Every finding on record at NHC HealthCare - Anderson

Based on review of the facility policy, observations and interviews, the facility failed to ensure biologicals were kept sterile in 1 of 6 medication rooms. Findings include: Review of the facility policy, revised 01/01/19, titled, Medication Storage in the Facility revealed, Expiration Dating (Beyond-use dating) J. Disposal of any medications prior to the expiration dating will be required if contamination or decomposition is apparent. An observation on 09/10/24 at 8:08 AM of the Medication Room on Hall 600 revealed the following: -Aquacel Ag Foam, Manufacturer-Convatec- 20 centimeters (cm)x20cm, 8inch x 8inch Sterile dressing was open and cut in half. There was an expiration date of 02/01/27, Lot#(10)4800949, with no open date. -Acticoat flex3, Manufacturer- [NAME] & Nephew- 10cm x 10cm, 4in x 4in Sterile was open without an open date and expiration date of 06/01/26, Lot#(10)2335 Ref# 66800406. -Aquacel Ag Advantage- Convatec 10cm x12cm, 4in x 5in Sterile was open without an open date and expiration date of 02/01/26, Lot#4302268 Ref#422299. -Allevyn Life, Manufacturer [NAME] & Nephew, 17.2 cm x 17.5 cm Sterile, open without an open date or expiration date, Lot#202410 Ref# 06801300. An interview and observation on 09/10/24 at 8:20 AM with the 600 Hall Nurse Supervisor revealed she was observed discarding open dressings in the trash. The Nurse stated, Open sterile dressings should be discarded, but I question if it is open, but still enclosed in an unopen container. An interview on 09/10/24 at 9:01 AM with the Director of Nursing (DON) revealed a Quality Assurance Performance Improvement (QAPI) document on Single Use Dressing Supplies packet with education to the staff of proper discarding of sterile supplies was conducted on 09/10/24 after the findings. The DON stated, We have educated all of our staff members on how to properly discard sterile dressing. We do use sterile dressings enclosed in a package, due to the sterility being maintained.

Based on review of the facility policy, record review, and interviews, the facility failed to identify the usage of bean bags chairs as a potential restraint for 1 out of 3 Residents, (R)407. Findings include: Review of the facility's Summary of Federal Residents' Rights, #18. States Restraints, the resident has the right to be free from any physical restraints or chemical restraints administered for the purpose of discipline for convenience. Review of an undated Face Sheet provided by the facility revealed R407 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia without behavioral disturbance, psychotic disturbance, anxiety, and fracture of unspecified part of neck of femur. Review of R407's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated R407 had moderate, cognitive impairment. Review of R407's Care Plan with a start date of [DATE] and target date of [DATE] revealed: Problem: Behaviors being observed and/or monitored AEB [as evidenced by] exit seeking, getting up unassisted, removing brief and urinating in floor. Goals: Will accept reassurance from staff as needed for 90 days from last review/update and/or will do no harm to self, others when exhibiting behaviors for 90 days from last review/update. Approach: Offer to call or suggest calling family member (s) when appropriate. Review of a Progress Note dated [DATE] at 10:34 AM, revealed,This nurse called son r/t resident safety concerns. Resident at the desk w staff currently for safety. Resident has been up unassisted several times this shift. Redirection provided and unsuccessful. This nurse provided education of bean bag use to son for residents safety. Residents son agreed to use of bean bag. Pleasant and thankful for phone call. Review of a Progress Note dated [DATE] at 10:39 PM, revealed, Resident resting on bean bag and resting comfortably w eyes closed. No s/sx of pain or discomfort noted. Daughter present at this time for a visit. Staff assisted back in w/c per daughter's request. Daughter pleasant and thankful for care provided by staff. During an interview on [DATE] at 3:31 PM, R407's son and his sister, stated that they have been told on numerous occasions by staff that their father is a fall risk and if they are not going to be in the room with their father, he will have to be at the nurse's station. R407's son stated that their father is often tired and wants to lie down and he is denied from that right. Many times, staff do not put sheets on his bed forcing the resident to endure being left in his wheelchair. Staff stated to the resident's son and daughter, since he's a fall risk, he needs to be in his wheelchair at the nursing station, because he has dementia. R407's son stated he received a call on [DATE], from staff informing him that his father had been getting up from bed and his wheelchair, and they were going to put him in a bed bag chair at the nursing station for his safety. The son stated, although staff tried to make easy with the son over the phone stating putting his father in the bean bag was not a restraint, but they knew that it was; he reluctantly agreed to the facility putting him in the bean bag. During an interview on [DATE] at 10:46 AM, R407's son stated that if he was able to, he would take his father out of the facility right now. R407's son stated that putting his father, who is a Veteran, in a bean bag chair was a restraint. R407's son further stated that his father was not able to get in or out of the bean bag chair unassisted. R407's son concluded that he's not only concerned about his father but all of the resident's in the facility. During an interview on [DATE] at 12:06 PM, Licensed Practical Nurse (LPN)2 stated R407 was in his wheelchair at the nurse's station, he had been trying to get up several times from his bed and repeatedly trying to get up out of his chair unassisted, he seemed agitated and none of the redirection help. LPN2 stated she called the resident's son, and she spoke with him in length and told him about the bean bag chair, the son said he understood and told them his main concern was keeping his father safe. LPN2 further stated, R407 was laid on the bean bag chair for maybe 40 - 45 minutes. The resident's daughter came and sat with him for about maybe another 20 minutes, and then LPN2 along with another staff, got R407 up and put him back in his wheelchair. LPN2 stated the resident was able to get up out of the bean bag chair unassisted. During an interview on [DATE] at 1:13 PM, Certified Nursing Assistant (CNA)3 revealed this was her first day being assigned to R407. CNA3 stated, His behavior was fine, he was not acting sporadic. When I started my shift at 7:00 AM, resident was already in the bean bag chair. I was told by the nurse that he was in the chair for comfort and rest. During an interview on [DATE] at 2:33 PM, the Director of Nursing (DON) revealed the bean bag chairs are used for residents for rest and to prevent falls. The DON stated, If they don't get rest they will crash. My husband used one before he died , he was [AGE] years old and that was the only way he would get any rest. When asked if there are any risk of using the bean bag chair, the DON stated No, the staff still check on them. We don't use them on a regular basis. Staff will make sure that residents are clean and dry. They will reposition residents; like I said that is the only rest and sleep that they get. They won't stay in their rooms. It's more of a good thing then a bad thing. The Medical Director (MD) is aware that we use bean bags, they like them. It does get them some rest. Using bean bag chairs over medication is a win for everyone. The MD have not talked with me about any risks with using bean bag chairs. And there are no policies written for the use of the bean bag chairs. When asked, how often are the staff required to check on the residents; the DON stated, Usually every two hours or often. We do not have a policy that addresses repositioning of residents in bean bag chairs. Staff will reposition residents on their side in the bean bag chairs. When asked is the use of bean bag chairs being used for interventions of falls, the DON stated Yes. The DON stated that the bean bag chairs are cleaned daily. The facility does not have any documentation of the scheduling of the cleaning of the bean bag chairs. Multiple residents use the bean bag chairs, unlike wheelchairs that are assigned to each resident. The facility does not currently monitor use of a bean bag chair. The DON stated the bean bag chairs are not used for restraints. When asked, what do you consider a restraint? The DON stated, A restraint is anything that limits the use of the body. When asked how the facility is assessing residents that have limited mobility issues in regards to the bean bag chairs. The DON stated, the facility works with therapy to ensure that no one is put in a bean bag chair who can not get up independently. The resident is identified by evaluation on admission and re-admission of mobility. No one that is immobiled utilizes the bean bag chair. The DON stated that she can see how the use of a bean bag chair could potentially be a restraint if a resident could not get up and down out of it. The DON further stated a safe amount of time for a resident to be sitting in a bean bag chair would depend on the patient and we ensure that they can get in and out the bean bag independently. They are assessed by therapy. The DON then confirmed that there are not any assessments being done for residents that would ensure their safety while in the bean bag chairs and residents are not care planned for the use of bean bag chairs.

Based on observations, record review, and staff interviews, the facility failed to ensure staff followed adequate transmission-based precautions to prevent the spread of COVID-19. Staff entered the rooms of 4 residents (Resident (R) 629, R143, R630, and R627) out of 8 residents on COVID-19 precautions, who were not up to date on COVID-19 vaccinations and were newly admitted to the facility. Staff did not apply the required personal protective equipment (PPE). These failures placed the residents and staff on Unit 4 at risk for transmission of COVID-19. Findings include: Review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website, accessed on 07/11/22 at https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=South+Carolina&data-type=Risk&list_select_county= , revealed the community transmission level was high. Review of the facility's 07/12/22 Staff Vaccination Matrix, provided by the Infection Preventionist, revealed 55 staff, or 18.82%, were not vaccinated due to granted medical and non-medical exemptions. Per the 02/02/22 CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) . In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission . COVID-19 vaccination should also be offered. Review of the facility's 02/15/22 COVID-19 Policy for: Testing and Quarantine of New Admit and Close Contact Exposure policy revealed, Up to date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible . All patients who are not up to date will all recommended COVID-19 vaccine doses and are new admssions and readmissions should be placed in quarantine, even if they have a negative test upon admission . Patients can be removed from Transmission-Based Precautions after day 10 following the new-admit/exposure (day 0) if they do not develop symptoms. Patients can be removed from Transmission-Based Precautions after day 7 following the new-admit/exposure (day 0) if a [CONDITION(S)] test is negative for [CONDITION(S)]-CoV-2 and they do not develop symptoms. 1. Review of the undated Resident Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R629 was admitted to the facility on [DATE] after a hospital stay from 06/22/22 to 07/06/22. R629 was [AGE] years old. Review of R629's undated Preventive Health Care record in the Preventive Health Care tab of the EMR revealed R629 received one dose of a one-dose COVID-19 vaccine on 11/02/21. There was no record of a booster dose; thus, R629 was not up to date. Review of R629's 07/12/22 Active Orders, located in the Orders tab of the EMR, revealed an order, which originated on 07/08/22, for Isolation Precautions Special Instructions: Isolation precautions: droplet precautions r/t [related to] possible COVID-19 exposure. 2. Review of the undated Resident Face Sheet, located in the Face Sheet tab of the EMR, revealed R143 was admitted to the facility on [DATE] after a hospital stay from 06/13/22 to 06/24/22. R143 was [AGE] years old. Review of R143's undated Preventive Health Care record in the Preventive Health Care tab of the EMR revealed R143 refused COVID-19 vaccination. R143 resided in the room with R629, who was on COVID-19 precautions for recent admission. 3. Review of the undated Resident Face Sheet, located in the Face Sheet tab of the EMR, revealed R630 was admitted to the facility on [DATE] after a hospital stay from 06/26/22 to 07/06/22. R630 was [AGE] years old. Review of R630's undated Preventive Health Care record in the Preventive Health Care tab of the EMR revealed R630 received her first dose of a two-dose COVID-19 vaccine on 06/24/21 and the second dose on 07/20/22. R630 received her first booster dose on 09/14/21. There was no record of a second booster dose; thus, R630 was not up to date. Review of R630's 07/12/22 Active Orders, located in the Orders tab of the EMR, revealed an order, which originated on 07/08/22, for Isolation Precautions Special Instructions: (droplet, contact, COVID) per admission guidelines. 4. Review of the undated Resident Face Sheet, located in the Face Sheet tab of the EMR, revealed R627 was admitted to the facility on [DATE] after a hospital stay from 06/16/22 to 06/22/22. R627 was [AGE] years old. Review of R627's undated Preventive Health Care record in the Preventive Health Care tab of the EMR revealed R627 received her first dose of a two-dose COVID-19 vaccine on 01/23/21 and the second dose on 02/12/21. R627 received her first booster dose on 09/22/21. There was no record of a second booster dose; thus, R627 was not up to date. R627 resided in the room with R630, who was placed on COVID-19 precautions as a new admission. On 07/11/22 at 1:24 PM, a Certified Occupational Therapy Assistant (COTA) and Physical Therapy Assistant (PTA) entered the shared room of R143 and R629 to provide treatment to R629. Both residents were in the room. Both the COTA and PTA were wearing N-95 masks, gowns, and gloves; however, neither were wearing eye protection. A sign on the room door read, COVID-19 Precautions: Use droplet and contact precautions. Wear gown, gloves, mask, and shield. A second sign on the door read, Everyone must . make sure their eyes, nose, and mouth are fully covered before room entry. On 07/11/22 at 2:06 PM, the PTA stated she had provided direct care to R629 doing certain standing and strengthening exercises. The COTA stated also stated she had provided direct care to R629 working on upper body strength. On 07/13/22 at 4:35 PM, the PTA stated she did not don eye protection during the above observation because, I just honestly forgot. The PTA stated she had received training on proper PPE use in COVID-19 precaution rooms. On 07/11/22 at 1:37 PM, a Physical Therapist (PT)1 entered the shared room of R627 and R630 without wearing a gown, gloves, or eye protection. She was wearing a surgical mask only. She spoke with R627 and a visitor in the room and then closed the door and remained in the room for approximately five minutes. A sign on the room door read, COVID-19 Precautions: Use droplet and contact precautions. Wear gown, gloves, mask, and shield. A second sign on the door read, Everyone must . make sure their eyes, nose, and mouth are fully covered before room entry. On 07/13/22 at 4:30 PM, PT1 stated she had received training on the use PPE and transmission-based precautions. PT1 stated a gown, gloves, face shield, and an N-95 mask were required in the rooms on COVID-19 Precautions. PT1 stated she did not don PPE during the above observation because she was under the impression that only R630 was on isolation, and R630 was not in the room at the time. Also, she was not in the room to provide direct care to the resident. PT1 stated that she found out later that R627 was also considered on isolation and all PPE was required to enter the room. On 07/11/22 at 1:40 PM, Housekeeper (HK)1 stated for rooms on COVID-19 precautions, staff were required to wear a gown, N-95 mask, face shield, and gloves. HK1 stated she had received training on proper use of PPE. On 07/12/22 at 11:39 AM, Housekeeper (HK)1 entered the shared room of R627 and R630 with both residents in the room wearing a gown, gloves, and face shield; however, she was only wearing a surgical mask that was pulled down below the nose. HK1 closed the door behind her and remained in the room for over 10 minutes. A sign on the room door read, COVID-19 Precautions: Use droplet and contact precautions. Wear gown, gloves, mask, and shield. A second sign on the door read, Everyone must . make sure their eyes, nose, and mouth are fully covered before room entry. On 07/13/22 at 4:00 PM, the Infection Preventionist (IP) stated the staff were expected to follow the guidelines posted on the door for appropriate PPE to wear when entering the rooms. The IP stated all staff, including housekeeping and therapy staff, received training on transmission-based precautions and use of PPE at orientation and annually. On 07/13/22 at 5:08 PM, the IP confirmed all housekeeping and therapy staff had been re-trained on use of PPE.

Based on record review and staff interviews, the facility failed to ensure the accurate staging of a pressure ulcer on the assessment for 1 resident (Resident (R) 103) of 3 residents reviewed for pressure ulcers out of a total of 37 sampled residents. R103's admission Minimum Data Set (MDS) assessment documented a stage two (break in the top two layers of skin), rather than unstageable (ulcer covered with dead tissue), pressure ulcer. This failure had the potential to lead to a lack of adequate care planning to heal R103's pressure ulcer. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) MDS 3.0 RAI Manual v1.17.1, October 2019, accessed at https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf revealed, Identify Unstageable Pressure Ulcers 1. Visualization of the wound bed is necessary for accurate staging. 2. If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer's/injury's anatomical tissues remain obscured such that the extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable. 3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable, as illustrated at http://www.npuap.org/wp-content/uploads/2012/03/NPUAP-Unstage2.jpg . Coding Instructions . Enter the number of pressure ulcers that are unstageable related to slough and/or eschar . Enter the number of these unstageable pressure ulcers related to slough and/or eschar that were first noted at the time of admission/entry . Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined. Review of R103's admission MDS assessment, with an Assessment Reference Date (ARD) of 05/17/22, revealed she was admitted to the facility on [DATE]. The MDS documented R103 was at risk for pressure ulcers and had one stage-two pressure ulcer that was present on admission. No unstageable wounds were documented. Review of the 05/11/22 Admission Observation, located in the Observations tab of the electronic medical record (EMR),revealed R103 had an unstageable pressure ulcer to her left heel that measured 3 centimeters (cm) long and 3 cm wide. Review of R103's 05/11/22 Care Plan, revised 06/30/22, in the RAI [Resident Assessment Instrument] tab of the EMR revealed, Problem: Skin integrity/pressure areas, at risk for r/t [related to] impaired mobility, incontinent episodes of bowel; admitted with Left Heel Un-stageable area. The approaches included: apply [padded] boots to BLE [bilateral lower extremities] while in bed for protection . Offer 30 ml [milliliters] ProHeal Protein Supplement BID [twice daily] . Skin care as ordered: [MEDICATION(S)] [antiseptic solution] 10% Left Heel Un-stageable area: Clean with normal saline or wound cleanser; allow to dry; paint with [MEDICATION(S)] daily; leave open to air . Observe skin for redness/breakdown . Pressure reducing mattress to bed . [and] Skin assessments weekly. Review of the 07/12/22 Active Orders found in the Orders tab of the EMR, revealed an order to treat a left heel un-stageable area every day: clean with normal saline or wound cleanser; allow to dry; paint with [MEDICATION(S)] every shift; leave open to air. The order was started on 06/29/22. Review of the undated Order history found in the Orders tab of the EMR revealed an order to treat a left heel un-stageable wound every shift: clean with normal saline or wound cleanser; allow to dry; paint with [MEDICATION(S)] every shift; leave open to air. The order was active from 05/12/22 to 06/29/22. Review of the weekly Wound Management Detail Reports, printed out and provided by the Director of Nursing (DON), revealed the presence of an unstageable pressure ulcer to the left heel, that was present on admission, was documented on 05/11/22, 05/18/22, 05/24/22, 05/31/22, 06/07/22, 06/14/22, 06/21/22, 06/28/22, and 07/05/22. In an interview on 07/13/22 at 10:09 AM, Unit Manager (UM) 4 stated R103 had an unstageable pressure ulcer since admission. UM4 stated the pressure ulcer was considered unstageable because it had been covered with a large scab and dead tissue, and the tissue underneath was not observable to determine the stage of the wound. UM4 stated the wound had been present since admission and she did not recall the wound ever being a stage two. In an interview on 07/13/22 at 12:40 PM, the DON stated the wound should have been coded as unstageable on the MDS. The DON stated the facility did not have a policy addressing MDS Accuracy, but the facility referred to the RAI Manual for direction on accurate coding of skin conditions. In an interview on 07/13/22 at 12:56 PM, the MDS Coordinator (MDSC) stated she relied on documentation on weekly wound management sheets and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated R103's ulcer should have been coded as unstageable.

Based on staff interviews and record review, the facility failed to ensure that 2 residents (Resident (R) 98 and R368) of 3 residents reviewed for falls had a thorough investigation following a fall to determine root cause of the fall and appropriate interventions needed to prevent recurrence. This failure placed both residents at risk for repeated falls. Findings include: 1. Review of R368's undated Face Sheet located in R368's electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE], with diagnoses including multiple fractures of ribs, left side; subsequent encounter of fracture with routine healing; spondylolisthesis (a spinal disorder in which a bone (vertebra) slips forward onto the bone below it); spinal stenosis cervical region; and history of falling. Review of R368's admission Minimum Data Set (MDS) assessment, located in R368's EMR under the RAI (Resident Assessment Instrument) tab, with an Assessment Reference Date (ARD) of 04/01/22 revealed R368's Brief Interview of Mental Status (BIMS) was scored as 15 out of 15, indicating the resident was cognitively intact. R368 required extensive assistance with bed mobility, transfers, and ambulation, and toilet use by one staff member. Further review of the MDS indicated R368 has had a fall with a fracture in the month prior to admission but had not fallen since facility admission. Review of R368's 03/28/22 Care Plan, located in the RAI tab of the EMR, revealed R368 was at risk for falls related to decreased mobility, history of falls, and use of [CONDITION(S)] medications. The approaches included: provide therapy for bed mobility, therapeutic exercise, gait training, and group therapy; assist with safe transfers from bed to chair, educate the resident on calling for assistance before getting up, alert staff to resident's risk for falls, monitor for environmental hazards, place personal items within the resident's reach, ensure use of safe footwear with nonskid treads, and provide assistive devices as needed. Review of R368's nursing Progress Note, written on 04/04/22 at 8:06 PM, located in the EMR under the Progress Notes tab, revealed Licensed Practical Nurse (LPN) 3 documented, Resident was being cleaned by staff in room in bed, when resident rolled to right side to be cleaned, resident rolled off the side of bed. Staff lowered resident to the ground during fall. Resident has complained of [c/o] right knee pain, PRN [as needed] pain meds to be given per order. Family notified and thankful for call. MD [Medical Doctor] notified. Resident in bed in room resting, call light in reach. Review of R368's Event Report, dated 04/04/22, located in the EMR under the Events tab revealed, Description of event: resident rolled in bed-while staff were cleaning resident and rolled off the bed . interventions-immediate measures taken included rest and floormats and the fall was witnessed . orders: 12 weeks fall safety documentation, special instructions: 12-week safety documentation for safety intervention effectiveness . 72 post fall documentation. The Event Report did not contain a documented interview with the certified nurse aide (CNA) who witnessed the fall, the name of the CNA witness, or interview with the resident, even though the resident's cognition was not impaired. Review of R368's Care Plan, updated on 04/04/22, revealed the addition of the intervention to provide floor mats next to the resident's bed was added to the falls Care Plan. There were no new interventions added to address the root cause of the fall or potential assistive devices that could be trialed to prevent recurrence. A request for further documentation was made on 07/12/22 from LPN2 and on 07/13/22 from the Administrator and Assistant Director of Nursing (ADON)1 of witness and resident interviews related to fall incident on 04/04/22. The facility was unable to provide the requested documentation. ADON1 stated the Event Report was where all fall documentation and investigation notes were kept. During an interview on 7/11/22 at 1:03 PM, R368's Power of Attorney (POA) reported that R368 had passed away shortly after being discharged from facility. The POA explained the fall on 04/04/22 was first reported to her by R368, who stated she was on the bedpan in her bed when Certified Nurse Aide (CNA) 4 had pushed her off the bedpan and onto the floor. During an interview on 07/12/22 at 9:00AM, LPN2 stated she was the person to finish and close out the fall event report for R368's 04/04/22 fall. LPN2 explained that she investigated the falls on the hall where R368 was located. LPN2 stated CNA4 was helping R368 off the bed pan and that R368 started to roll too far, so CNA4 reached over and assisted the resident to the floor. LPN2 stated she did not have any interview notes from staff or the resident available and that the Event Report located in the EMR was all that was available. During an interview on 07/12/22 at 10:26 AM, LPN3 stated CNA4 had reported to him that she was on the door side of the room while R368 was on the bed pan in her bed. CNA4 had R368 roll toward the window side of the room to remove the bed pan and noticed R368 was rolling too far. CNA4 tried to assist the resident as well as possible to the floor. R368 required assistance by only one staff member with bed mobility. When questioned about documentation pertaining to falls, LPN3 responded that if the resident complained of pain, then there would be additional paperwork. But if not, there would be a note in the nursing Progress Notes after the event file had been opened. During an interview on 07/12/22 at 10:35 AM, CNA4 stated she was helping R368 off the bed pan and R368 started to roll off the bed. CNA4 reached over and assisted R368 onto the floor. CNA4 stated she did not remember all details of the event. During an interview with the Administrator and ADON1 on 07/13/22 at 11:30 AM, the Administrator explained all information and documentation related to the fall was located on the Event Report and that there was no documentation of interviews with the resident and/or witnesses. 2. Per the undated Resident Face Sheet, located in the Face Sheet tab of the EMR, R98 was admitted to the facility on [DATE]. Per the Medical Diagnosis tab in the EMR, R98 had diagnoses of hip fracture, [CONDITION(S)], and [CONDITION(S)]. Review of R98's admission MDS assessment, with an ARD of 02/18/22 and located in the RAI tab of the EMR, revealed R98 had a fall with a fracture prior to facility admission. She had not fallen since admission to the facility. R98 required extensive assistance by one staff member with bed mobility and transfers and had unsteady balance with transfers and walking. The BIMS score was 13 out of 15, indicating minimally impaired cognition. Review of R98's 02/14/22 fall risk Care Plan, found in the RAI tab of the EMR, revealed that interventions put in to place upon admission were as follows: low bed with bedside floor mats, assist patient in safe transfer techniques as needed for transfer from bed to chair, educate R98 on importance of calling for assistance before getting up, and post call before you fall signs in resident's room. Review of a 03/22/22 Event Report, located in the Events tab of the EMR, documented R98 experienced an unwitnessed fall and was found sitting on the floor at her bedside. Under the Event Details section of the report, the type of fall was marked as found on floor. The location of the fall was marked as resident room. The section labeled What was the resident doing just prior to the fall was marked Res [resident] stated she was standing up. The Event Report also documented that there were no changes to R98's mental status, and that possible contributing factors to the fall could be her neurological disorder. The report indicated that her physician and resident representative were notified and the Care Plan in place was reviewed. R98 had a bruise above her left eye but reported no pain at that time. She was sent to the Emergency Department on 03/23/22 after complaining of discomfort in her left hand. Upon examination and X-ray, it was found that R98 had a non-displaced fracture at the base of the fourth finger on her left hand. No abnormalities were found in the X-ray to the left side of her face. R98's hand was splinted, she was given [MEDICATION(S)] as needed for pain, and she was sent back to the facility. Though 03/22/22 Event Report documented R98 said she was attempting to stand up when she fell . It did not document the specific circumstances, such as if she was getting up from the bed or wheelchair, what type of footwear she was wearing, the reason the resident was trying to stand, or the placement and functioning of the call light. Review of R98's Care Plan, located in the RAI tab of the EMR, revised on 03/31/22 and 06/07/22, revealed she required extensive assistance with bed mobility, toileting, transfers, and activities of daily living, and was at high risk for falls related to gait/balance problems, vision impairment, limited mobility, and limited safety awareness. The approaches included: -Continue to keep soft touch call light within reach; -Apply Dycem [a sticky mat to prevent slipping] to wheelchair for added fall prevention; -Continue using the Call Before You Fall signage as a reminder; -Continue to keep low bed with side fall mats; -Continue placing personal items within reach; -Educate resident on importance of calling for assistance before getting up; -Continue use of safe footwear with non-skid treads; -Monitor environmental hazards; [and] -Continue to remind staff of resident's risk for falls. The Care Plan did not reflect any new interventions to address the root cause of the 03/22/22 fall. On 07/12/22, Assistant Director of Nursing (ADON)1 reported that the facility did not keep documentation of resident or staff interviews surrounding an incident in their EMR. She stated the information was completed on worksheets and sent to their Regional Office but were not available to facility staff after 72 hours had passed. ADON1 stated that any documentation of the event was simply reported in the resident's Progress Notes or on the Event Report; the facility did not use an official Investigation Report form. When asked about how she determined the root cause analysis of the fall, the ADON1 was unable to clearly provide distinct information on the facility's process. On 07/12/22 and 07/13/22, requests were made to speak to the Falls Nurse (FN), who was the staff person responsible for the facility's fall information and documentation; however, the FN did not appear for interview and ADON1 stated she would answer the questions. On 7/13/22, the facility was asked to provide documentation of their Falls Policy. They provided an undated policy, typed on blank copy paper and titled, Fall Safety with little information to show that an active fall prevention program was in place and fall incidents were monitored and investigated as required. The policy did not address completing a root cause analysis or an incident investigation including any contributing factors and interviews with the resident, staff, or witnesses. The policy documented, Purpose: To assess resident for risk of fall and initiate appropriate interventions. Procedure: When a fall occurs, assess resident status. Assess position of the resident immediately after the fall. Notify MD [medical doctor] and responsible part of fall. Review situation regarding the fall and initiate the appropriate intervention as necessary.

Based on record review and staff interviews, the facility failed to ensure weekly skin assessments documented the presence of an unstageable (ulcer covered with dead tissue) pressure ulcer for 1 resident (Resident (R) 103) of 3 residents reviewed for pressure ulcers out of a total of 37 sampled residents. This failure had the potential to cause a lapse in treatment and lack of monitoring of the pressure ulcer for R103. Findings include: Review of the facility's undated policy titled, Skin Assessments, which was typed on a blank piece of paper without facility letterhead, revealed, Skin assessments are documented via the EHR [electronic health record] . 1. Admission Skin Assessment: skin should be observed within 8 hours of admission and documented not later than 24 hours of admission via the EHR. The Admission Observation or Wound Management entry includes a body diagram to mark location of skin integrity. The nurse should use as much description as possible to describe the wound . 2. Ongoing Skin assessment: All patients' skin is assessed on a weekly basis by a licensed nurse and findings are documented in the Weekly Skin Observation. 3. Pressure ulcer and other wound documentation: Documentation requirements are the same for all types of wounds with the addition of staging requirements for pressure ulcers. Assessments are completed weekly and when applicable include location of ulcer, staging, . [etc.]. Review of R103's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/17/22, revealed she was admitted to the facility on [DATE]. Staff assessed R103's cognition as severely impaired with memory problems. The MDS documented R103 was at risk for pressure ulcers and had one stage-two pressure (break in the top two layers of skin) ulcer that was present on admission. No unstageable wounds were documented (cross-reference F641: Accuracy of Assessments). Review of the 05/11/22 Admission Observation, located in the Observations tab of the electronic medical record (EMR), revealed R103 had an unstageable pressure ulcer to her left heel that measured 3 centimeters (cm) long and 3 cm wide. Review of R103's 05/11/22 Care Plan, revised 06/30/22, in the RAI [Resident Assessment Instrument] tab of the EMR revealed, Problem: Skin integrity/pressure areas, at risk for r/t [related to] impaired mobility, incontinent episodes of bowel; admitted with Left Heel Un-stageable area. The approaches included: Skin assessments weekly. Review of the 07/12/22 Active Orders found in the Orders tab of the EMR, revealed an order to treat a left heel un-stageable area every day: clean with normal saline or wound cleanser; allow to dry; paint with [MEDICATION(S)] every shift; leave open to air. The order was started on 06/29/22. Review of the undated Order history found in the Orders tab of the EMR revealed an order to treat a left heel un-stageable wound every shift: clean with normal saline or wound cleanser; allow to dry; paint with [MEDICATION(S)] every shift; leave open to air. The order was active from 05/12/22 to 06/29/22. Review of the weekly Wound Management Detail Reports, printed out and provided by the Director of Nursing (DON), revealed the presence of an unstageable pressure ulcer to the left heel that was present on admission and was documented on 05/11/22, 05/18/22, 05/24/22, 05/31/22, 06/07/22, 06/14/22, 06/21/22, 06/28/22, and 07/05/22. Review of R103's Weekly Skin Observations, located in the Observations tab of the EMR, revealed assessments were completed 05/17/22, 05/31/22, 06/08/22, 06/14/22, 06/21/22, 06/28/22, and 07/05/22 and contained inconsistent documentation of the presence of the left heel pressure ulcer: a. The 05/17/22 assessment did not document any skin issues. b. The 05/31/22 documented the presence of a left foot wound and documented, see wound management. c. The 06/14/22 Weekly Skin Observation documented a wound to the left foot and documented, See wound sheet. d. The 06/21/22 Weekly Skin Observation documented a wound to the left foot but did not include any additional details. e. The 06/28/22 and 07/05/22 Weekly Skin Observation documented no skin issues. In an interview on 07/13/22 at 10:09 AM, Unit Manager (UM) 4 stated R103 had an unstageable pressure ulcer since admission and should have been reflected on the skin assessments. She stated the pressure ulcer was considered unstageable because it had been covered with a large scab and dead tissue. In an interview on 07/13/22 at 12:40 AM, the DON stated the skin assessments that did not reflect a left heel pressure ulcer were inaccurate.

Based on random observation, interview, and review of the facility policy titled, Infection Control Manual Transmission- Based Procedures the facility failed to ensure that Resident #99 and Emergency Medical Staff (E.M.S) had personal protective equipment (PPE) on a droplet precaution unit. The findings included: An observation on 01/21/21 at 1:48 PM of E.M.S Transport Member #1 assisting Resident #99 back into the facility on a stretcher from the hospital. Upon entering the unit, E.M.S was screened by facility staff and allowed to enter the unit. At 1:56 PM E.M.S was observed on a droplet precaution unit without full PPE in Resident #99 room assisting him/her into bed. An interview with EMS Staff #1 and #2 at 2:08 PM stated that they were unaware that the unit was on droplet precautions and to enter a room that they needed a gown, face shield, n95 mask, and gloves. An interview with Licensed Practice Nurse (L.P.N.) #1, Registered Nurse (R.N.) #1 and RN#2 at approximately 2:15 PM revealed that everyone entering rooms on the droplet precaution unit are required to wear full PPE when entering a resident 's room. An interview with the Director of Nurses (D.O.N.) at approximately 2:45 revealed that EMS staff not wearing full PPE on droplet precaution units has been an ongoing issue and that they have been educated on the importance of wearing full PPE to minimize the spread of germs. On 1/21/2021 at approximately 3:00 review of the facility policy titled Infection Control Manual Transmission- Based Procedures stated, under Patient Transport When transport is necessary, assure that precautions are taken to minimize the risk of transmission of microorganisms to other patients and the environment.

Based on record review and interview, the facility failed to ensure the Approach (Interventions) on the Care Plan for Anticoagulant Monitoring continued to be included on the Care Plan for Resident #42 for each quarterly review. The findings include: A review of Resident #42 ' s Care Plan revealed no anticoagulant monitoring interventions such a signs and symptoms for bleeding, bruising, etc for the drug Eliquis 2.5 milligrams which is currently given twice a day for [MEDICAL CONDITION] Fibrillation in the Approach(Interventions) on the Care Plan for the last quarter dated 11/09/2020. The Problem start date was 8/15/2019. Staff # 3 was interviewed on 01/20/2021 at 3:30 PM and stated he/she would investigate. Staff #3 presented an updated new version of the Problem, Goal, Approach, and Discipline marked Edited 01/20/2021 by Staff #3 with the Interventions included. Staff #3 admitted he/she edited the Care Plan to include the missing Anticoagulant interventions. In an additional interview with Staff #3 and Staff #4 on 01/20/2021 at 3:35 PM, Staff #4 confirmed the Interventions were dropped off of the Care Plan. Staff #4 presented a copy of information on the Care Plan History indicating the Anticoagulant Monitoring interventions for Eliquis were deleted on 02/17/2020. The facility ' s Documentation Guidelines for Inpatient Medical Records, VII-6 R(revised)-7/3/08, states 13. Updating and Revising Care Plans a. Routine Reviews and Updates. Care plans are updated as needed, but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of the completion (R2b date) of the clinical MDS assessment.

Based on interview, record review and observation, the facility failed to investigate and report an allegation of resident to resident abuse. This affected two of 28 sampled residents. Resident #84 poured soda on Resident #130's head on 3/24/19. According to staff interviews multiple staff were aware of the incident on the day that it occurred, the facility failed to thoroughly investigate and report to the State Agency. The findings include: During the initial resident interview on 03/26/19 at 11:33 AM, Resident #84 stated that s/he needed to confess to something s/he did during the previous weekend (3/24/19). Resident #84 stated that while sitting in the day room, the Certified Nursing Assistants (CNAs) were busy helping other residents and Resident #84 was mad that they weren't helping her/his roommate (Resident #130). Resident #130 was trying to pour soda into her/his coffee, and Resident #84 didn't want to see her/his roommate ruin her/his coffee. Resident #84 poured the can of soda over her/his roommate's head. Resident #130 is severely cognitively impaired and unable to be interviewed. Review of Resident #84's clinical record revealed an admission history form dated 11/14/14. The admission history documented Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, documented that the resident had no memory impairment, brief interview for mental status (BIMs) of 15, and s/he was supervised at a wheelchair level for mobility around the facility. Review of Resident #84's Plan of Care (P[NAME]) for mood, dated 02/08/19 documented an approach that stated, Resident very upset when other residents do not do what (s/he) requests. Redirected and very upset. Continued under the P[NAME] for mood was documented, Patient is moderately impaired with daily decision making. The approach was to encourage interactions with others, assisting others with tasks had always brought (her/him) pleasure. Review of Resident #130's quarterly minimum data set (MDS) assessment, dated 02/18/19, revealed Resident #130 had a BIMS of 04; severe cognitive impairment. Resident #130 was unable to be interviewed. Resident #130 required extensive assistance of two people for all of her/his ADLs. Review of Residents #130's medical record revealed no documentation of the incident on 3/24/19 with Resident #84. On 03/26/18 at 4:08 PM, Registered Nurse (RN) #195 was interviewed. RN #195 was the Unit Supervisor. RN #195 stated that s/he was not there when the incident occurred on 3/24/19. RN #195 stated that last weekend (3/24/19) Resident #84 was helping her/his roommate with a soda and then reported spilling it over her/his head. RN #195 stated that s/he had not done any type of investigation into the incident. On 03/26/18 at 4:45PM, RN #169 was interviewed. RN #169 stated that s/he was the House Supervisor that day (3/24/19). RN #169 stated that at approximately 2:00 PM, RN #169 received a call from the Station 200 nurse (Licensed Practical Nurse #163) requesting her/him to bring over a shower cap because one resident had just poured a can of soda over Resident #130's head. RN #169 stated that s/he only interviewed Resident #84 because Resident #84 stated it was an accident. RN #169 stated that staff had reported to her/him that Resident #84 poured a can over her/his roommate's head. RN #169 stated that s/he did not interview any of the staff to see if anyone was witness to the incident. On 03/26/18 at 5:00 PM, Resident #84 was interviewed by RN #169 and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. On 03/26/18 at 5:32PM, Resident #84 was interviewed by the Nursing Home Administrator (NHA) and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. Resident #84 stated that s/he did not want to harm her/his roommate and that s/he felt bad that s/he did it. On 03/27/19 at 9:01 AM, Resident #84's daughter and son-in-law were interviewed. The daughter stated when they arrived at the facility the day of the incident on 3/24/19, s/he was informed by two unnamed CNAs that he/his (mother/father) (Resident #84) had just poured a can of soda over her/his roommate's head. The daughter asked Resident #84 day it happened (3/24/19) why s/he poured the soda over her/his roommate's head. The resident replied s/he wanted one of the CNAs to come help her/his roommate eat. While the family was visiting Resident #84 on 3/24/19, RN #169 came down to find out why s/he had poured a can of soda over her/his roommate's head. The daughter stated her/his (mother/father) changed her/his story while talking to RN #169, saying it was an accident. The family member stated RN #169 indicated this incident was very concerning and that (s/he) was going to have to file a report. On 03/27/19 at 10:13 AM, LPN #163 was interviewed. LPN #163 was the charge nurse on Station 200 at the time of the incident on 3/24/19. LPN #163 stated about 2:00 PM s/he heard Resident #84 yell for someone to bring her paper towels. Resident #84 told LPN #163 that s/he did not want her/his roommate to ruin her/his coffee by pouring soda into it. When Resident #84 tried to assist her/his roommate, the roommate jerked her/his hand back causing the drink to spill. LPN #163 stated that s/he called for the House Supervisor (RN #169) to bring her a dry shower cap and talk to Resident #84. LPN #163 stated that s/he did not document anything in Resident #84's medical record. On 03/27/19 at 11:39 AM, CNA #240 was interviewed. CNA #240 stated that s/he was walking through the station 200-day room on 3/24/19 when Resident #84 was saying something about her/his roommate trying to mix her/his coffee with another drink. S/he stated that Resident #84 seemed confused. CNA #240 sated that s/he continued to walk on once Resident #84 told her/him to go back home. On 03/27/19 at 11:57 AM, CNA #214 was interviewed. CNA #214 stated that s/he was in the station 200-day room, but her/his back was to Resident #84 and her/his roommate. CNA #214 heard the roommate make a startled sound and turned around to see what happened. The roommate's hair was wet and dripping a bit. Resident #84 stated that s/he was trying to stop her/his roommate from pouring the soda into her/his coffee. CNA #214 stated that s/he only attended to the roommate to get her/him cleaned up. On 03/27/19 at 4:59PM, LPN #249 was interviewed. LPN #249 stated that in the shift change report on 3/24/19, LPN #163 stated that there had been an incident where Resident #84 poured a can of soda over her/his roommate's head. LPN #249 stated that when s/he went to give Resident #84 her/his medications on 3/24/19, Resident #84 stated to LPN #249 I guess you heard what I did earlier today. LPN #249 stated that Resident #84 was apologetic. The facility had a policy entitled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 08/01/01 and revised on 11/28/16. The policy, in part, documented under #3. Training Policy - Policy: The center will train all partners, through orientation, and ongoing in-services, on the prevention, identification, investigation and reporting of abuse, neglect, misappropriation of patient property and exploitation. Documented under #5. Identification Policy - Policy: Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria: 7. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action. #6. Reporting Policy - Policy: Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect misappropriation of patient property or exploitation must report the event immediately, no later than two hours if the allegation involves abuse or serious bodily injury, but not to exceed 24 hours. All allegations of possible abuse, neglect, misappropriation of patient property or exploitation will be immediately assessed to determine the appropriate direction of the investigation.

Based on interview, record review and observation, the facility failed to report an allegation of resident to resident abuse. This affected two of 28 sampled residents. Resident #84 poured soda on Resident #130's head on 3/24/19. According to staff interviews multiple staff were aware of the incident on the day that it occurred, the facility failed to report this incident to the State Agency. The findings include: During the initial resident interview on 03/26/19 at 11:33 AM, Resident #84 stated that s/he needed to confess to something s/he did during the previous weekend (3/24/19). Resident #84 stated that while sitting in the day room, the Certified Nursing Assistants (CNAs) were busy helping other residents and Resident #84 was mad that they weren't helping her/his roommate (Resident #130). Resident #130 was trying to pour soda into her coffee, and Resident #84 didn't want to see her/his roommate ruin her/his coffee. Resident #84 poured the can of soda over her/his roommate's head. Resident #130 is severely cognitively impaired and unable to be interviewed. Review of Resident #84's clinical record revealed an admission history form dated 11/14/14. The admission history documented Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, documented that the resident had no memory impairment, brief interview for mental status (BIMs) of 15, and s/he was supervised at a wheelchair level for mobility around the facility. Review of Resident #84's Plan of Care (P[NAME]) for mood, dated 02/08/19 documented an approach that stated, Resident very upset when other residents do not do what (s/he) requests. Redirected and very upset. Continued under the P[NAME] for mood was documented, Patient is moderately impaired with daily decision making. The approach was to encourage interactions with others, assisting others with tasks had always brought (her/him) pleasure. Review of Resident #130's quarterly minimum data set (MDS) assessment, dated 02/18/19, revealed Resident #130 had a BIMS of 04; severe cognitive impairment. Resident #130 was unable to be interviewed. Resident #130 required extensive assistance of two people for all of her/his ADLs. Review of Residents #130's medical record revealed no documentation of the incident on 3/24/19 with Resident #84. On 03/26/18 at 4:08 PM, Registered Nurse (RN) #195 was interviewed. RN #195 was the Unit Supervisor. RN #195 stated that s/he was not there when the incident occurred on 3/24/19. RN #195 stated that last weekend (3/24/19) Resident #84 was helping her/his roommate with a soda and then reported spilling it over her/his head. RN #195 stated that s/he had not done any type of investigation into the incident. On 03/26/18 at 4:45PM, RN #169 was interviewed. RN #169 stated that s/he was the House Supervisor that day (3/24/19). RN #169 stated that at approximately 2:00 PM, RN #169 received a call from the Station 200 nurse (Licensed Practical Nurse #163) requesting her/him to bring over a shower cap because one resident had just poured a can of soda over Resident #130's head. RN #169 stated that s/he only interviewed Resident #84 because Resident #84 stated it was an accident. RN #169 stated that staff had reported to her/him that Resident #84 poured a can over her/his roommate's head. RN #169 stated that s/he did not interview any of the staff to see if anyone was witness to the incident. Review of the facility Abuse Complaint Reporting Guidelines revealed 4. Obtain written statements from the employee and any witnesses. On 03/26/18 at 5:00 PM, Resident #84 was interviewed by RN #169 and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. On 03/26/18 at 5:32PM, Resident #84 was interviewed by the Nursing Home Administrator (NHA) and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. Resident #84 stated that s/he did not want to harm her/his roommate and that s/he felt bad that s/he did it. On 03/27/19 at 9:01 AM, Resident #84's daughter and son-in-law were interviewed. The daughter stated when they arrived at the facility the day of the incident on 3/24/19, s/he was informed by two unnamed CNAs that he/his (mother/father) (Resident #84) had just poured a can of soda over her/his roommate's head. The daughter asked Resident #84 day it happened (3/24/19) why s/he poured the soda over her/his roommate's head. The resident replied s/he wanted one of the CNAs to come help her/his roommate eat. While the family was visiting Resident #84 on 3/24/19, RN #169 came down to find out why s/he had poured a can of soda over her/his roommate's head. The daughter stated her/his (mother/father) changed her/his story while talking to RN #169, saying it was an accident. The family member stated RN #169 indicated this incident was very concerning and that (s/he) was going to have to file a report. On 03/27/19 at 10:13 AM, LPN #163 was interviewed. LPN #163 was the charge nurse on Station 200 at the time of the incident on 3/24/19. LPN #163 stated about 2:00 PM s/he heard Resident #84 yell for someone to bring her paper towels. Resident #84 told LPN #163 that s/he did not want her/his roommate to ruin her/his coffee by pouring soda into it. When Resident #84 tried to assist her/his roommate, the roommate jerked her/his hand back causing the drink to spill. LPN #163 stated that s/he called for the House Supervisor (RN #169) to bring her a dry shower cap and talk to Resident #84. LPN #163 stated that s/he did not document anything in Resident #84's medical record. On 03/27/19 at 11:39 AM, CNA #240 was interviewed. CNA #240 stated that s/he was walking through the station 200-day room on 3/24/19 when Resident #84 was saying something about her/his roommate trying to mix her/his coffee with another drink. S/he stated that Resident #84 seemed confused. CNA #240 sated that s/he continued to walk on once Resident #84 told her/him to go back home. On 03/27/19 at 11:57 AM, CNA #214 was interviewed. CNA #214 stated that s/he was in the station 200-day room, but her/his back was to Resident #84 and her/his roommate. CNA #214 heard the roommate make a startled sound and turned around to see what happened. The roommate's hair was wet and dripping a bit. Resident #84 stated that s/he was trying to stop her/his roommate from pouring the soda into her/his coffee. CNA #214 stated that s/he only attended to the roommate to get her/him cleaned up. On 03/27/19 at 4:59PM, LPN #249 was interviewed. LPN #249 stated that in the shift change report on 3/24/19, LPN #163 stated that there had been an incident where Resident #84 poured a can of soda over her/his roommate's head. LPN #249 stated that when s/he went to give Resident #84 her/his medications on 3/24/19, Resident #84 stated to LPN #249 I guess you heard what I did earlier today. LPN #249 stated that Resident #84 was apologetic. Review of the facility policy Reporting Policy revealed Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, no later than two our if the allegation involves abuse or serious bodily injury, but no to exceed 24 hours. All allegations of possible abuse, neglect, misappropriation of patient property or exploitation will e immediately assessed to determine the appropriate direction of the investigation . under the Procedure section it revealed All alleged violations and all substantiated incidents will be reported immediately to the Administrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency).

Based on interview, record review and observation, the facility failed to investigate an allegation of resident to resident abuse. This affected two of 28 sampled residents. Resident #84 poured soda on Resident #130's head on 3/24/19. According to staff interviews multiple staff were aware of the incident on the day that it occurred, the facility failed to thoroughly investigate this incident. The findings include: During the initial resident interview on 03/26/19 at 11:33 AM, Resident #84 stated that s/he needed to confess to something s/he did during the previous weekend (3/24/19). Resident #84 stated that while sitting in the day room, the Certified Nursing Assistants (CNAs) were busy helping other residents and Resident #84 was mad that they weren't helping her/his roommate (Resident #130). Resident #130 was trying to pour soda into her coffee, and Resident #84 didn't want to see her/his roommate ruin her/his coffee. Resident #84 poured the can of soda over her/his roommate's head. Resident #130 is severely cognitively impaired and unable to be interviewed. Review of Resident #84's clinical record revealed an admission history form dated 11/14/14. The admission history documented Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, documented that the resident had no memory impairment, brief interview for mental status (BIMs) of 15, and s/he was supervised at a wheelchair level for mobility around the facility. Review of Resident #84's Plan of Care (P[NAME]) for mood, dated 02/08/19 documented an approach that stated, Resident very upset when other residents do not do what (s/he) requests. Redirected and very upset. Continued under the P[NAME] for mood was documented, Patient is moderately impaired with daily decision making. The approach was to encourage interactions with others, assisting others with tasks had always brought (her/him) pleasure. Review of Resident #84's Social Services note dated 1/28/19 revealed Pt. (patient) also cont. (continues) with intrusive behaviors towards other residents care Redirection works at times, some times pt. becomes angry. Review of Resident #130's quarterly minimum data set (MDS) assessment, dated 02/18/19, revealed Resident #130 had a BIMS of 04; severe cognitive impairment. Resident #130 was unable to be interviewed. Resident #130 required extensive assistance of two people for all of her/his ADLs. Review of Residents #130's medical record revealed no documentation of the incident on 3/24/19 with Resident #84. On 03/26/18 at 4:08 PM, Registered Nurse (RN) #195 was interviewed. RN #195 was the Unit Supervisor. RN #195 stated that s/he was not there when the incident occurred on 3/24/19. RN #195 stated that last weekend (3/24/19) Resident #84 was helping her/his roommate with a soda and then reported spilling it over her/his head. RN #195 stated that s/he had not done any type of investigation into the incident. On 03/26/18 at 4:45PM, RN #169 was interviewed. RN #169 stated that s/he was the House Supervisor that day (3/24/19). RN #169 stated that at approximately 2:00 PM, RN #169 received a call from the Station 200 nurse (Licensed Practical Nurse #163) requesting her/him to bring over a shower cap because one resident had just poured a can of soda over Resident #130's head. RN #169 stated that s/he only interviewed Resident #84 because Resident #84 stated it was an accident. RN #169 stated that staff had reported to her/him that Resident #84 poured a can over her/his roommate's head. RN #169 stated that s/he did not interview any of the staff to see if anyone was witness to the incident. On 03/26/18 at 5:00 PM, Resident #84 was interviewed by RN #169 and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. On 03/26/18 at 5:32PM, Resident #84 was interviewed by the Nursing Home Administrator (NHA) and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. Resident #84 stated that s/he did not want to harm her/his roommate and that s/he felt bad that s/he did it. On 03/27/19 at 9:01 AM, Resident #84's daughter and son-in-law were interviewed. The daughter stated when they arrived at the facility the day of the incident on 3/24/19, s/he was informed by two unnamed CNAs that he/his (mother/father) (Resident #84) had just poured a can of soda over her/his roommate's head. The daughter asked Resident #84 day it happened (3/24/19) why s/he poured the soda over her/his roommate's head. The resident replied s/he wanted one of the CNAs to come help her/his roommate eat. While the family was visiting Resident #84 on 3/24/19, RN #169 came down to find out why s/he had poured a can of soda over her/his roommate's head. The daughter stated her/his (mother/father) changed her/his story while talking to RN #169, saying it was an accident. The family member stated RN #169 indicated this incident was very concerning and that (s/he) was going to have to file a report. On 03/27/19 at 10:13 AM, LPN #163 was interviewed. LPN #163 was the charge nurse on Station 200 at the time of the incident on 3/24/19. LPN #163 stated about 2:00 PM s/he heard Resident #84 yell for someone to bring her paper towels. Resident #84 told LPN #163 that s/he did not want her/his roommate to ruin her/his coffee by pouring soda into it. When Resident #84 tried to assist her/his roommate, the roommate jerked her/his hand back causing the drink to spill. LPN #163 stated that s/he called for the House Supervisor (RN #169) to bring her a dry shower cap and talk to Resident #84. LPN #163 stated that s/he did not document anything in Resident #84's medical record. On 03/27/19 at 11:39 AM, CNA #240 was interviewed. CNA #240 stated that s/he was walking through the station 200-day room on 3/24/19 when Resident #84 was saying something about her/his roommate trying to mix her/his coffee with another drink. S/he stated that Resident #84 seemed confused. CNA #240 sated that s/he continued to walk on once Resident #84 told her/him to go back home. On 03/27/19 at 11:57 AM, CNA #214 was interviewed. CNA #214 stated that s/he was in the station 200-day room, but her/his back was to Resident #84 and her/his roommate. CNA #214 heard the roommate make a startled sound and turned around to see what happened. The roommate's hair was wet and dripping a bit. Resident #84 stated that s/he was trying to stop her/his roommate from pouring the soda into her/his coffee. CNA #214 stated that s/he only attended to the roommate to get her/him cleaned up. On 03/27/19 at 4:59PM, LPN #249 was interviewed. LPN #249 stated that in the shift change report on 3/24/19, LPN #163 stated that there had been an incident where Resident #84 poured a can of soda over her/his roommate's head. LPN #249 stated that when s/he went to give Resident #84 her/his medications on 3/24/19, Resident #84 stated to LPN #249 I guess you heard what I did earlier today. LPN #249 stated that Resident #84 was apologetic. Review of the facility policy Internal Investigation Policy revealed All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. Under the Procedure section it revealed a. The investigation is conducted immediately under the following circumstances: i. When it is identified that an alleged incident may have occurred. ii. As soon as any partner has knowledge and reports an alleged event. **When there is a question as to whether to conduct an investigation, it is best to do so.

Based on observation, interviews and record review, the facility failed to ensure nebulizer mask and tubing was changed timely. This affected one out of four sampled residents. Resident #207 had been using the same nebulizer mask and tubing for approximately 16 days, two times per day. The findings include: Review of Resident #207's clinical record revealed an admission history form dated 03/01/19. The admission history documented Resident #207 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 03/08/19, documented that Resident #207 was on oxygen therapy for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The baseline Plan of Care (P[NAME]) and the physician's orders [REDACTED].#207 was on [MEDICATION NAME] 0.83mg/ml, give contents of one nebule via hand held nebulizer two times per day. The facility's policy on oxygen stated, Per NHC Policy: All oxygen equipment (this includes nasal cannulas, masks, tubing) and suction equipment must be changed weekly, dated and a set up bag provided for each item Nebulizer tubing to be changed every 3 days. During the initial interview on 03/26/19 at 11:27 AM, Resident #207 was observed having her/his morning nebulizer treatment. The mask and the tubing were dated 03/10/19. On 03/26/19 at 4:15 PM, Registered Nurse (RN) #198 was interviewed. RN #198 stated that oxygen tubing should be changed weekly, and nebulizer masks and tubing should be changed every three days. RN #198 verified that the nebulizer mask and tubing for Resident #207 was dated 03/10/19 and should have been changed 13 days prior and every three days after that date. RN #198 stated that the orders for Resident #207's nebulizer treatments were for twice a day. RN #195 was interviewed on 03/26/19 at 4:27 PM. RN #195 stated that this was the responsibility of the overnight shift to change out the nebulizer mask and tubing and that s/he would have to find out how it got missed.

Based on resident and staff interviews and record review, the facility failed to allow residents access to money in personal fund accounts timely for 11 of 11 sampled residents with accounts. Interviews and policy review revealed that residents only had access to $5 cash per day. Findings include: Resident #74 was admitted to the facility on [DATE]. On 3/27/19 at 4:45 PM, a review of Resident #74's Minimum Data Set (MDS) assessment revealed a Brief Mental Status score of 10 indicating moderately impaired cognition. On 03/25/19 at 12:03 PM, an interview was completed with Resident #74. Resident #74 said, They will only give you $5 a day when you go down there (to the front desk). On 03/27/19 at 10:06 AM, an interview was completed with Nurse #120. S/he stated, If they (residents) want money, they go up the front desk. They can get $5 at the time. An interview was completed with Bookkeeper #146 on 03/27/19 at 10:12 AM. Bookkeeper #146 said, They (residents) can get $5 at a time. More than that has to go through the head bookkeeper. If s/he isn't here, the DON (Director of Nurses) has been instructed on how to approve a request for more than $5. An interview was completed with the DON on 03/27/19 at 10:24 AM. The DON said, I'm not aware of any restrictions on what they can get out (of personal fund accounts) as long as they have that much in their accounts. On 03/27/19 at 10:42 AM, an interview was completed with Bookkeeper #2. S/he stated, We give them (residents) up to $5 so they don't have a lot of money in their room. If they want more, we give them a check and usually their family member cashes it for them. We've not had an issue getting in touch with the family, but if they want more cash, then they would come up each day and get $5 each day. When asked how a resident would get $20 in cash, Bookkeeper #2 said that the resident would request $5 each day for 4 days. On 03/27/19 at 2:50 PM, an interview was completed with the Administrator. The Administrator said, Our policy says that we will give a check for anything more than $5. That is more secure than the regulation. The guidance says they have to have access to cash, but the regulation doesn't; and we don't get surveyed on the guidance. The families usually want more money to reimburse them for purchases and they take a check. On 03/27/19, a review of the facility policy titled NHC Bookkeeping Manual, dated 08/07, was reviewed. The policy noted Disbursements by Check. All disbursements from the Patient Trust Fund which exceed $5.00 are made by check. A follow up interview was completed with Resident #74 on 03/27/19 at 4:04 PM. Resident #74 said, They gave me a check once and I gave it back. If they gave me a check, I would have to have my daughter or son-in-law take it to get it cashed. I don't see her/him very much, maybe once a month.

Based on record review and interview, the facility failed to adequately assess Resident #3 for signs and symptoms of infection and other possible complications resulting from the continuing use of an indwelling catheter, 1 of 3 residents reviewed with a catheter. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. On 11/08/17 at 2:55 PM, review of the Daily Skilled Nurse's Note dated 02/13/17 through 03/09/17 revealed on 02/12/17 the resident was noted to have hematuria in the urine. On 02/14/17, the urologist visited the resident at the nursing home at 1:41 PM and a new order was received to change the Foley catheter on Monday (February 20, 2017). On 02/16/17, the resident was again noted to have hematuria. At 12:00 PM on 02/20/17, the nurse documented that the daughter reported no urine in the Foley catheter collection bag. The nurse also documented that the resident reported no urinary output since the catheter was changed at 5:00 AM and that the abdomen was slightly distended. There was no nurse's notes regarding the change of the catheter at 5:00 AM. Further review revealed a note timed at 1:30 PM on 02/20/17 that the nurse checked the catheter placement, deflated the bulb, repositioned the catheter and re-inflated the bulb and obtained [AGE]0 plus cc (cubic centimeters) of urine drained to the collection bag. There was no documentation of abnormal characteristics of the urine at that time. A late entry on 02/21/17 for 3:00 PM on 02/20/17 stated [AGE]0 ml (milliliters) of yellow urine (with) small amount of blood noted; Res(ident) stated My stomach feels relieved will monitor. At 10:00 PM on 02/20/17, the resident c/o (complained of) dysuria (and) thick yellow pus noted inside brief (and) on tip of penis. Will monitor. At 4:00 AM on 02/21/17, Resident #3 again c/o dysuria, hematuria noted. in the collection bag and stated will monitor. There was no documentation the physician was notified of the dysuria or pus noted at 10:00 PM or the hematuria at 4:00 AM. At 7:20 AM on 02/21/17, the resident's daughter reported that the resident was having increased abdominal pain. The nurse documented the abdomen was tender and distended, sluggish bowel sounds present in all 4 quadrants, increased pain to the left lower quadrant when palpated and that the catheter was intact and draining and noted a small amount of yellow urine in the collection bag with a small blood clot present. The resident stated It hurts all over down to my private area. Vital signs were taken at that time and the daughter requested the resident be sent to the emergency room . The physician was notified at that time and an order received to send the resident to the emergency room for evaluation per the daughter s request. Review of the hospital history and physical dated 2/21/17 revealed the patient had Foley catheter adjusted, after which s/he drained 1500 cc of urine in the ER. Review of the Medication, Treatment and Task Administration Record revealed a Pain Assessment that indicated the resident had no pain on the 11:00 PM - 7:00 AM shift on 02/20-02/21/17. Further review revealed the resident was medicated with [MED] for c/o gen(eralized) pain at 1:30 AM on 02/21/17. In addition, review of the record indicated a pulse and respiratory rate were documented before and after a nebulizer treatment at 2:00 AM but no temperature or blood pressure were documented. Review of the Hospital History and Physical indicated the resident had Acute [MEDICATION NAME] with Hematuria, Urinary Tract Infection due to Chronic Foley Catheter, [MEDICAL CONDITION] with Benign [MED]e Hypertrophy, and Abdominal Pain with Constipation. During an interview on 11/08/17 at 6:20 PM the Director of Nursing (DON) confirmed the physician should have been notified of pus in urine and hematuria. The DON stated that the resident had a TURP (Transurethral Resection of the [MED]e) but when told the TURP was done when the resident went to the hospital following the episodes, the DON stated that's not good and that I wish I had known about that. During an interview on 11/09/17 at 11:40 AM, the attending physician stated that he/she did not recall when he/she was notified by the Nurse Practitioner of the lack of urine output on 2/20/17. The physician also stated that the nurses were familiar with catheter care and know to monitor for signs and/or symptoms systemic infection. When asked if the nurse would be expected to notify the physician of hematuria from a resident with a Foley, the doctor stated it could wait until the next morning and that was within the standard of care. The physician further stated that he/she would have seen the resident the next day ordered a urinalysis and culture and sensitivity at that time if the resident had still been at the facility. During an interview on 11/09/17 at approximately 12:45 PM, RN (Registered Nurse) #1 stated systemic signs and symptoms of infection would be identified by looking at the resident for changes, listlessness, pallor, changes in mental status, pain, vital signs, or if they've voided. For a resident with an indwelling catheter, the resident would be monitored for output, monitor the insertion site for drainage/ redness, characteristics of the urine for clarity/ blood/ sediment, amount. The nurse confirmed blood in the urine and pus would be a symptom of infection and stated that blood could also be related to trauma and that would be a symptom unless it was already in the urethra. The RN also confirmed the presence of pus usually means infection. RN #1 also stated s/he would have notified the physician in the morning because the on-call doctors typically would not treat for 1 symptom and would have instructed the nurse to monitor the resident. The nurse also stated because the resident was being followed by a urologist, the on-call physician usually would wait until the specialist could be notified. The RN confirmed that the documentation indicated the resident had dysuria, pain, hematuria, and pus and that s/he did not take full vital signs during the episodes.

Based on record review and interview, the facility failed to adequately assess Resident #3 for signs and symptoms of infection and other possible complications resulting from the continuing use of an indwelling catheter, 1 of 3 residents reviewed with a catheter. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. On 11/08/17 at 2:55 PM, review of the Daily Skilled Nurse's Note dated 02/13/17 through 03/09/17 revealed on 02/12/17 the resident was noted to have hematuria in the urine. On 02/14/17, the urologist visited the resident at the nursing home at 1:41 PM and a new order was received to change the Foley catheter on Monday (February 20, 2017). On 02/16/17, the resident was again noted to have hematuria. At 12:00 PM on 02/20/17, the nurse documented that the daughter reported no urine in the Foley catheter collection bag. The nurse also documented that the resident reported no urinary output since the catheter was changed at 5:00 AM and that the abdomen was slightly distended. There was no nurse's notes regarding the change of the catheter at 5:00 AM. Further review revealed a note timed at 1:30 PM on 02/20/17 that the nurse checked the catheter placement, deflated the bulb, repositioned the catheter and re-inflated the bulb and obtained [AGE]0 plus cc (cubic centimeters) of urine drained to the collection bag. There was no documentation of abnormal characteristics of the urine at that time. A late entry on 02/21/17 for 3:00 PM on 02/20/17 stated [AGE]0 ml (milliliters) of yellow urine (with) small amount of blood noted; Res(ident) stated My stomach feels relieved will monitor. At 10:00 PM on 02/20/17, the resident c/o (complained of) dysuria (and) thick yellow pus noted inside brief (and) on tip of penis. Will monitor. At 4:00 AM on 02/21/17, Resident #3 again c/o dysuria, hematuria noted. in the collection bag and stated will monitor. There was no documentation the physician was notified of the dysuria or pus noted at 10:00 PM or the hematuria at 4:00 AM. At 7:20 AM on 02/21/17, the resident's daughter reported that the resident was having increased abdominal pain. The nurse documented the abdomen was tender and distended, sluggish bowel sounds present in all 4 quadrants, increased pain to the left lower quadrant when palpated and that the catheter was intact and draining and noted a small amount of yellow urine in the collection bag with a small blood clot present. The resident stated It hurts all over down to my private area. Vital signs were taken at that time and the daughter requested the resident be sent to the emergency room . The physician was notified at that time and an order received to send the resident to the emergency room for evaluation per the daughter s request. Review of the hospital history and physical dated 2/21/17 revealed the patient had Foley catheter adjusted, after which s/he drained 1500 cc of urine in the ER. According to professional standards set by (Potter, Perry, Stockert, & Hall, 2013) Report any extreme increase or decrease in urine volume. An hourly output of less than 30ml for more than 2 consecutive hours is cause for concern. Document and report any abnormal color or sediment, especially if the cause is unknown. (p.1052). Review of the Medication, Treatment and Task Administration Record revealed a Pain Assessment that indicated the resident had no pain on the 11:00 PM - 7:00 AM shift on 02/20-02/21/17. Further review revealed the resident was medicated with [MED] for c/o gen(eralized) pain at 1:30 AM on 02/21/17. In addition, review of the record indicated a pulse and respiratory rate were documented before and after a nebulizer treatment at 2:00 AM but no temperature or blood pressure were documented. Review of the Hospital History and Physical indicated the resident had Acute [MEDICATION NAME] with Hematuria, Urinary Tract Infection due to Chronic Foley Catheter, [MEDICAL CONDITION] with Benign [MED]e Hypertrophy, and Abdominal Pain with Constipation. During an interview on 11/08/17 at 6:20 PM the Director of Nursing (DON) confirmed the physician should have been notified of pus in urine and hematuria. The DON stated that the resident had a TURP (Transurethral Resection of the [MED]e) but when told the TURP was done when the resident went to the hospital following the episodes, the DON stated that's not good and that I wish I had known about that. During an interview on 11/09/17 at 11:40 AM, the attending physician stated that he/she did not recall when he/she was notified by the Nurse Practitioner of the lack of urine output on 2/20/17. The physician also stated that the nurses were familiar with catheter care and know to monitor for signs and/or symptoms systemic infection. When asked if the nurse would be expected to notify the physician of hematuria from a resident with a Foley, the doctor stated it could wait until the next morning and that was within the standard of care. The physician further stated that he/she would have seen the resident the next day ordered a urinalysis and culture and sensitivity at that time if the resident had still been at the facility. During an interview on 11/09/17 at approximately 12:45 PM, RN (Registered Nurse) #1 stated systemic signs and symptoms of infection would be identified by looking at the resident for changes, listlessness, pallor, changes in mental status, pain, vital signs, or if they've voided. For a resident with an indwelling catheter, the resident would be monitored for output, monitor the insertion site for drainage/ redness, characteristics of the urine for clarity/ blood/ sediment, amount. The nurse confirmed blood in the urine and pus would be a symptom of infection and stated that blood could also be related to trauma and that would be a symptom unless it was already in the urethra. The RN also confirmed the presence of pus usually means infection. RN #1 also stated s/he would have notified the physician in the morning because the on-call doctors typically would not treat for 1 symptom and would have instructed the nurse to monitor the resident. The nurse also stated because the resident was being followed by a urologist, the on-call physician usually would wait until the specialist could be notified. The RN confirmed that the documentation indicated the resident had dysuria, pain, hematuria, and pus and that s/he did not take full vital signs during the episodes.