left the resident alone in her room to calm down and proceeded to go on break. The NA stated that she notified her peers that she was leaving for break but did not report to them that Resident #1 was still up. The NA added that she assumed the other nurse aides knew to monitor her residents while she was on break. The NA explained that when she returned from break she was told Resident #1 fell and was injured. On 03/10/15 at 11:15 AM the Nurse Supervisor was interviewed and reported she was working the night of 02/18/15 and heard Resident #1 yelling from inside the room. The Nurse Supervsior stated Resident #1 sounded like she was in distress. The Nurse Supervisor opened Resident #1's door and found the resident in the floor and called for help. The Nurse Supervisor added that Resident #1 was unable to report what happended and was crying. The Nurse Supervisor reported that Resident #1's personal alarm was not sounding. She explained that she did not investigate to determine why the alarm was not sounding because her priority was the injured resident. The Nurse Supervisor added that Resident #1's door was closed and that the door to the resident's room should not have been closed because the resident was at risk for falls and required frequent monitoring. On 03/10/15 at 1:15 PM Nurse #1 was interviewed and reported that NA #1 did not report Resident #1 had been combative with care and was still up when the nurse aide left for break. Nurse #1 added that she would expect nurse aides to report incidents of residents being combative and/or resisting care.