Every finding on record at NHC Healthcare, Knoxville

Based on facility policy review, observation, and interview, the facility failed to ensure expired food items were not available for resident use in 1 of 2 nourishment room refrigerators observed. The findings include:Review of the facility's policy titled, Safety & [and] Sanitation Best Practice Guidelines, dated 6/2025, revealed .REFRIGERATOR .STORAGE .Refrigerated .foods will be stored properly for optimal product safety .Expiration dates .will be used .to ensure food safety .During an observation and interview on 4/27/2026 at 10:56 AM, revealed the 2nd floor nourishment room refrigerator contained five unopened 10 fluid ounce bottles of orange juice with an expiration date of 4/8/2026. The Certified Dietary Manager confirmed the items were expired and available for resident use.

Based on review of facility policy, medical record review, review of facility investigations, observations and interviews, the facility failed to ensure 4 residents (Residents #1, #7, #9, and #3) were free from physical abuse during 4 separate resident versus resident altercations of 23 sampled residents. The findings include: Review of the Administrative Procedures Manual, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated [DATE], revealed .Abuse: the willful infliction of injury .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse: includes hitting, slapping, pinching and kicking . 1. Review of the medical records and facility investigation documentation revealed a resident-versus-resident altercation occurred between Resident #1 and Resident #2 on [DATE]. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Hypertensive Disease, Cellulitis of Left Lower Limb, Adult Failure to Thrive, Chronic Pain Syndrome, Anxiety and Delusional Disorders. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the Nursing Progress Notes for Resident #1 dated [DATE] at 5:05 PM, revealed .Resident [#1] yelling let go of my hair staff [Certified Nursing Assistant-CNA R] witnessed another resident [Resident #2] pulling her [Resident #1's] hair, and immediately separated residents [Resident #1 and Resident #2]. NP [Nurse Practitioner], Psych [psychiatric] provider, Administration [Director of Nursing-DON], SS [Social Services], and family [of Resident #1] made aware. Resident [#1] assessed with no injuries noted. Resident [#1] stated 'my head hurts.' Tylenol offered per order and accepted. Resident [#1] provided a safe calm environment . Review of the Nursing Progress Notes for Resident #1 dated [DATE] at 5:49 PM, revealed .Resident [#1] alert and verbal. Denies pain or discomfort at this time, resident [#1] states 'I'm fine, its [it's] not a big deal, she [Resident #2] dont [don't] know what shes [she's] [Resident #2] doing.' Resident [#1] has no changes in range of motion to head neck or upper body at this time. Will continue to observe for changes and provide a safe calm environment . Review of the Nursing Progress Notes for Resident #1 dated [DATE] at 1:41 AM, revealed .Resident [#1] resting on bed .No signs of injuries noted from recent incident. No complaints of pain . Review of the Nursing Progress Notes for Resident #1 dated [DATE] at 9:30 AM, revealed .moves extremities per usual with minimal discomfort noted to left side of neck. Resident cheerful and pleasant . Review of the Social Services Progress Note for Resident #1 dated [DATE] at 10:24 AM, revealed the resident reported she was okay. Resident #1 verbalized she was not afraid of Resident #2. Review of the Physician Progress Notes for Resident #1 dated [DATE] at 11:27 AM, revealed .regulatory visit today, and also to follow-up on a patient incident that happened yesterday evening .Yesterday evening another patient [Resident #2] with known Dementia became agitated and pulled her [Resident #1's] hair . A cervical spine x-ray was ordered and revealed .Degenerative changes are identified. Postsurgical .hardware seen .cervical spine. No fracture dislocation or bony destructive lesions [abnormality in bone tissue] are identified . Review of the Nursing Progress Notes for Resident #1 dated [DATE] at 3:04 PM, revealed .Resident sitting up in dining room participating in activities. No c/o pain or discomfort .pleasant and interacting with other resident . Review of the Nursing Progress Notes for Resident #1 dated [DATE] at 8:15 PM, revealed the resident denied pain and discomfort . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Severe Dementia with Anxiety, Senile Degeneration of Brain and Delusional Disorder. The resident expired on [DATE]. Review of a quarterly MDS assessment dated [DATE], revealed Resident #2 scored 99 on the BIMS assessment, indicating severe cognitive impairment. The resident experienced hallucinations and exhibited behaviors not directed toward others (hitting or scratching self or verbal/vocal symptoms like screaming, disruptive) during the assessment period. Review of the Nursing Progress Notes for Resident #2 dated [DATE] at 4:57 PM, revealed .Resident [#2] noted to have pulled another resident's [#1] hair as seen by staff [CNA R], and hearing the other resident [Resident #1] say 'let go of my hair.' Residents [Resident #1 and Resident #2] immediately separated. Administration [DON], SS, Psych provider, and NP made aware. [Resident #1's] Family and hospice also made aware. Resident [#1] will be moved to 3rd floor . Review of a comprehensive care plan for Resident #2 dated [DATE], revealed .Behaviors .false beliefs .yelling .worry about babies .pulling other resident's hair .room change to third floor .Provide patient with calm environment and remove from high traffic areas during periods of anxiety and agitation. Provide one on one care as needed .provide 1:1 as needed when resident may have aggressive episodes towards others . Review of the witness statement by CNA R dated [DATE], revealed .[Resident #1] yelling for help [on 200 hall] [Resident #2] had her hands in [Resident #1's] hair. Had to physically open [Resident #2's] hands to remove [Resident #1's] hair. Brought [Resident #2] back to her room. [Resident #2] Been one on one since . Review of the Physician Progress Notes for Resident #2 dated [DATE] at 11:08 AM, revealed .Patient [Resident #2] seen today due to an incident that happened yesterday evening. Evidently, she became agitated while being weighed and then reached out and grabbed another resident's [Resident #1] hair and pulled it .Today I find her [Resident #2] in bed relaxed with her eyes closed . During an observation and interview on [DATE] at 8:55 AM, Resident #1 stated Resident #2 had pulled her hair during activities 7 or 8 months ago. The resident did not voice concerns of pain or discomfort following the incident with Resident #2. Resident #1 stated the facility investigated the incident, she felt safe, and was not afraid of anyone in the facility. 2. Review of a facility investigation dated [DATE], revealed a resident versus resident altercation occurred between Resident #7 and Resident #8. Review of a facility investigation dated [DATE], revealed Resident #8 was seated in her wheelchair and was observed patting Resident #7's hand, also seated in a wheelchair. Resident #7 moved Resident #8's hand at which time Resident #8 hit Resident #7 in the face. The residents were immediately separated. The MD/NP (Medical Doctor/Nurse Practitioner), families, Ombudsman, police, and state agency were notified. The residents were assessed for injury with none noted. Residents with a BIMS score greater than 8 were interviewed for abuse, residents with a BIMS score less than 8 received skin assessments. Staff who provided care for the residents were also interviewed to determine if the residents had exhibited behaviors prior to the altercation, no concerns were identified. Resident #7 expired in the facility on [DATE], Resident #8 expired in the facility on [DATE]. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Dementia with Anxiety. Review of the annual MDS assessment dated [DATE], revealed Resident #7 scored 1 on the BIMS assessment, which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan revealed the facility identified Resident #7 was at risk for behaviors with interventions and monitoring implemented. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus Type 2, Chronic Kidney Disease and Vascular Dementia with Anxiety. Review of the quarterly MDS dated [DATE] revealed Resident #8 scored 6 on the BIMS assessment, indicating the resident had significant cognitive impairment. Continued review revealed the resident had delusions (beliefs that are firmly held, contrary to reality) and verbal behavior symptoms directed toward others. Review of the comprehensive care plan revealed the facility had identified Resident #8 was at risk for behaviors .hitting others . During an interview on [DATE] at 12:50 PM, with Licensed Practical Nurse (LPN C) she confirmed she had assessed Resident #7 and #8 for injuries with none noted, and Resident #8 was immediately relocated to a different room. During a telephone interview on [DATE] at 9:00 AM, CNA L confirmed he witnessed the altercation. The CNA stated .it appeared as if [Resident #8] swiped something off of [Resident #7's] face, it was not a smack . 3. Review of a facility investigation dated [DATE], revealed a resident versus resident altercation occurred between Resident #9 and Resident #10. Resident #10 entered Resident #9's room and confronted him about his (Resident #9) behavior of cursing facility employees. A CNA heard Resident #9 and Resident #10 exchange words and alerted the nurse. The residents were immediately separated and assessed for injury, with none noted. Resident #9 reported Resident #10 hit him on the leg. The Administrator, DON, MD/NP, families, state agency, police, and Ombudsman were notified. Residents with a BIMS score 8 or greater were interviewed for abuse. Residents with a BIMS score less than 8 received skin assessments. Staff who provided care for the residents, were also interviewed to determine if the residents had exhibited behaviors prior to the altercation, with no concerns identified. Resident #9 and Resident #10 remained in the facility at the time of the complaint survey conducted on [DATE]-[DATE]. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Unspecified Mood Disorder, Chronic Obstructive Pulmonary Disease, Congestive Heart Disease and Unspecified Hearing Loss. Review of the annual MDS dated [DATE], revealed Resident #9 scored 15 on the BIMS assessment, which indicated the resident was cognitively intact. Review of the comprehensive care plan revealed Resident #9 had a history of verbal/manipulative behaviors with interventions and monitoring implemented. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder, Diabetes Mellitus, Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, Low Vision to Right Eye and Blindness to Left Eye. Review of the annual MDS assessment dated [DATE], revealed Resident #10 scored 15 on the BIMs assessment, which indicated the resident was cognitively intact. Review of the comprehensive care plan revealed the facility identified Resident #10 was at risk for verbal and physical behaviors with interventions and monitoring implemented. During an interview on [DATE] at 8:50 AM, Resident #9 stated Resident #10 entered his room ([DATE]) and . just started in on me . and hit his leg. During an interview on [DATE] at 9:20 AM, Resident #10 confirmed he had confronted Resident #9 about his recent cursing at the staff. Continued interview revealed Resident #10 reported Resident #9 became angry when confronted. Resident #10 reported Resident #9 then reached for his grabber (a assistive device to extend reach) that was lying on the bed beside his leg. Resident #10 stated he then hit Resident #9 on his leg with an open hand. 4. Review of the medical records and facility investigation documentation dated [DATE], revealed a resident versus-resident altercation occurred between Resident #3 and Resident #4. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Anemia, Chronic Obstructive Pulmonary Disease and Dementia with Mood Disturbance. Review of an annual MDS assessment dated [DATE], revealed Resident #3 scored 6 on the BIMS assessment, indicating severe cognitive impairment. Review of the Social Services Progress Notes for Resident #3 dated [DATE] at 3:36 PM, revealed .[Resident #3] understands that the other patient [Resident #4] was confused. She [Resident #3] denies feeling scared and states she's not injured or hurt .Trauma Screen completed and [Resident #3] denies trauma from interaction. [Resident #3] states she is fine . Review of the Nursing Progress Notes for Resident #3 dated [DATE] and [DATE], revealed no signs of bruising or injury. The resident denied pain or discomfort. Review of the Psychiatric Diagnostic Evaluation Notes for Resident #3 dated [DATE], revealed .[Resident #3] was recently involved in an altercation with another resident [Resident #4]. [Resident #3] says she is doing 'just fine . She denies any pain, distress, or fear. She says understands .'people get confused around here' .Staff reports no specific concerns regarding behaviors or issues .Recommendations: Continue to monitor and offer supportive care. Continue current treatment plan and medications. No adverse effects or distress/fear from recent patient altercation noted or reported . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Anxiety, Depression and Severe Dementia with Mood Disturbance. Review of a quarterly MDS assessment dated [DATE], revealed Resident #4 scored 3 on the BIMS assessment, indicating severe cognitive impairment. The resident had not exhibited behaviors or aggression toward others during the assessment period. Review of the Nursing Progress Notes for Resident #4 dated [DATE] at 3:01 PM, revealed .resident [#4] was removed from activities today because she continued to yell. she then removed a wheelchair from behind another resident [#3] when she stood up almost causing her [Resident #3] to fall. then, she begin to hit another resident [#3] .activity staff removed her [Resident #4] from the activity and brought her back to west station where she continues to yell, verbally abuse staff, and ask for us to let her leave this place . Review of the Nursing Progress Notes for Resident #4 dated [DATE] at 3:10 PM, revealed the resident was moved to the 3rd floor. Review of the Social Services Progress Notes for Resident #4 dated [DATE] at 3:53 PM, revealed .Social worker spoke with [Resident #4] regarding patient interaction. [Resident #4] stated she would never hit anyone and does not remember doing so . Review of a comprehensive care plan for Resident #4 dated [DATE], revealed .Psychosocial Well-Being .at risk for complication related to psychosocial well being related to patient to patient interaction .Encourage choices and allow control over daily routine .Encourage to express feelings of .anger . Review of the Psychiatric Follow Up Notes for Resident #4 dated [DATE], revealed .[Resident #4] recently had a physical altercation with another resident [Resident #3]. [Resident #4] is very confused and unable to tell me anything about it. She tells me that she needs to go home. She denies any pain or injuries. No distress noted or reported . Review of the facility's investigation dated [DATE], revealed .During a cornhole activity a patient [Resident #4] hit .[Resident #3] when she [Resident #3] sat down in her rolling walker . Resident #3 and Resident #4 were separated and placed on different floors to avoid contact. A skin assessment was performed for Resident #3 with no injuries noted. Resident #4 was interviewed and denied feeling scared and stated she was not injured. Resident #3 was interviewed and stated she would never hurt anyone and did not remember hitting Resident #4. Continued review revealed Resident #4 had been a resident at the facility since [DATE], and had no indication of aggressive behaviors toward other residents. Further review revealed .The incident was verified through interviews and witnesses. No indication of harm to victim [Resident #3] physically or psychologically . Continued review of the facility investigaiton revealed The MD/NP (Medical Doctor/Nurse Practitioner), families, Ombudsman, police, and state agency were notified of the altercation. Review of Resident #3's statement dated [DATE], revealed .Social worker spoke with [Resident #3] regarding her patient-to-patient altercation. [Resident #3] stated she was finishing her turn at cornhole, and the other patient [Resident #4] grabbed her rollator [walker equipped with a seat] from her. [Resident #3] said when she got her rollator back, she sat down, and [Resident #4] softly hit her on her head. [Resident #3] states she tried to remove herself from the situation. [Resident #3] states she knows [Resident #4] gets confused sometimes .[Resident #3] denies injury, states she is not fearful and reports being okay . Review of Resident #4's statement dated [DATE], revealed .Social worker spoke with [Resident #4] regarding patient-to-patient altercation in activities. [Resident #4] denies any altercation. [Resident #4] stated she would never hit anyone. [Resident #4] Denies any distress, and fully denies any event. Reports that she [Resident #4] doesn't even remember going to activities today . During an interview on [DATE] at 2:51 PM, the Activities Director stated Resident #4 was sitting behind Resident #3 during a cornhole activity. The Activities Director stated Resident #4 pulled Resident #3's rollator walker as she (Resident #3) went to sit down on the walker. Resident #4 started striking Resident #3 in the back of her head. Further interview revealed Resident #4 struck Resident #3 with her forearm. The residents were immediately separated. The Activities Director reported she took Resident #4 back to her room and reported the incident to the resident's nurse. The Activities Director stated Resident #3 thought it was minor and continued with activities. The Activities Director stated Resident #4 was relocated to the 3rd floor. During an interview on [DATE] at 9:47 AM, the DON acknowledged when physical contact was made during resident versus resident altercations, the facility was required to report the altercations as allegations of abuse.

Based on facility policy review, medical record review, interview, and observations, the facility failed to ensure 4 residents (Resident #30, Resident #75, Resident #31, and Resident #57) were free from abuse of 65 potential residents. Resident #30 grabbed Resident #75 and Resident #57 and pushed and choked Resident #31. Resident #57 struck Resident #30 in response to Resident #30's aggressiveness. Resident #75 and Resident #57 expressed being fearful of Resident #30, resulting in psychosocial harm for Residents #75 and #57. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, showed .Abuse, neglect .will not be tolerated by anyone, including .patients .The patient has the right to be free from abuse, neglect .The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect holds the highest priority .Abuse: the willful infliction of injury .pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Physical Abuse: includes hitting, slapping .Mental Abuse: includes, but is not limited to .harassment .PREVENTION POLICY .The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors .All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors .Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict .The Interventions .will include .Identification of patients whose personal histories render them at risk for abusing other patients or partners .Assessment of appropriate interventions strategies to prevent occurrences .Monitoring the patient for any changes that would trigger abusive behavior .Reassessment of the protective strategies on a regular basis .PROTECTION POLICY .Staff will respond immediately to protect the alleged victim .Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior including, but not limited to room or staffing changes, if necessary, to protect the patient(s) from the alleged perpetrator .Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .Increased supervision of the alleged victim and patients . Resident #30 was admitted to the facility on [DATE], with diagnoses including Blindness Right Eye, Dementia with Anxiety, Insomnia, and Weakness. Review of Resident #30's comprehensive care plan dated 6/27/2022, showed .Diagnosis of dementia with anxiety disorder, restlessness and agitation .Combative behavior towards staff with rejection of care. Patient known to inappropriately grasp at objects and wander related to poor eyesight. Anxiety and agitation worse in PM [evening] . with approach dated 1/19/2023, .Redirect patient when he is seen wandering or grasping into or at inappropriate objects . Review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #30's vision was highly impaired. Resident #30 had no mood indicators or behavioral symptoms toward others documented and rejection of care occurred 1 to 3 days in the past 7 days. Resident #30 used a wheelchair as a mobility device. Further review revealed Resident #30 required extensive assist of one staff member for locomotion on unit, eating, and personal hygiene. Medical record review of Resident #30's Behavior Monitoring sheet for December 20, 2022, revealed .grabbing others . Review of Resident #30's Psychiatric Periodic Evaluation dated 1/2/2023, showed .Staff state patient has had several episodes of increased anxiety and agitation over the last few days. This is not unusual for patient, but behavior appears to have increased .he has been combative and very agitated with staff during care . Review of Resident #30's nursing progress note by Licensed Practical Nurse (LPN) #4 dated 1/4/2023 at 4:30 PM, showed Resident #30 .was agitated and having behaviors. Pt [patient] was witnessed to have multiple verbal outbursts. Also kicking and swinging arms while in common area, around other residents .was removed from the area and taken to his room .Resident continued with behaviors . Review of Resident #30's nursing progress note by LPN #5 dated 1/4/2023 at 6:06 PM, showed .noted to be agitated this shift arguing with staff and other residents throwing trash in hallway floors . Medical record review revealed two events documented on Resident #30's Behavior Monitoring sheet on 1/4/2023. First entry at 6:56 PM, Certified Nurse Aide (CNA) #2 documented cursing at others and the second event documented at 6:57 PM, by CNA #2, Cursing at others. Review of Resident #30's nursing progress note by LPN #2 dated 1/4/2023 at 7:15 PM, showed Resident #30 .APPEARS AGITATED AND AGRESSIVE [aggressive] DURING TRANSFER BACK TO BED . Review of Resident #30's nursing progress note by Registered Nurse (RN) #2 dated 1/5/2023 at 9:42 PM, showed Resident #30 .has exhibited increased agitation and behaviors towards staff, and was tested for UTI [urinary tract infection] Patient is currently receiving abt [antibiotic therapy] r/t [related to] uti [urinary tract infection] . Review of Resident #30's nursing progress note by LPN #6 dated 1/7/2023 at 4:22 PM, showed Resident #30 .up in the chair roaming the halls . Medical record review revealed two events documented on Resident #30's Behavior Monitoring sheet on 1/7/2023. First entry at 6:24 PM, CNA #3 documented cursing at others and the second event documented at 6:25 PM, by CNA #3, Disrobing in public. Medical record review of Resident #30's Behavior Monitoring sheet revealed on 1/15/2023 at 2:04 AM, LPN #2 documented, cursing at others. Review of Resident #30's Psychiatric Periodic Evaluation dated 1/17/2023, showed .Patietn [Patient] delusional, exit seeking, and aggressive with redirection at times . Medical record review of Resident #30's Behavior Monitoring sheet revealed on 1/17/2023 at 7:29 PM, NA #4 documented, grabbing others. Medical record review of Resident #30's Behavior Monitoring sheet revealed on 1/19/2023 at 12:20 PM, CNA #2 documented, cursing at others for 5 minutes. At 12:21 PM, CNA #2 documented, hitting others. At 8:37 PM, LPN #2 documented, cursing at others for 20 minutes. Review of Resident #30's nursing progress note by RN #1 dated 2/13/2023 at 3:22 PM, revealed .is agitated and aggressive .[NAME] [propels] self in chair, needs to be redirected numerous times out of other resident rooms . Medical record review of Resident #30's Behavior Monitoring sheet revealed on 2/13/2023 at 4:49 PM, Nurse Aide (NA) #4 documented, grabbing at others for 20 minutes. Redirect, One on one, provide calm environment interventions were documented as not effective. At 4:52 PM, NA #4 documented hitting others for 15 minutes and One on one, provide calm environment interventions were not effective. At 4:54 PM, NA #4 documented, cursing at others and One on one, provide calm environment interventions were not effective. At 4:56 PM, NA #4 documented amended and more data available, however, no further notes noted. Telephone interview on 3/15/2023 at 7:15 PM, when asked to clarify the 2/13/2023 note, NA #4 stated, .This was the night two other CNAs come and got me to help because [RN #1] asked them to come and get me to get him [Resident #30] off a lady [Resident #31] that he had pushed his feet on the back of her wheelchair and grabbed her by the back of her shirt and was choking her . When asked to further clarify the amended note, NA #4 stated, .I was asked to change the note and not put all that in there . When asked who asked him to change the note, NA# 4 replied, .I don't remember . NA #4 further stated, .that was not the first time he [Resident #30] tried to choke somebody . When asked to provide further information and details, NA #4 stated he could not recall, .exactly Review of Resident #30's nursing progress note by RN #1 dated 2/14/2023 at 6:26 PM, revealed .Resident [#30] increased agitation and aggressive. Going in others rooms. Difficult to redirect. Cursing staff and other residents . Review of Resident #30's social services progress note by Social Worker (SW) #1 dated 2/24/2023 at 4:30 PM revealed Resident #30 .has restlessness, trouble concentrating on things, and can be easily agitated at times . Review of Resident #30's progress note by the Director of Activities dated 2/27/2023 at 11:12 AM, revealed Resident #30 .propels around in his w/c [wheelchair] as he likes pulling himself along the handrails and door facings (pulling off corner protectors) and at times will pull on other resident chairs and needs redirection several times during the day as he goes in other resident rooms due to his poor eyesight. Pt [patient] can get agitated from time to time during redirection and will reach out to grab clothing or your hands when doing so and can be hard to redirect . Resident #30 can .be disruptive as he propels himself into others, pulls their W/C [wheelchair] or pulls the table clothes [cloths] off the tables with items on them due to his poor eyesight . Review Resident #30's quarterly MDS assessment dated [DATE], showed Resident #30 had a BIMS score of 3, indicating severe cognitive impairment. Resident #30's vision was highly impaired. Resident #30 had mood indicators of feeling tired; having little energy for several days in the last 14 days; trouble concentrating on other things, such as newspaper or watching television nearly every day in the last 14 days; moving or speaking so slowly that other people noticed or being so fidgety or restless that he had been moving around a lot more than usual for half or more of the days; and being short-tempered, easily annoyed for half or more of the days in the past 14 days. Resident #30 had behaviors of hallucinations and delusions. Physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms directed toward others occurred 1 to 3 days in the past 7 days. Rejection of care occurred 1 to 3 days in the past 7 days. Resident #30 used a wheelchair as a mobility device. Further review revealed Resident #30 required extensive assist of two or more staff members for locomotion on unit, eating, and personal hygiene. Observations of Resident #30 on 3/13/2023 during the afternoon hours of 1:00 PM - 5:00 PM and on 3/14/2023 during the morning hours of 8:00 AM - 11:00 AM, revealed the resident sitting in a reclined Broda chair (rolling chair that reclines with a footrest), in the hallway outside his room, reclined at a 30-45-degree angle, with his feet on the floor, quiet and sleeping. During observation on 3/14/2023 at 2:00 PM, the resident had been moved to his room with the door closed. During an interview on 3/14/2023 at 3:15 PM, the Administrator stated .There are people that are intimidated . by Resident #30's behaviors.He'll get in a mood, and he'll pull himself .I've heard people complain because he'll go around the whole floor .We've tried to redirect him . During an interview on 3/14/2023 at 3:22 PM, LPN #8 stated Resident #30 .with his vision impairment .likes to try to go in rooms . The staff .must redirect . During an interview on 3/14/2023 at 3:42 PM, the Director of Activities mentioned Resident #30's behavior when he .was pulling on someone's wheelchair . When asked if other residents complained about Resident #30's behavior, the Director of Activities stated .most of them [the residents] don't . complain and she stated that the other residents understood that Resident #30 was blind, and Resident #30 didn't realize what he was doing. During an interview on 3/15/2023 at 10:17 AM, Housekeeper #1 stated Resident #30 .be out in the hallways .He don't mean no harm .he might grab .he grab somebody's chair to scoot through the hallway . Housekeeper #1 stated there was an incident involving Resident #30 and an unidentified resident where Resident #30 .grabbed her chair and she hit him .I think she's gone .they sent her to [another nursing home] .She got irritated with him [Resident #30]. Housekeeper #1 stated .he [Resident #30] can't hurt nobody .he's blind .he'll grab and try to feel . During an interview on 3/15/2023 at 10:29 AM, Housekeeper #2 stated .He [Resident #30] can't see but he can still be a little aggressive .He's got that strength .be resistant . Housekeeper #2 denied knowing of any instances of Resident #30 hurting anyone. Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Anemia and Chronic Kidney Disease. Review of Resident #75's Quarterly MDS dated [DATE] showed a BIMS score of 15 which indicated the resident was cognitively intact. The resident exhibited no behaviors, required extensive assistance of 1 staff for bed mobility, and supervision of 1 staff for ambulation, dressing, toilet use and personal hygiene. Review of Resident #75's Care Plan dated 5/17/2021 showed .receives psychotropic medication for depression, insomnia, and anxiety . Review of Resident #75's Psychotherapy Progress Note dated 2/15/2023, revealed .Patient is seen today for current significant symptoms of depression and anxiety. Patient processed anxious feelings and stressors due to medical issues .Clinician plans to continue psychotherapy and recommends medication evaluation/treatment as needed for significant symptoms of depression and anxiety due to patient is minimally stable/requires ongoing interventions at this time . Review of Resident #75's Psychotherapy Progress Note dated 2/28/2023, reveals .Patient is seen today for current significant symptoms of depression and anxiety. Patient processed anxious feelings and stressors due to medical issues. She reports efforts to cope with getting out of bed/out of room and engaging in walking with walker activities .Clinician plans to continue psychotherapy and recommends medication evaluation/treatment as needed for significant symptoms of depression and anxiety due to patient to minimally stable/requires ongoing interventions at this time . During an interview with Resident #75 on 3/13/2023 at 3:59 PM, Resident #75 stated that Resident #30 comes down the corridor and tries to make it out the door. Resident #75 stated Resident #30 was losing his eyesight and he rolled his chair and pushed on it and jerked the fire alarm and made it sound. Resident #75 stated Resident #30 .He's hurting quite a few people . Resident #75 mentioned an incident she thought occurred three weeks ago. Resident #30 was behind Resident #31 and pushing and got hold of Resident #31's shirt and it took 2 staff members to separate Resident #30 from Resident #31. Resident #75 stated that she heard Resident #31 say Stop .leave me alone . Resident #30 was pushing Resident #31's wheelchair with his feet. Resident #31 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Severe Dementia, and Anxiety Disorder. Review of Resident #31's Annual MDS assessment dated [DATE] showed a BIMS score of 4, indicating the resident had severe cognitive impairment. The resident exhibited no behaviors and required extensive assistance of 2 staff for bed mobility and transfer, extensive assistance of 1 staff for dressing, eating, toilet use and personal hygiene, and required limited assistance of 1 staff for locomotion. Review of Resident #31's comprehensive care Plan dated 1/9/2023 showed .Cognitive Deficit .BIMS score indicates severe impairment with difficulty communicating as evidenced by Dementia Dx [diagnoses] and Hard of hearing . The resident was not interviewable. During an interview on 3/14/2023 at 3:03 PM, the Administrator was informed of the allegation of abuse involving Resident #30 against Resident #31 which was witnessed by Resident #75. The Administrator stated .I have not heard about this . and stated .We weren't aware of it . The Administrator stated that there was a previous allegation involving Resident #30 and a person of a name similar to Resident #31's last name. The Administrator stated that .APS [Adult Protective Services] came .State Survey came in . The Administrator was also informed that Resident #75 stated she was fearful of Resident #30 because of his behavior and the Administrator expressed that he was not aware of this. The Administrator stated .He [Resident #30] pulls himself down the hallway .he can't see very well . During an interview on 3/14/2023 at 3:18 PM, the Assistant Director of Nursing (ADON) was asked about the allegation of abuse regarding Resident #30 against Resident #31, and she responded .I've never heard that .There was one time he [Resident #30] had a few behaviors and we had a urinalysis drawn . The ADON described the previous behaviors as .He [Resident #30] was yelling .trying to go in and out of the dining room .pushed bedside table .but wasn't anyone around . During an interview on 3/14/2023 at 3:24 PM, the ADON stated that after Resident #30 completed the antibiotics in January 2023, there have been .no more issues . The ADON stated that the behaviors shown prior to the antibiotics were that Resident #30 had .shown anxiety and .pushed a table out of the way . During an interview on 3/14/2023 at 3:29 PM, the Administrator stated that he spoke with Resident #75 regarding Resident #30 moving down the hallway and he stated that Resident #75 identified only one staff member being present and identified the nurse by RN #1's first name. During an interview with RN #1 on 3/14/2023 at 3:36 PM, RN #1 denied seeing an altercation between Resident #30 and Resident #31. The RN stated .I've never seen him [Resident #30] get aggressive .I've not had any trouble .He's not had any behaviors with me . The RN stated that she does not normally work on Resident #30's floor, but that she worked on that floor .a couple of weeks ago . During an interview with Resident #75 on 3/15/2023 at 10:10 AM, Resident #75 confirmed her fear of Resident #30 .I feel he's a threat .violence . Resident #75 stated .He's [Resident #30] grabbed my arms and jerked me .finally I just don't come near his wheelchair . Resident #75 stated that this behavior by Resident #30 has happened .several times .I don't know what the dates were . Resident #75 stated she .did not tell the staff . about the incident where Resident #30 grabbed her arms and jerked her. During an interview on 3/15/2023 at 11:39 AM, the Administrator stated .the incident she [Resident #75] described that she was fearful did not occur . The Administrator stated that he interviewed Resident #75 who told him one staff member was involved in the incident and not two staff members. The Administrator stated he spoke with the nurse Resident #75 identified as being present during the incident who was identified as RN #1. The Administrator stated .the nurse [RN #1] said the incident didn't occur . Review of Resident #31's nursing progress note dated 3/15/2023 at 1:05 PM, revealed .This nurse [RN #3] reported, to daughter, allegation of abuse with an undetermined time frame . Interview with 27 residents with BIMS scores of 9 or higher were conducted on 3/15/2023 between 8:35 AM - 1:30 PM, with one additional complaint of abuse reported by Resident #57 against Resident #30. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, Adjustment Disorder with Mixed Anxiety with Depressed Mood, Major Depressive Disorder and Post-traumatic Stress Disorder. Review of Resident #57's quarterly MDS assessment dated [DATE], showed a BIMS score of 15 indicating the resident was cognitively intact. The resident required extensive assistance of 1 staff for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Resident Mood Interview showed Resident #57 had feelings of being down, depressed, or hopeless and poor appetite or overeating for 2-6 days over the last 2 weeks. Rejection of care behavior occurred 1 to 3 days in the past 7 days. There were no other behaviors noted. Resident #57 used mobility devices of cane/crutch and wheelchair. Review of Patient #57's comprehensive care plan with a start date of 5/1/2020, edited 1/2/2023, showed .Psychotropic medication use r/t [related to] Psychiatric Diagnoses- stress or trauma inducing event that may affect patient's mood/behavior .Goal .Patient will be protected from re-traumatization as much as possible .7/30/2020 .Patient reports h/o [history of] stress or trauma .may affect patient's mood/behavior .Goal .Patient will be protected from re-traumatization as much as possible .Avoid actions that may trigger memories of trauma/stress inducing event . Review of Resident #57's Psychiatric Periodic Evaluation dated 2/27/2023, showed .On exam, patient is up in wheelchair. She is attempting to find social services. Appears anxious. She is trying to find out when psychotherapy comes to visit .Denies depression, but states 'I just have some things I want to tell her' .Patient still exhibiting symptoms of anxiety and occasional depression . Review of Resident #57's Psychotherapy Progress Note dated 2/28/2023, showed .Patient is seen today for current significant symptoms of depression and anxiety. Social worker referral due to patient request for psychotherapy .Patient processed anxious feelings and stressors .She also processed difficulty expressing her feelings to others due to trust issues .Clinician plans to continue psychotherapy and recommends medication evaluation/treatment as needed for significant symptoms of depression and anxiety due to patient is minimally stable/requires ongoing interventions at this time . During an interview with Resident #57 on 3/15/2023 at 12:04 PM, the resident stated Resident #30 came into her room multiple times. Resident #57 stated there was an incident where two staff members came into her room to get Resident #30 out of her room. These 2 staff members told Resident #57 to wait in the hallway while the staff members removed Resident #30 from Resident #57's room. The 2 staff members removed Resident #30 from Resident #57's room and returned Resident #30 to his room. The 2 staff members returned to Resident #57's room to clean up the mess Resident #30 made in the room. While Resident #57 waited outside her room, Resident #30 came back out of his room and came toward Resident #57 as she waited in the hallway. Resident #30 attempted to stand up and grabbed the arm of her wheelchair and then touched her right arm and moved his hand up her arm. Resident #57 hit Resident #30 on his hand with her grabber device. The staff intervened and told Resident #57 she could not hit Resident #30 and the staff removed Resident #30. Resident #57 stated she was fearful of Resident #30 because she did not know his capabilities. Resident #57 felt like she was abused by Resident #30 and had the right to defend herself from Resident #30 and did not feel comfortable with Resident #30. Resident #57 was aware if she held her door handle, Resident #30 could not come in her room. Resident #57 stated she did not want to have to think about defending herself from Resident #30 and needed to think of her own well-being. Resident #57 was fearful at night that Resident #30 would come into her room so she would move her bedside table in front of her so Resident #30 could not get to her as quick. Resident #57 stated she told staff members about Resident #30, and they were aware of his behaviors. Resident #57 did not know the date or time of the incident in which she defended herself from Resident #30 and struck him and could not remember the names of the staff members who intervened because they were not wearing name badges. Resident #57 stated she knew of another resident who resided in the room that belonged to Resident #31 and Resident #75 who was also fearful of Resident #30. Resident #57 stated when she was socializing with Resident #75, Resident #75 returned to her room when she saw Resident #30 coming down the hallway. Resident #57 stated Resident #75 stopped their conversation and went into her room to get away from Resident #30. During an interview with the Administrator and the Regional [NAME] President on 3/15/2023 at 3:51 PM, the Administrator stated that the investigation into the abuse allegation involving Resident #30 and Resident #75 was .still ongoing . The Regional [NAME] President stated that 23 other residents had been interviewed by staff and no other abuse complaints had been reported. The Administrator and Regional [NAME] President were asked if they had interviewed Resident #57, and they confirmed that the facility had not interviewed Resident #57. The Administrator and Regional [NAME] President were notified that Resident #57 reported an altercation with Resident #30 and reported that she was fearful of Resident #30. The Regional [NAME] President and Administrator confirmed that the facility was not aware of an incident between Resident #57 and Resident #30. Review of Resident #57's progress note by RN #3 dated 3/15/2023 at 4:43 PM, showed .Resident reports being fearful of another resident. Resident assessed and is safe and without s/s [signs and symptoms] of increased anxiety at this time. NP made aware. Psych to [be] made aware to assess resident. Will continue to observe for increased anxiety . During an interview on 3/15/2023 at 6:40 PM, the Administrator stated that Resident #30 was moved to another unit and staff has been assigned to monitor him. The Administrator stated that Resident #30 was moved because there was not another private room available for Resident #57 and .because the social worker talked to her [Resident #57] and she did say she was fearful . of Resident #30.

Based on facility policy review, observations, and interview, the facility failed to ensure kitchen staff wore protective beard coverings while preparing food observed for 2 of 2 staff members. The facility failed to maintain a sanitary kitchen environment as evidenced by undated food and food open to air observed in 1 of 1 dry storage rooms and failed to maintain sanitary kitchen equipment which had the potential to affect 100 of 102 residents. The findings include: Review of the facility policy, Hygiene & Safety Practices, revised 11/2017, revealed .partners shall wear hair restraints such as hats, hair coverings, or nets, beard restraints .that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . Review of the facility policy titled, Safety & Sanitization Best Practice Guidelines, dated 11/2017, showed .packages should be closed securely . Review of the facility policy titled, Safety & Sanitization Best Practice Guidelines, dated 11/2017, showed .Equipment must be cleaned and/or sanitized after every use according to the manufacturer's directions .Non-food contact surfaces of foodservice equipment should be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance .Department inspection should be conducted to review sanitation and immediate action should be taken to correct any problems that interfere with meeting sanitary standards . Review of kitchen cleaning policy could not be completed. The kitchen cleaning policy was requested twice and was not provided. During an observation on 3/13/2023 at 10:28 AM, 2 of 2 dietary staff members in the kitchen were not wearing face coverings to ensure all facial hair was covered. During an interview on 3/13/2023 at 10:28 AM, the Certified Dietary Manager (CDM) confirmed beards were not fully covered in the kitchen area. The CDM stated he thought the mask would be sufficient to cover their beards . During an observation on 3/13/2023 at 10:30 AM, in the kitchen dry storage room was a loaf of bread with a hole in the package and was undated after use. During an interview on 3/13/2023 at 10:30 AM, the CDM stated all dry foods should be dated and sealed . The CDM confirmed the loaf of bread had a hole in the package and was undated after use. During an observation on 3/13/2023 at 10:37 AM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). During the tour, the following items were observed: - The steamer had spatter of dried food debris on window of unit. - The equipment cleaning schedule had not been completed for 14 of 14 days. - The can opener had solid food debris and a metal shard protrusion. - The cooler had food debris located in the bottom. - Four dessert cups had solid food debris present with dried food observed on the tray underneath. - Coffee dispenser on beverage cart had dried food substance present. - Dish room temperature form had not been completed 13 of 13 morning shifts, 12 of 12 afternoon shifts, and 4 of 12 evening shifts. - Kitchen air unit and ceiling tiles were soiled with a thick, black dirt substance. During an interview on 3/13/2023 at 10:42 AM, the CDM stated he was responsible to oversee the cleanliness and sanitary operation of the kitchen in the facility. The CDM confirmed the equipment in the facility's kitchen had not been maintained in a sanitary condition, the equipment cleaning schedule had not been completed in 14 of 14 days, and the Dishroom Temperature monitoring form had not been completed as scheduled. During an observation on 3/13/2023 at 11:54 AM, the second-floor dining area showed solid, dried food debris on the coffee dispenser on the beverage cart. During an interview on 3/13/2023 at 11:55 AM, Nurse Aide #1 confirmed the presence of solid debris on the coffee dispenser on the beverage cart located on the second floor. During an observation on 3/13/2023 at 12:12 PM, the second-floor dining area showed food debris on three serving spoons. During an interview on 3/13/2023 at 12:12 PM, Dietary Aide #1 confirmed the presence of food debris on three serving spoons. During an observation on 3/14/2023 at 10:08 AM, the second-floor dining area showed food debris inside a food pan that stored packaged jelly. During an interview on 3/14/2023 at 10:08 AM, Dietary Aide #2 confirmed the presence of food debris inside the food pan that stored packaged jelly and stated this needs to be cleaned .

Based on facility policy review, observations, and interviews, the facility failed to provide a clean and homelike environment for 13 of 38 resident rooms. The facility failed to repair wallpaper in 8 of 38 resident rooms and in 5 out of 5 hallways. The facility failed to clean air vents on 5 of 5 hallways. The facility failed to replace ceiling tiles in 5 of 38 resident rooms. The facility failed to repair window seals which resulted in uncomfortable temperature levels in 5 of 38 resident rooms. The findings include: Review of the facility policy titled, NHC Knoxville Housekeeping Policy, dated 3/15/2023, showed .NHC expects to maintain our building in a manor [manner] that is clean, presentable for our patients and staff. Routine cleaning of patient rooms Daily. High-Touch surfaces, floors and sinks are cleaned daily. Low touch surfaces are scheduled weekly or when visibly soiled. Weekly High surfaces .such as tops of cupboards, vents, walls, baseboards and corners. Monthly window blinds, bed curtains and any AC [Air conditioning] units/vents in room . Review of the facility policy titled, NHC Knoxville Maintenance Policy, dated 3/15/2023 showed .NHC expects to maintain our building in a manor [manner] that is clean and operational. Should items need to be updated, repaired, cleaned, or replaced, we will do so . During an observation on 3/14/2023 at 10:10 AM, in the shared bathroom between rooms [ROOM NUMBERS], the flooring tile was heavily stained with dirt. During an interview on 3/14/2023 at 10:15 AM, a housekeeper assigned to the second floor was aware of the dirt-stained floor and she stated, We need something stronger .bleach cleanser or something to get the stains up . During an interview on 3/14/2023 at 10:30 AM, the Housekeeping Supervisor revealed she had a staff member responsible for the floors. The Housekeeping Supervisor stated there was a scrubber small enough to get into the bathrooms for cleaning. Continued interview revealed she did not have a process in place to keep a list of bathroom floors needing to be deep cleaned. During a follow up interview on 3/14/2023 at 10:45 AM, the Housekeeping Supervisor returned with a list of bathrooms she identified on the second floor needing to be deep cleaned which included rooms 212, 215, 218, and 265. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, rooms 200, 201, 203, 205, 209, 211, 213, 214, 217, 221, 223 were observed with thick, gray-black dirt substance on the air vents. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, rooms 200, 201, 208, 214, 220, 221, 223 were observed with dead bugs and brown-gray dust with debris on the window seals. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, rooms 203, 211, 212, 213, 214, 217, 219, 224 were observed with the wallpaper needing repair with holes and tears ranging from 1 inch to 12 inches long and wallpaper coming apart from wall. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, 5 of 5 hallways needed wallpaper repairs with holes and tears ranging from 1 inch to 12 inches long. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, the ceiling air vents had thick, black dust substance present. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, rooms 203, 209, 221, 223, 227 needed ceiling tile repairs with holes ranging from dime size to golf ball size. During multiple observations on 3/15/2023 from 8:31 AM to 1:38 PM, rooms 200, 203, 220, 223, 224 had a cool air draft around the window area. During an interview on 3/15/2023 at 10:42 AM, the Maintenance Director confirmed the window seal in resident room [ROOM NUMBER] had temperature changes around the window area with a thermometer reading ranging from 63 degrees Fahrenheit to 68 degrees Fahrenheit. During an interview on 3/15/2023 at 10:43 AM, the Maintenance Director confirmed 5 of 5 hallways and all the resident rooms on the second floor had wallpaper torn, several ceiling tiles in 5 of 5 hallways and several resident rooms were damaged and needed to be replaced, the window seals in 200, 203, 220, 223 and 224 had a cool draft, several rooms had dead bugs and brown-gray dust with debris on the window seals, and the air vents in 13 of 38 rooms on the second floor had brownish-gray dusty debris. During an interview in resident room [ROOM NUMBER] on 3/15/2023 at 10:56 AM, the Maintenance Director confirmed the brownish-black dirt substance behind the torn wallpaper next to the bathroom door was brown rust from the metal underlay . During an interview on 3/15/2023 at 11:00 AM, the Maintenance Director confirmed 2 holes in the ceiling in resident room [ROOM NUMBER]. During an interview on 3/15/2023 at 1:36 PM, the Maintenance Assistant stated the facility had 3 full rolls of wallpaper and a partial roll of wallpaper to be used for repairs. He stated the plan was to replace the wallpaper in the halls first . The Maintenance Assistant confirmed that the resident rooms on the second floor were not planned for repair at this time.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 10 residents (Resident #80) was treated in a dignified manner during incontinence care. The findings include: Review of the facility's policy titled Resident Rights dated 2/2020, showed .We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services . Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident with Right-sided Hemiplegia, Diabetes and Atherosclerotic Heart Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #80 had no speech, absence of spoken words, was always incontinent of bladder and bowel, and required extensive assistance of two persons for toileting (includes change of incontinent pads). Observation while passing by Resident #80's room on 3/14/2023 at 3:46 PM, revealed the door into the room was open, the privacy curtain was not pulled around the resident's bed, and the resident's perineum was exposed, in full view from the hallway. Observation included a Nurse Aide Student (#1) was at Resident #80's bedside providing incontinence care. During an interview on 3/14/2023 at 3:50 PM, the observed Nurse Aide Student #1 stated today was her first day of clinical training. Interview with the RCC (Resident Care Coordinator) on 3/14/2023 at 4:00 PM, revealed the student Nurse Aides are not to do any hands on care alone today. She confirmed the observation of Resident #80's exposure while receiving incontinence care did not maintain her dignity. During an interview on 3/15/2023 at 4:30 PM, the acting Director of Nursing stated the mentor for Nurse Aide Student #1 had left the room to obtain more supplies and left the Student Nurse Aide alone. Interview confirmed Resident #80's perineum area should have been covered and the privacy curtain closed, prior to the mentor exiting the room. The interview confirmed Resident #80 was non-verbal and could not object to the exposure and lack of dignity provided while receiving incontinence care.

Based on review of facility policy, medical record review, and interviews, the facility staff failed to report allegations of abuse to the Administrator for 2 residents (Resident #57 and Resident #30) of 5 residents reviewed for abuse. The findings included: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, showed .REPORTING POLICY .Any partner having either direct or indirect knowledge of any event that might constitute abuse .must report the event immediately, but not later than 2 hours .All allegations of possible abuse .will be immediately assessed .It is the policy of this facility that 'abuse' allegations .are reported per Federal and State Law . Resident #30 was admitted to the facility on [DATE], with diagnoses including Blindness Right Eye, Dementia with Anxiety, Insomnia, and Weakness. Review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review Resident #30's quarterly MDS assessment dated [DATE], showed Resident #30 had a BIMS score of 3, indicating severe cognitive impairment. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, Adjustment Disorder with Mixed Anxiety with Depressed Mood, Major Depressive Disorder and Post-traumatic Stress Disorder. Review of Resident #57's quarterly MDS assessment dated [DATE], showed a BIMS score of 15 indicating the resident was cognitively intact. During an interview with Resident #57 on 3/15/2023 at 12:04 PM, the resident stated Resident #30 came into her room multiple times. Resident #57 stated there was an incident where two staff members came into her room to get Resident #30 out of her room. These 2 staff members told Resident #57 to wait in the hallway while the staff members removed Resident #30 from Resident #57's room. The 2 staff members returned to Resident #57's room and while Resident #57 waited outside her room, Resident #30 came back out of his room and came toward Resident #57 as she waited in the hallway. Resident #30 attempted to stand up and grabbed the arm of her wheelchair and then touched her right arm and moved his hand up her arm. Resident #57 hit Resident #30 on his hand with her grabber device. The staff intervened and told Resident #57 she could not hit Resident #30. Resident #57 stated she felt like she was abused by Resident #30 and had the right to defend herself from Resident #30 and did not feel comfortable with Resident #30. Resident #57 stated she told staff members about Resident #30, and they were aware of his behaviors. Resident #57 stated she did not know the date or time of the incident and could not remember the names of the staff members who intervened. During an interview with the Administrator and the Regional [NAME] President on 3/15/2023 at 3:51 PM, the Administrator and Regional [NAME] President confirmed they were not aware of the incident between Residents #57 and #30.

Based on medical record review, interview, and observations, the facility failed to ensure care and interventions for 1 resident (Resident #30) with Dementia of 13 residents with Dementia reviewed. Resident #30 exhibited behaviors of grabbing other residents, wandering, and agitation with no effective person-centered interventions in place. The findings include: Resident #30 was admitted to the facility on [DATE], with diagnoses including Blindness Right Eye, Dementia with Anxiety, Insomnia, and Weakness. Review of Resident #30's comprehensive care plan showed [DATE] .Diagnosis of dementia with anxiety disorder, restlessness and agitation. Patient has difficulty sleeping at night- insomnia. Combative behavior towards staff with rejection of care. Patient known to inappropriately grasp at objects and wander related to poor eyesight. Anxiety and agitation worse in PM [evening] .Goal .Mood/Behaviors will be well managed with current regimen without undue side effects . Review of the care planned interventions revealed, XXX[DATE] Administer medication to aid in sleep as ordered .Administer anti-depressant medication per MD [physician] orders and monitor for side effects .Attempt to discover root cause of behavior/mood disturbance to assist with interventions and anticipate patient's needs .Identify name, roll and function. Visit them to establish trust .Monitor resident for changes in mood and/or behaviors .Notify MD/NP [physician or Nurse Practitioner] if medication not effective .Psych [Psychological/Psychiatric] services as needed XXX[DATE] administer sleep aid as ordered XXX[DATE] Administer anti-anxiety medication per MD orders. Observe the resident closely for significant side effects XXX[DATE] Redirect patient when he is seen wandering or grasping into [onto] or at inappropriate objects . Review of the section Recreation/Wellness with a Start Date of [DATE] and an Edited date of [DATE] showed, .Condition does not allow leisure time to be spent as in past .Goal .I will accept daily visits from staff, peers and visitors and interact during visits as well as redirecting when out in the hallways where I may not know where I am going . The interventions for Recreation/Wellness were all dated [DATE], .Encourage and support activities as preferred with continued COVID precautions .I enjoy church/spiritual services. Offer me room visits as interested .I enjoy seeing pets when feeling well. Animals are fine to visit when in the facility. Invite pet therapy to visit with me when in the facility .I like to be outside when the weather is nice. Invite me to sit in the courtyards and assist as needed .I like to listen to music when feeling well. I like the older types like [NAME] Jones the best. I can listen on my TV in room. I am HOH [Hard of Hearing]. Invite me to join the music groups and assist as needed. Important: TV, visits, Encouragement . There were no new approaches or interventions since [DATE]. Review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #30's vision was highly impaired. Resident #30 had no mood indicators or behavioral symptoms toward others documented and rejection of care occurred 1 to 3 days in the past 7 days. Resident #30 used a wheelchair as a mobility device. Further review revealed Resident #30 required extensive assist of one staff member for locomotion on unit, eating, and personal hygiene. Medical record review of Resident #30's Behavior Monitoring sheet for [DATE], revealed .grabbing others . and the intervention of redirection was not effective. Medical record review revealed on [DATE] at 6:56 PM, Nurse Aide (NA) #2 documented on Resident #30's Behavior Monitoring sheet, other behavior occurred for 180 minutes with intervention, provide calm environment. Review of Resident #30's Psychiatric Periodic Evaluation dated [DATE], showed .Staff state patient has had several episodes of increased anxiety and agitation over the last few days. This is not unusual for patient, but behavior appears to have increased. On [DATE], he required two 1x [one time] dose of ativan [a medication used to treat anxiety] .he has been combative and very agitated with staff during care . Review of Resident #30's nursing progress note by Licensed Practical Nurse (LPN) #4 dated [DATE] at 4:30 PM, showed Resident #30 .was agitated and having behaviors. Pt [patient] was witnessed to have multiple verbal outbursts. Also kicking and swinging arms while in common area, around other residents .was removed from the area and taken to his room .Resident continued with behaviors . Review of Resident #30's nursing progress note by LPN #4 dated [DATE] at 4:50 PM, showed Resident #30 was given .Ativan [antianxiety medication] 0.5 mg [milligrams] IM [intramuscularly] given times 1 dose. Multiple staff assisted to give injection . Review of Resident #30's nursing progress note by LPN #5 dated [DATE] at 6:06 PM, showed .noted to be agitated this shift arguing with staff and other residents throwing trash in hallway floors . Medical record review revealed two events documented on Resident #30's Behavior Monitoring sheet on [DATE]. First entry at 6:56 PM, Certified Nurse Aide (CNA) #2 documented cursing at others and the second event documented at 6:57 PM, by CNA #2, Cursing at others with redirection not effective. Review of Resident #30's nursing progress note by LPN #2 dated [DATE] at 7:15 PM, showed Resident #30 .APPEARS AGITATED AND AGRESSIVE [aggressive] DURING TRANSFER BACK TO BED . Review of Resident #30's nursing progress note by LPN #4 dated [DATE] at 8:30 PM, showed .Pt [patient - Resident #30] continues to have behaviors. NP [nurse practitioner] notified and orders received . Review of Resident #30's nursing progress note by LPN #4 dated [DATE] at 8:30 PM, showed Resident #30 received .Ativan 0.5 mg IM given per order without incident . Review of Resident #30's nursing progress note by Registered Nurse (RN) #2 dated [DATE] at 9:42 PM, showed Resident #30 .has exhibited increased agitation and behaviors towards staff, and was tested for UTI [urinary tract infection] Patient is currently receiving abt [antibiotic therapy] r/t [related to] uti [urinary tract infection] . Review of Resident #30's nursing progress note by LPN #6 dated [DATE] at 4:22 PM, showed Resident #30 .up in the chair roaming the halls . Medical record review revealed two events documented on Resident #30's Behavior Monitoring sheet on [DATE]. First entry at 6:24 PM, CNA #3 documented cursing at others and the second event documented at 6:25 PM, by CNA #3, Disrobing in public with redirection not effective with the first event. Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 2:04 AM, LPN #2 documented, cursing at others. One on one intervention had to be provided. Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 4:20 PM, Nurse Aide (NA) #4 documented exit seeking for 200 minutes. Review of Resident #30's Psychiatric Periodic Evaluation dated [DATE], showed .Staff requesting renewal of PRN [as needed] ativan, due to continued agitation and anxiety at times. Worse in PM [evening] and after bed time. Patietn [Patient] delusional, exit seeking, and aggressive with redirection at times . Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 7:29 PM, NA #4 documented, grabbing others. Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 12:20 PM, CNA #2 documented, cursing at others for 5 minutes with redirection not effective. At 12:21 PM, CNA #2 documented, hitting others with redirection not effective. At 8:37 PM, LPN #2 documented, cursing at others for 20 minutes, with redirection not effective. Review of Resident #30's nursing progress note by LPN #3 dated [DATE] at 6:33 AM, showed Resident #30 .was combative with caregiver, refused to get up this morning . Review of Resident #30's Psychiatric Periodic Evaluation dated [DATE], showed .PRN ativan was renewed .He does still have some anxiety and agitation at times. Worse in PM . Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 9:15 AM, LPN #3 documented, wandering for 120 minutes with redirection not effective and one on one intervention had to be provided. Review of Resident #30's Psychiatric Periodic Evaluation dated [DATE], showed .PRN ativan was ordered. Recently expired. Appears last dose was used ,d+[DATE]. Staff state still has some PM agitation and anxiety at times . Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 9:32 PM, LPN #3 documented, other behavior for 60 minutes and interventions of Redirection, One on one, offer food/fluids were not effective. Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 9:29 PM, LPN #3 documented other behavior for 120 minutes and Redirection, One on one, offer food/fluids interventions were not effective. Review of Resident #30's nursing progress note by RN #1 dated [DATE] at 3:22 PM, revealed .is agitated and aggressive, anxiety medication given as a prn [as needed dose of medication]. Unable to voice needs. [NAME] [propels] self in chair, needs to be redirected numerous times out of other resident rooms. Will cot [continue] to monitor behaviors . Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 4:49 PM, NA #4 documented, grabbing at others for 20 minutes. Redirect, One on one, provide calm environment interventions were documented as not effective. At 4:52 PM, NA #4 documented hitting others for 15 minutes and One on one, provide calm environment interventions were not effective. At 4:54 PM, NA #4 documented, cursing at others and One on one, provide calm environment interventions were not effective. Telephone interview on [DATE] at 7:15 PM, NA #4 stated, .This was the night [[DATE]] two other CNAs come and got me to help because [RN #1] asked them to come and get me to get him [Resident #30] off a lady [Resident #31] that he had pushed his feet on the back of her wheelchair and grabbed her by the back of her shirt and was choking her . Review of Resident #30's nursing progress note by RN #1 dated [DATE] at 6:26 PM, revealed .Resident [#30] increased agitation and aggressive. Going in others rooms. Difficult to redirect. Cursing staff and other residents. PRN med given. Report to next shift. Will cont [continue] to monitor behaviors . Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 9:25 PM, LPN #3 documented other behavior for 45 minutes with redirection, one on one, offer food/fluids documented as not effective. Review of Resident #30's social services progress note by Social Worker (SW) #1 dated [DATE] at 4:30 PM, revealed Resident #30 .has restlessness, trouble concentrating on things, and can be easily agitated at times . Review of Resident #30's progress note by the Director of Activities dated [DATE] at 11:12 AM, revealed Resident #30 .propels around in his w/c [wheelchair] as he likes pulling himself along the handrails and door facings (pulling off corner protectors) and at times will pull on other resident chairs and needs redirection several times during the day as he goes in other resident rooms due to his poor eyesight. Pt [patient] can get agitated from time to time during redirection and will reach out to grab clothing or your hands when doing so and can be hard to redirect . Resident #30 can .be disruptive as he propels himself into others, pulls their W/C [wheelchair] or pulls the table clothes [cloths] off the tables with items on them due to his poor eyesight . Review Resident #30's quarterly MDS assessment dated [DATE], showed Resident #30 had a BIMS score of 3, indicating severe cognitive impairment. Resident #30's vision was highly impaired. Resident #30 had mood indicators of feeling tired; having little energy for several days in the last 14 days; trouble concentrating on other things, such as newspaper or watching television nearly every day in the last 14 days; moving or speaking so slowly that other people noticed or being so fidgety or restless that he had been moving around a lot more than usual for half or more of the days; and being short-tempered, easily annoyed for half or more of the days in the past 14 days. Resident #30 had behaviors of hallucinations and delusions. Physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms directed toward others occurred 1 to 3 days in the past 7 days. Rejection of care occurred 1 to 3 days in the past 7 days. Resident #30 used a wheelchair as a mobility device. Further review revealed Resident #30 required extensive assist of two or more staff members for locomotion on unit, eating, and personal hygiene. Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 9:29 PM, LPN #3 documented wandering for 90 minutes and redirection, one on one, offer food/fluids was documented as not effective. Observations of Resident #30 on [DATE] during the afternoon hours of 1:00 PM - 5:00 PM and on [DATE] during the morning hours of 8:00 AM - 11:00 AM, revealed the resident sitting in a reclined Broda chair (rolling chair that reclines with a footrest), in the hallway outside his room, reclined at a ,d+[DATE]-degree angle, with his feet on the floor, quiet and sleeping. During observation on [DATE] at 2:00 PM, the resident had been moved to his room with the door closed. During an interview on [DATE] at 3:15 PM, the Administrator stated .There are people that are intimidated . by Resident #30's behaviors.He'll get in a mood, and he'll pull himself .I've heard people complain because he'll go around the whole floor .We've tried to redirect him . During an interview on [DATE] at 3:18 PM, the Assistant Director of Nursing (ADON) stated .There was one time he [Resident #30] had a few behaviors and we had a urinalysis drawn . The ADON described the previous behaviors as .He [Resident #30] was yelling .trying to go in and out of the dining room . During an interview on [DATE] at 3:22 PM, LPN #8 stated Resident #30 .with his vision impairment .likes to try to go in rooms . The staff .must redirect . During an interview on [DATE] at 3:24 PM, the ADON stated that after Resident #30 completed the antibiotics in [DATE], there have been .no more issues . The ADON stated that the behaviors shown prior to the antibiotics were that Resident #30 had .shown anxiety and .pushed a table out of the way . The ADON stated that resident behaviors were discussed in morning meetings. During an interview on [DATE] at 3:29 PM, the Administrator was asked if he was aware of behaviors by Resident #30 and he stated that .my maintenance guys are familiar . and that Resident #30 had damaged areas moving himself down the hallway. Regarding other behaviors by Resident #30, the Administrator stated .I haven't heard it at morning meeting . During an interview on [DATE] at 3:42 PM, the Director of Activities was asked about activities for Resident #30. The Director of Activities stated .I try to give him a pop-it [tactile toy] .stuffed animals .he likes music .take him to church . The Director of Activities mentioned Resident #30's behavior when he .was pulling on someone's wheelchair . When asked if other residents complained about Resident #30's behavior, the Director of Activities stated .most of them [the residents] don't . complain and she stated that the other residents understood that Resident #30 was blind, and Resident #30 didn't realize what he was doing. Medical record review of Resident #30's Behavior Monitoring sheet revealed on [DATE] at 11:39 PM, LPN #3 documented, other behavior for 45 minutes with redirection, one on one, offer food/fluids documented as not effective. Review of Resident #30's nursing progress note by LPN #3 dated [DATE] at 1:03 AM, revealed .PRN Ativan was given for restlessness with agitation .was somewhat effective . Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Anemia and Chronic Kidney Disease. Review of Resident #75's Quarterly MDS dated [DATE] showed a BIMS score of 15 which indicated the resident was cognitively intact. During an interview with Resident #75 on [DATE] at 10:10 AM, Resident #75 stated .He's [Resident #30] grabbed my arms and jerked me .finally I just don't come near his wheelchair . Resident #75 stated that this behavior by Resident #30 has happened .several times .I don't know what the dates were . During an interview on [DATE] at 10:17 AM, Housekeeper #1 stated Resident #30 .be out in the hallways .He don't mean no harm .he might grab .he grab somebody's chair to scoot through the hallway . Housekeeper #1 stated there was an incident involving Resident #30 and an unidentified resident where Resident #30 .grabbed her chair and she hit him .I think she's gone .they sent her to [another nursing home] .She got irritated with him [Resident #30]. Housekeeper #1 stated .he [Resident #30] can't hurt nobody .he's blind .he'll grab and try to feel . Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, Adjustment Disorder with Mixed Anxiety with Depressed Mood, Major Depressive Disorder and Post-traumatic Stress Disorder. Review of Resident #57's quarterly MDS assessment dated [DATE], showed a BIMS score of 15 indicating the resident was cognitively intact. During an interview with Resident #57 on [DATE] at 12:04 PM, the resident stated Resident #30 came into her room multiple times. On one occasion, Resident #30 came into her room, pilfered through her things, and attempted to touch the wall air unit. Resident #57 stated there was an incident where two staff members came into her room to get Resident #30 out of her room. These 2 staff members told Resident #57 to wait in the hallway while the staff members removed Resident #30 from Resident #57's room. The 2 staff members removed Resident #30 from Resident #57's room and returned Resident #30 to his room. The 2 staff members returned to Resident #57's room to clean up the mess Resident #30 made in the room. While Resident #57 waited outside her room, Resident #30 came back out of his room and came toward Resident #57 as she waited in the hallway. Resident #30 attempted to stand up and grabbed the arm of her wheelchair and then touched her right arm and moved his hand up her arm. Resident #57 stated she hit Resident #30 on his hand with her grabber device. During an interview and medical record review with the facility MDS Coordinator on [DATE] at 4:40 PM, the MDS Coordinator showed the Surveyor Resident #30's Behavior Monitoring sheets and compared them with the Progress Notes. The MDS Coordinator stated Resident #30, .has Behavior Monitoring Sheets, for [DATE]; [DATE]; February 2023 and current to date for month of [DATE] . Interview with the MDS Coordinator revealed staff had not always made progress notes with details of Resident #30's behaviors when they documented on the Behavior Monitoring records that behaviors had occurred. During an interview with the ADON on [DATE] at 5:16 PM, the ADON stated Resident #30, .doesn't have behavior monitoring sheets [MDS Coordinator had presented the behavior monitoring sheets at 4:40 PM]. There has to be a doctor's order for it to flow onto the behavior sheet and he does not have an order . The ADON showed the computer listing of documents for Resident #30 and stated, .see here, he doesn't have a Behavior Monitoring Sheet . When asked if she was certain, the ADON stated, .yes . During an interview on [DATE] at 6:40 PM, the Administrator stated that Resident #30 was moved to another unit and staff has been assigned to monitor him.

Based on facility policy review, observation, and interview, facility staff failed to follow handwashing procedures for 1 resident (#299) of 1 resident in contact isolation precautions. The findings include: Review of the facility policy titled, Infection Control Clinical Supplement dated 12/2019, showed .This is intended as a supplement to help provide more detailed disease specific direction for initiation and duration of precautions .Contact Precautions .For patients with known or suspected .infections or colonization with resistant organisms transmitted by direct or indirect contact with residents or the environment .Hand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings .When dealing with C. difficile infection, hand washing with either plain or antiseptic-containing soap and water is recommended over alcohol based products because spores are not killed by alcohol products; the mechanical action of washing with soap and water washed off the spores [C. difficile spores] . Resident #299 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side and Enterocolitis due to Clostridium Difficile. Medical record review of Resident #299's 5-day Minimum Data Set assessment dated [DATE] showed the resident was moderately cognitively impaired and required assistance of 1 staff member for bed mobility, transfer, ADL's, dressing, toileting, and bathing. Medical record review of Resident #299's physician order dated 3/9/2023, showed .Contact Isolation-C.Diff [Clostridium Difficile] . During an observation on 3/13/2023 at 9:46 AM, the following signs were posted outside of Resident #299's room: 1. Please Speak With Nurse Before Entering Room Thank You. 2. Contact Isolation (Mandatory PPE [Personal Protective Equipment] in addition to mask and eye protection) GOWN GLOVES. 3. A picture collage used to depict the handwashing procedure using soap and water. During an observation on 3/13/2023 at 1:03 PM, Certified Nursing Assistant (CNA) #1 and Nursing Assistant (NA) #2 donned PPE (gown and gloves) prior to entering the room of Resident #299 to deliver a meal tray. The nursing assistant delivered the tray, exited the room after doffing PPE, then sanitized their hands with alcohol based hand sanitizer from the dispenser located in the hallway. During an interview on 3/13/2023 at 1:05 PM, CNA #1 and NA #2 could not explain why Resident #299 was placed on contact isolation. They were unaware the resident had Clostridium-Difficile (C-Diff-an organism that causes diarrhea) and why it was important to wash hands with soap and water. Both CNA #1 and NA #2 confirmed they did not follow the facility policy for infection prevention. During an interview on 3/13/2023 at 3:20 PM, the Assistant Director of Nursing (ADON) and Infection Preventionist (IP) confirmed Resident #299 was placed on isolation precautions and the expectation prior to exiting the resident's room, was staff were to wash the hands with soap and water. The ADON confirmed both CNA #1 and NA #2 did not follow the facility's policy for proper infection control practice.

Based on facility policy review, review of facility contracts and agreements, review of nursing student guidelines, medical record review, facility documentation review, review of hospital records, and interview, the facility failed to prevent a significant medication error for 1 resident (Resident #1) of 7 residents reviewed for medication errors. Resident #1 received 12 medications that were prescribed for Resident #4. The medication error resulted in Resident #1 experiencing [CONDITION(S)] (decreased heart rate) and chest pains. The facility's failure to ensure medications were administered to the correct resident resulted in a significant medication error and Harm for Resident #1. The findings include: Review of the facility policy, Preparation and General Guidelines, dated 1/1/2019, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Before Administering a medication, the nurse should assure he/she is administering to the correct patient, verify the medication, dose, time and route .Administration .Medications are administered in accordance with written orders of the prescriber .Residents are identified before medication is administered by using a method of identification .Possible methods of identification include .Checking photograph attached to the medical record .Calling a resident by name (except residents with cognitive impairment) .Having the resident verify his/her last name . Review of the School of Nursing Clinical Education Center Affiliation Agreement dated 8/20/2019 revealed, .PROVISIONS FOR INSTRUCTION AND SUPERVISION OF STUDENTS .The COLLEGE shall acquaint the STUDENTS with the rules and regulations of the FACILITY .and shall hold them responsible for same .The COLLEGE'S School of Nursing through its faculty maintains its responsibility for instruction, supervision, and evaluation of treatment skills NURSING STUDENTS assigned to the facility for clinical experience .The COLLEGE'S School of Nursing will provide on-site clinical supervision of its STUDENTS .The FACILITY retains responsibility to the patient . Review of the facility's House Rules for Nursing Students dated 11/2019 revealed, .GUIDELINES .Medication Administration .Students will only administer medications with the permission of the nursing instructor and approval of facility staff they are assigned to for that day .All staff and students should follow facility accepted medication administration guidelines .At no time should a student give medication without a facility staff member being present . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 10, which indicated the resident was moderately cognitively impaired. Continued review revealed the resident received 7 doses of Insulin and received antibiotics and antidepressants in the last 7 days, and did not receive any antipsychotics, antianxiety, opioids or hypnotics in the last 7 days. Medical record review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Potassium Chloride (potassium supplement) 10 milliequivalents (mEq) extended-release tablet -[MEDICATION(S)] (to treat [CONDITION(S)]) 100 micrograms (mcg) -[MEDICATION(S)] (for high blood pressure) 5 milligrams (mg) -Senna Plus (for constipation) 8.6-50 mg -[MEDICATION(S)] (for high blood pressure) 40 mg -[MEDICATION(S)] (for high blood pressure) 50 mg -[MEDICATION(S)] (for gastroesophageal reflux) 5 mg -[MEDICATION(S)] (for high blood pressure) 75 mg -[MEDICATION(S)] (for depression) 175 mg -[MEDICATION(S)] (for urinary tract infection) 400-80 mg -[MEDICATION(S)] (for pain) 100 mg -[MEDICATION(S)] (vitamin B supplement) 0.4 mg Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #1's quarterly MDS dated [DATE], revealed the resident had a BIMS of 10, which indicted the resident was moderately cognitively impaired. Continued review revealed the resident received antipsychotic and antidepressant medications. Medical record review of Resident #1's Vital Signs Flow sheet dated 5/16/2021 at 8:04 AM, revealed the resident's blood pressure was 100/64 and pulse was 52 (normal pulse 60-100 beats per minute). Review of facility documentation dated 5/16/2021 revealed Resident #1 received the following medications on 5/16/2021 at 9:42 AM: [MEDICATION(S)] 400-800 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 0.4 mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] 50 mg, [MEDICATION(S)] 100 mcg, [MEDICATION(S)] 40 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 75 mg, potassium 10 mEq, senna plus, and [MEDICATION(S)] 175 mg. Continued review revealed .Students administered medications to wrong patient without checking the arm band .Type of Error .Incorrect Dose .Incorrect Medication .Incorrect Patient .Category of Medication .Cardiac . Further review revealed an adverse drug reaction section on the document with the following adverse drug reactions marked as present .Cardiovascular/Respiratory - arrhythmia [abnormal heart rhythm], [CONDITION(S)], chest pain, dyspnea [shortness of breath], [CONDITION(S)] [swelling], [CONDITION(S)] [low blood pressure], ortho. [orthostatic] [CONDITION(S)] [drop in blood pressure when moving from sitting to standing position], resp. [respiratory] depression [decreased respirations], [CONDITION(S)] [[CONDITION(S)]], wt.[weight] gain .Notified on call provider, q [every] 15 min [minute] v/s [vital signs] checks, heart rate dropped to 38 .notified on call provider for orders to send to ER [emergency room ] . Medical record review of Resident #1's Resident Orders dated 5/2021 revealed the resident was ordered the following medications to be administered on 5/16/2022 at 10:00 AM: -Acetaminophen (pain medication) 500 mg tablet -[MEDICATION(S)] (for high blood pressure) 10 mg tablet -Aspirin (pain medication) 81 mg tablet -[MEDICATION(S)] (to prevent blood clots) 75 mg tablet -[MEDICATION(S)] (Vitamin D) 50 mcg capsule -[MEDICATION(S)] (Vitamin B) 1,000 mcg tablet -[MEDICATION(S)] (for high blood pressure) 20 mg tablet -[MEDICATION(S)] (for high blood pressure) 10 mg tablet -Aspercreme (pain patch) 4% adhesive patch -[MEDICATION(S)] (to treat Alzheimer's Disease) 5 mg tablet -[MEDICATION(S)] (for high blood pressure, chest pains, and Heart Failure) 25 mg tablet -Omega 3 fatty acids (fatty acid supplement) 1,000 mg capsule -[MEDICATION(S)] (to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, and social anxiety) 100 mg tablet Medical record review of Resident #1's Vital Signs Flow Sheet dated 5/16/2021 at 10:00 AM, revealed the resident's pulse was 56 and blood pressure was 101/57. Medical record review of Resident #1's Vital Signs Flow Sheet dated 5/16/2021 at 10:30 AM, revealed the resident's pulse was 48 and blood pressure was 100/56. Medical record review of Resident #1's Nursing Progress Note dated 5/16/2021 at 10:33 AM, revealed .Notified by staff pt [patient] received wrong medications notified on call provider, orders to Nursing monitor pt v/s q15 min for 2 hrs [hours] q30 min for 2.5 hrs, q1 hr for 4 hrs, q4 hrs until provider can see 5/17/2021 . Medical record review of Resident #1's Vital Signs Flow sheet dated 5/16/2021 at 10:45 AM, revealed the resident's pulse was 43. Medical record review of Resident #1's Vital Signs Flow Sheet dated 5/16/2021 at 11:14 AM, revealed the resident's pulse was 38. Medical record review of Resident #1's Nursing Progress Note dated 5/16/2022 at 11:14 AM, revealed .Orders to send to ER for [CONDITION(S)] and [CONDITION(S)] . Review of Resident #1's Hospital Emergency Documentation dated 5/16/2021 revealed Emergency Medical Services (EMS) started 1 liter of normal saline while transporting the resident to emergency room . Further review revealed .patient presents to the Emergency Department for an accidental drug overdose onset PTA [prior to admission] .Patient .received another patients medication .EMS reports the patients HR [heart rate] is currently at 38 .and her BP [blood pressure] is 89/41 .Severity of symptoms are moderate .Symptoms are constant .Patient complains of back pain . The resident had a Chest X-ray performed at 11:44 AM due to shortness of breath. An EKG was conducted on 5/16/2021 which showed the resident had sinus [CONDITION(S)] (normal heart rhythm with slow rate) and a first-degree AV (Atrioventricular - section of the heart) block. Resident #1 was diagnosed with an accidental overdose, dehydration, and sinus [CONDITION(S)]. The resident was observed in the ER for over 6 hours and was discharged on [DATE] at 8:15 PM. The resident's heart rate improved, and the resident was returned to the facility with instructions to hold all hypertensive medications causing [CONDITION(S)] until her heart rate was above 60 beats per minute. Review of a Supervisory Adverse Action Notice dated 5/17/2021 revealed .Supervisor's statement of Incident .During training a nursing student .Student ventured off and administered medication without nurse [LPN #1] being present .Close observation/(Direct) supervision during med [medication] pass was not followed .If the nurse is training a nursing student Trainer is not to leave student unattended at any time during Medication Administrations or care 1:1 [one to one] training is to be provided . During a telephone interview on 4/6/2022 at 4:52 PM, the Nurse Supervisor (RN #1) stated she was notified by LPN #1 of a medication error for Resident #1. LPN #1 had notified her the nursing student had administered Resident #4's 10:00 AM medications to Resident #4's roommate, Resident #1. The RN stated, I called the Nurse Practitioner and pulled the medication list for [Resident #4] and [Resident #1] .We were concerned about the [MEDICATION(S)] .it's a cardiac med [medication] . Resident #1 was prescribed [MEDICATION(S)] but had received 50 mg more than her scheduled dose when the nursing student administered Resident #4's morning medications to Resident #1 on 5/16/2021. RN #1 stated, .I had someone sit with her [Resident #1] .and I placed a crash cart outside her room .The resident complained of chest pain. The nursing instructor had multiple students in the building she was monitoring [5/16/2021] .She came down to the 2nd floor [the instructor was on the 3rd floor with other nursing students and Resident #1 was on the 2nd floor] .I told her the student gave the patient [Resident #1] someone else's medications . RN #1 stated Resident #1's pulse dropped to 38. I called 911. She had chest pains and sent her out .her heart rate dropped below the parameters . RN #1 stated, .[LPN #1] said she pulled the meds [medications] and did not see the resident take the pills . The Nurse Supervisor confirmed the medication error was a significant medication error. During a telephone interview on 4/7/2022 at 12:45 PM, the Nursing Student stated, .I got the names of the 2 women wrong [Resident #1 and Resident #4], and I gave the B bed patient [Resident #1] the wrong medication instead of giving the medication to the patient in A bed [Resident #4] .The LPN [LPN #1] was not with me .I was not supposed to give meds without the Nurse or instructor .I didn't double check the armband or the resident's name .I didn't do the 5 rights [right patient, right drug, right dose, right route, right time] .I didn't make sure it was the right patient . During a telephone interview on 4/6/2022 at 12:51 PM, the Nurse Instructor stated, .If giving meds the student must be accompanied by a nurse .[Nursing Student] gave those meds without the nurse .She admitted she did not do the 5 rights .I do consider it a significant medication error .She [Resident #1] went to the hospital and her heart rate dropped to the 30's . During a telephone interview with LPN #1 on 4/11/2022 at 12:21 PM, LPN #1 stated she had been assigned two nursing students on 5/16/2021 and had an assigned hall. The LPN stated the nursing student was with her at the medication cart while she was preparing Resident #4's 10:00 AM medications on 5/16/2021. The LPN stated, .The nursing student took the pill cup, went into the resident's room without me seeing it .I thought she was still with me at the cart . The LPN stated she and other staff monitored Resident #1's pulse and blood pressure and placed a crash cart outside of Resident #1's room after the resident received the wrong medications. The LPN stated .I was going to hold the resident's [Resident #1] [MEDICATION(S)] that day because her pulse was already low earlier that morning .She got almost 3 times her dose .Her heart rate started dropping .she complained of chest pain, and we called 911 .She went to the hospital for cardiac monitoring . The LPN stated, .She [Resident #1] would not have received her dose of [MEDICATION(S)] that day [5/16/2021] based on her heart rate. It was low, in the 50's I think . LPN #1 stated, .Her heart rate was slowing down .It was a touchy situation. Her heart rate ran in the 30's .Not a good place for a heart rate . Continued interview confirmed Resident #1 had a significant medication error after receiving Resident #4's medication on 5/16/2021. Telephone interview with the Nurse Practitioner (NP) on 4/12/2022 at 12:12 PM, revealed the NP was on call on 5/16/2022 and was notified of the medication error. The NP confirmed Resident #1 was exhibiting [CONDITION(S)] and her pulse was decreasing. Continued interview confirmed the resident was sent to the hospital due to receiving [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The NP stated [MEDICATION(S)] affects the heart rate more than the other 3 medications. The NP stated, .It is a significant medication error. It resulted in the resident having to go to the emergency room . The NP stated the resident had a change in condition and required close monitoring for further decline or side effects from the medications received in error. During an interview on 4/12/2022 at 1:18 PM, the Pharmacy Consultant stated she was notified of the medication errors that occurred on 5/16/2021. The Pharmacy Consultant stated the resident received [MEDICATION(S)] and was sent to the ER to be monitored for symptoms of [CONDITION(S)]. The Pharmacy Consultant stated, .It was a significant medication error .potential harm . During an interview on 4/12/2022 at 1:41 PM, the Medical Director stated the resident was at a moderate risk with a heart rate of 38. The Medical Director stated the [MEDICATION(S)] was the medication of concern the resident had received. The Medical Director stated Resident #1 needed to be transferred to the emergency room for a higher level of care. During an interview on 4/12/2022 at 2:06 PM, the Director of Nursing (DON) confirmed Resident #1 received [MEDICATION(S)] 400/800 mg, [MEDICATION(S)] 5mg, [MEDICATION(S)] 0.4 mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] 50 mg, [MEDICATION(S)] 100 mcg, [MEDICATION(S)] 40 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 75 mg, potassium 10 mEq, Senna Plus, and [MEDICATION(S)] 175 mg on 5/16/2021 at 9:42 AM and Resident #1 received those medications in error. The DON stated Resident #1 was sent to the hospital due to a pulse of 38. The DON stated, .The floor nurse and the nursing instructor were responsible for the student while on the floor . The DON stated, .This [medication error] could have been a bad thing. It was a significant medication error . During an interview on 4/12/2022 at 2:52 PM, the Administrator confirmed the nursing student administered medications to Resident #1 that was prescribed to Resident #4; a medication error resulting in Resident #1 needing to be transferred by ambulance to the emergency room .

Based on review of Centers For Disease Control and Prevention (CDC) guidelines, review of the facility's testing documentation, review of the facility's time, schedule and assignment sheets, review of employee screening logs, interview, and review of state and local health department guidance, the facility failed to follow guidance for staff working while infected with COVID-19 (transmissible Coronavirus that causes respiratory illness ranging from no symptoms to severe life-threatening illness) for 3 of 31 staff who tested positive for COVID-19, potentially affecting 80 residents in the facility. The findings include: Review of the CDC guidelines titled, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 (COVID-19 Coronavirus) Infection (Interim Guidance), updated [DATE], showed, .HCP (Healthcare Personnel) with mild to moderate illness .At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved .HCP with severe to critical illness .At least 10 days and up to 20 days have passed since symptoms first appeared. At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved . Review of CDC guidelines titled, Preparing for COVID-19 In Nursing Homes, updated [DATE], showed, .As part of routine practice, ask HCP (including consultant personnel and ancillary staff such as environmental and dietary services) to regularly monitor themselves for fever and symptoms consistent with COVID-19. Remind HCP to stay home when they are ill. If HCP develop fever (T (Temperature) (greater than or equal to) 100.0 F (Fahrenheit)) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace .Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19 .If they are ill, have them .leave the workplace .Develop (or review existing) plans to mitigate staffing shortages from illness or absenteeism . Review of the CDC guidelines titled, Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated [DATE], showed, .Contingency Capacity Strategies to Mitigate Staffing Shortages .HCP should still report temperature and absence of symptoms each day before starting work .If HCP develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work .Crisis Capacity Strategies to Mitigate Staffing Shortages .When staffing shortages are occurring, healthcare facilities .may need to implement crisis capacity strategies to continue to provide patient care. When there are no longer enough staff to provide safe patient care: -Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing -If not already done, implement plans .to allow asymptomatic HCP who have had a high-risk unprotected exposure to [DIAGNOSES REDACTED]-CoV-2 but are not known to be infected to continue to work. -If HCP are tested and found to be infected with [DIAGNOSES REDACTED]-CoV-2, they should be excluded from work until they meet all Return to Work Criteria (unless they are allowed to work as described below). -If shortages continue despite other mitigation strategies, as a last resort consider implementing criteria to allow HCP with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection who are well enough and willing to work but have not met all Return to Work Criteria to work. If HCP are allowed to work before meeting all criteria .facilities should consider prioritizing their duties in the following order: 1. If not already done, allow HCP with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services. 2. Allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care only for patients with confirmed [DIAGNOSES REDACTED]-CoV-2 infection, preferably in a cohort setting. 3. Allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care for patients with suspected [DIAGNOSES REDACTED]-CoV-2 infection. 4. As a last resort, allow HCP with confirmed [DIAGNOSES REDACTED]-CoV-2 infection to provide direct care for patients without suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. If this is being considered, this should be used only as a bridge to longer term strategies that do involve care of uninfected patients by potentially infectious HCP. If HCP are permitted to return to work before meeting all Return to Work Criteria, they should still adhere to all Return to Work Practices and Work Restrictions recommendations described in that guidance. These include .They should self-monitor for symptoms and seeking re-evaluation from occupational health if respiratory symptoms recur or worsen . Review of facility documentation showed 71 residents tested positive for COVID-19 from [DATE] - [DATE]. Forty-six of the 71 residents tested positive after [DATE]. Review of facility documentation dated [DATE] - [DATE] showed 18 of the 71 residents were transferred to the hospital and 16 residents expired (or did not recover) due to COVID-19. Review of facility documentation dated [DATE] - [DATE] showed 31 staff tested positive for COVID-19. Review of facility staffing dated [DATE] showed 3 Registered Nurses (RN), 3 Licensed Practical Nurses (LPN), and 11 Certified Nurse Aides (CNA) worked the 7:00 AM - 7:00 PM shift. Four LPN's, and 6 CNA's worked the 7:00 PM - 7:00 AM shift and 1 CNA worked 3:00 PM - 11:00 PM shift. Review of a COVID-19 test dated [DATE] showed CNA #2 tested positive for COVID-19. Review of the facility schedule assignments showed CNA #2 was scheduled to work the COVID-19 unit on [DATE]. Review of CNA #2's time punch documentation showed CNA #2 worked on [DATE] from 7:00 AM - 3:01 PM and from 3:30 PM - 7:00 PM (12-hour shift). Review of the facility COVID-19 screening log dated [DATE] showed CNA #2 answered yes to having signs and symptoms of COVID-19. Review of facility-provided email communications of corporate guidance to the facility dated [DATE] showed .(Facility) will need to ask asymptomatic staff to work RED ZONE (unit for residents who test positive for COVID-19) and if needed symptomatic staff following the CDC Crisis staffing guidance . In the email communications, the Administrator stated 2 of the 3 night shift nurses were asymptomatic and would be able to work. Two night shift asymptomatic CNA's were also going to work (the Red Zone) .nursing partner situation is better . Review of a COVID-19 test dated [DATE] showed LPN #2 tested positive for COVID-19. Review of LPN #2's time punch documentation showed LPN #2 worked 12.5 hours on [DATE] from 6:50 PM - 7:00 AM and 7:00 AM - 7:13 AM. The time punch documentation showed LPN #2 worked on [DATE] from 7:00 AM - 8:08 AM, a total of 1.25 hours (1 day after positive COVID-19 test). The time punch documentation showed LPN #2 did not work [DATE]-[DATE] and returned to work on [DATE] (8 days after symptom onset and positive COVID-19 result). Review of the facility COVID-19 screening log dated [DATE] showed LPN #2 marked yes to having signs and symptoms of COVID-19 (cough, new loss of taste or smell, new shortness of breath or difficulty breathing, nausea, vomiting or diarrhea in the last 24 hours) on the questionnaire, and marked yes to having at least 2 symptoms of these COVID-19 symptoms - fever, muscle pain, sore throat, repeated shaking with chills, headache, new loss of taste or smell, chills, congestion or runny nose. Review of the facility COVID-19 screening log showed no entry for LPN #2 on [DATE] and it was unclear if LPN #2 was symptomatic on that day when working 1.25 hours. Review of the facility staffing dated [DATE] showed 2 RN's, 3 LPN's, and 11 CNA's worked the 7:00 AM - 7:00 PM shift. Two RN's, 2 LPN's, and 6 CNA's worked the 7:00 PM - 7:00 AM shift, and 1 RN worked the 3:00 PM - 11:00 PM shift. Review of a COVID-19 test dated [DATE] showed RN #7 tested positive for COVID-19. Review of the facility staffing assignment showed RN #7 was scheduled to work the COVID-19 unit on [DATE] from 7:00 AM - 7:00 PM. Review of RN #7's time punch documentation showed RN #7 worked 7:33 AM - 10:01 AM, a total of 2.5 hours, on [DATE]. RN #7 worked 7:06 AM - 4 :23 PM and 4:55 PM - 7:45 PM, a total of 12.25 hours on [DATE] (1 day after receipt of the positive COVID-19 test). The time punch log showed RN #7 did not work from [DATE] - [DATE] and returned to work on [DATE] (6 days after testing positive for COVID-19). Review of the facility COVID-19 screening log dated [DATE] and [DATE] showed RN #7 answered yes to having 2 of these symptoms - fever, muscle pain, sore throat, repeated shaking with chills, headache, new loss of taste or smell, chills, congestion or runny nose. During a telephone interview on [DATE] at 12:31 PM, CNA #2 confirmed she tested positive for COVID-19 on [DATE]. I felt like I had a head cold . The CNA confirmed that she had worked on [DATE] and .we were screening ourself (ourselves) in (performing self-screening for COVID-19 symptoms). I don't think they had anyone to work the door that day . CNA #2 stated her supervisor (RN #5) stated .I (CNA #2) didn't look well .I felt like I had a head cold or something .(RN #5) could just tell by looking at me that I didn't feel well .Later on the symptoms got worse .I had chills, body aches, fever, and a headache .After I went home I started feeling really bad .I do now think I should have reported it when I first got to work, but at the time I didn't think so .I probably shouldn't have worked . The CNA stated she was quarantined for 10 days and returned to work on [DATE]. She worked on the COVID-19 unit on [DATE] and was advised to use the exit doors of the COVID-19 unit if she needed to leave the building during the shift, but was never told before she had to leave through that door at the end of the shift. CNA #2 stated she had always exited through the front doors, including on [DATE], when she was symptomatic for COVID-19. CNA #2 stated after the shift ended, she received a call from the Director of Nursing (DON) and RN #5 instructing her to quarantine at home. CNA #2 stated a few days before she tested positive for COVID-19, she worked with CNA #1 on the COVID unit. CNA #2 stated several times .when I was in the break room she (CNA #1) was in the break room too and we both pulled down our mask to take a drink or eat something .(CNA #1) and (LPN #3), when they would talk sometimes, they would pull it (N95 respirator mask) down .We all three had been in the breakroom at one time or another .We all ended up with it (COVID-19) . During a telephone interview on [DATE] at 12:53 PM, the DON confirmed staff with fevers testing positive for COVID-19 could not work. The DON stated he was not aware staff with mild signs and symptoms and afebrile could not work the COVID unit. The DON stated he had used the CDC guidance for staffing crisis to work facility staff who had COVID-19 for a short duration on the COVID unit. The DON stated he was not aware the staff who worked on the COVID unit left the building at the end of their shift through the front lobby doors. Staff were expected to exit through the COVID unit doors if they worked on the unit. During review of facility documentation and telephone interview on [DATE] at 3:08 PM, the DON stated there were 27 staff members in quarantine from [DATE] - [DATE], and included 6 Nurses, 14 CNA's, 4 Dietary Staff, 2 Housekeeping Staff, and 1 Maintenance Staff. The DON stated the COVID-19 positive staff only worked the COVID unit and the facility allowed the staff to work under the emergency crisis staffing guidance. The DON stated he was not aware the Tennessee Department of Health (TDH) or HAI needed to be notified prior to allowing symptomatic staff to work. Review of email documentation from the HAI Infection Preventionist/Doctor of Nursing Practice (HAI/DNP) of the Southeast Region on [DATE], showed .On [DATE], (HAI RN #1) reached out to (the facility's Director of Nursing). She attached an 'Infection Prevention Outbreak Response Recommendations' guidance which states: 'Please note that TDH does not recommend any facility allow HCP who have tested positive to working (work) during their isolation period. CDC does have recommendations for contingency capacity and crisis capacity strategies for staffing shortages, but they are an option of last resort! Should your staffing concerns reach this level, please reach out to your local or Regional health department or the Healthcare Associated Infections Program at HAI.health@tn.gov so we can provide additional guidance and recommendations before allowing COVID19 HCP to work during their infectious period!' . During email communication with the Knox County Health Department COVID-19 Response Cluster Team RN #2 on [DATE], the RN stated .I have not spoken with (facility DON) in quite some time as (the facility Administrator) has taken over the reporting duties. On the occasions I spoke with (the DON) I asked about staffing and was told 'we're okay and making it currently. We have a lot of OT (overtime) right now'. When they (the facility) had an influx of 23 positive cases I discussed with (the facility DON) there were circumstances in which positive staff could work, but I told him that he should reach out to the many sister facilities first, as well as, to contact me if there were any questions .They (the facility staff) have not reached out to me about any staffing crisis .I've had several facilities contact me about this and I always refer them (facilities) to CDC website and I also email the guidance . During email communication with HAI Infection Preventionist of the East Tennessee (TN) Region RN #1 on [DATE], the RN stated she had reached out to the DON via email on [DATE]. RN #1 stated the email advised the DON she was available to assist the facility as an Infection Preventionist (IP). The RN provided information about the Infection Control and Assessment Response Program (ICAR) to the facility's DON, with outbreak response resources that included the crisis staffing information by the CDC. RN #1 stated she reached out by phone to offer assistance to the DON on [DATE] and left a voicemail with no return call. RN #1 stated she was never informed the facility was having any crisis staffing issues. RN #1 stated .symptomatic HCP should never be allowed to work .As a last resort option, CDC recommendations allow asymptomatic, infectious HCP to work as a crisis strategy but the details included in step ,[DATE] of the document should be adhered to . Review of additional emailed documentation provided by the HAI Infection Preventionist of the East Tennessee (TN) Region RN #1 to the State Survey Agency and the facility's DON on [DATE], confirmed COVID-19 outbreak response best practice recommendations were emailed to the DON on [DATE]. The email stated .The reason TDH recommends that you notify your local/Region health department or HAI is so we can stress the ramifications and expectations if you implement this crisis strategy which is truly a last resort options and increases the risk of transmission within your facility .CDC provides best practice recommendations, they are not requirements. There are Regulations on this topic .Executive Order and Board Policy .those are Regulations and can invoke deficiencies or citations by Regulatory agencies . The email further stated .per TDH recommendations, symptomatic staff should never be allowed to work . Review of email communication from the Lead Epidemiology Reporting Nurse RN #3 to the State Survey Agency and the facility's DON on [DATE] stated it was RN #3's understanding that positive healthcare workers could not work and that had been RN #3's direction to facilities.The only exception I've seen mentioned from any guidance was in extreme emergency situations, such as a mobile hospital for COVID-19 only patients where there were not enough hospital staff. And this was only with asymptomatic positives .Obviously, even then, the risk would be that positive healthcare workers could expose the other non-positive healthcare workers (coming and going from work, break areas, bathrooms, non-care areas) .We did not allow nursing homes to work positive healthcare workers at other clusters because of this risk .my understanding that crisis staffing is a true emergency situation .

Based on medical record review, observation, and interview, the facility failed to follow the care plan for falls for 1 resident (#86) of 23 sampled residents. The findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan, dated 11/19/19, revealed .fall risk .bed in lowest position . Medical record review of Resident #86's Admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 persons for transfers, bed mobility, and toileting. Medical record review of the Comprehensive Care Plan, dated 12/3/19 revealed .Keep bed in lowest position . Medical record review of the Certified Nursing Assistant Care Plan, dated 12/3/19, revealed to keep Resident #86's bed in lowest position. Review of an Event Report dated 12/12/19 revealed Resident #86 had an unwitnessed fall from bed, without injury, on 12/12/19 at 6:20 PM. Continued review revealed .PT (patient) BACK UP AGAINST THE BED WITH BRIEF OBSERVED DOWN TO ANKLES BED IN HIGH POSITION . Observation on 12/17/19 at 3:57 PM, in the resident's room, revealed Resident #86 lying in a low positioned bed. Interview and review of the facility fall investigations with Licensed Practical Nurse (LPN) #1 on 12/18/19 at 9:12 AM, in the conference room, confirmed the resident was not in the low position bed on 12/12/19. Interview with the Director of Nursing on 12/18/19 at 9:54 AM, in the conference room, confirmed the care planned low bed intervention was not in place at the time of the fall.

Based on facility policy review, medical record review, facility documentation review, observation and interview the facility failed to add a new intervention after a fall for 1 resident (#69) and failed to implement a care plan intervention to prevent accidents for 1 resident (#86) of 5 residents reviewed for accidents. The findings include: Review of the facility policy, Falls Policy, revised 7/14/17 revealed .Based on the preceding assessment, the staff and/or physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falls .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falls, until falling reduces or stops or until a reason is identified for its continuation . Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #69's care plan revised 3/5/19 revealed .Bed Alarm, ensure functioning and placement qshift (every shift) . Continued review revealed no new interventions had been implemented after the 9/20/19 fall. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment and required extensive assistance of 1 for bed mobility, transfers, toileting, and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #69 scored a 19. Continued review revealed a resident score greater that 13 indicated a high risk for falls. Review of an Event Report facility dated 9/20/19 revealed Resident #69 had an unwitnessed fall in the resident's room on 9/20/19 without injury. Continued review revealed the immediate measures implemented was a bed alarm (implemented on 3/5/19). Observation on 12/18/19 at 8:30 AM, in the resident's room, revealed Resident #69 sleep in bed with a bed alarm in place, a fall mat to the left side of the bed, and the call light within reach. Interview with the Director of Nursing (DON) on 12/18/19 at 2:00 PM, in the DON's office, confirmed the facility failed to implement a new falls intervention after the fall on 9/20/19 and failed to follow the facility policy for falls. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan, dated 11/19/19, revealed .fall risk .bed in lowest position . Medical record review of Resident #86's Admission MDS dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 persons for transfers, bed mobility, and toileting. Medical record review of Resident #86's Fall Risk Assessment Tool dated 11/26/19 revealed the resident was a high fall risk. Medical record review of the Certified Nursing Assistant Care Plan dated 12/3/19, revealed .Keep bed in lowest position . Medical record review of the Comprehensive Care Plan dated 12/3/19 revealed Resident #86 had a history of [REDACTED]. Review of an Event Report dated 12/12/19 revealed Resident #86 had an unwitnessed fall from bed without injury on 12/12/19 at 6:20 PM. Further review revealed .PT (patient) BACK UP AGAINST THE BED WITH BRIEF OBSERVED DOWN TO ANKLES BED IN HIGH POSITION .Patient fell to floor from bed trying to roll herself off a bedpan . Observation on 12/17/19 at 3:57 PM, in the resident's room, revealed Resident #86 lying in a low positioned bed. Interview and review of the facility fall investigations with Licensed Practical Nurse (LPN) #1 on 12/18/19 at 9:12 AM , in the conference room, confirmed the resident's bed .was not in the low position as I would have expected for a resident here for falls and [MEDICAL CONDITION] . Interview with the DON on 12/18/19 at 9:54 AM, in the conference room, confirmed the low bed intervention was not in place. In summary, the facility failed to ensure the low bed intervention was in place to prevent a fall for Resident #86 on 12/12/19.

Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of abuse to the state survey agency timely for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 12/11/17 revealed 6. Reporting Policy .It is the policy of this facility that 'abuse' allegations .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of a facility investigation dated 5/27/19 at 8:45 AM revealed Resident #1 reported an allegation of inappropriate contact to a Certified Occupational Therapy Assistant (COTA). Continued review revealed the COTA immediately reported the incident to the Administrator, Director of Nursing (DON) and the physician. Further review revealed Resident #1 alleged the incident occurred the morning of 5/25/19, but did not report it to the facility until 5/27/19. Continued review revealed Resident #1 was examined by the physician on 5/27/19 at 12:30 PM and no obvious physical injuries or conclusive findings were discovered. Further review revealed the resident was sent to a local hospital on [DATE] at 2:23 PM for further examination by a Sexual Assault Nurse Examiner (SANE) nurse and no clinical findings of an assault were discovered. Continued review revealed the facility reported the incident to the state survey agency on 5/27/19 at 3:23 PM (6 hours and 38 minutes after the facility was aware of the allegation). Telephone interview with the Administrator on 6/4/19 at 8:25 AM confirmed the facility failed to report the allegation until 5/27/19 at 3:23 PM (6 hours and 38 minutes after the facility was aware) and the facility failed to follow facility policy.

Based on medical record review and interview the facility failed to resubmit a PASARR Level 1 (Pre Admission Screening and Resident Review that determines whether or not an individual who has an active [DIAGNOSES REDACTED].#56 and #59) of 4 residents reviewed for PASARR level 2 (The results of this evaluation result in a determination of need, determination of appropriate setting and a set of recommendations for service to inform the individual's plan of care) of 36 residents reviewed. The finding include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated 6/11/14 revealed Resident #56 did not have a [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Progress Note dated 10/19/18 revealed .Pt (patient) seen for the management of dementia, anxiety, and depression . Medical record review of Resident #56's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #56 had current [DIAGNOSES REDACTED]. Medical record review of Resident #56's Comprehensive Care Plan updated 11/6/18 revealed, .Side effects, potential for: [MEDICATION NAME] (an antidepressant medication), [MEDICATION NAME] (a mood stabilization medication) .Dx (diagnosis) depression, anxiety, behaviors .becomes agitated .Mental Health Consult & Tx (treatment) . Medical record review of the current physician's orders [REDACTED].[MEDICATION NAME] HCL (a medication for depression) 30 mg (milligrams) . with order dated 1/19/18 and .[MEDICATION NAME] Acid (a medication for mood stabilization) 250 mg/5ml (milliliters) . with order dated 3/8/18. Further review revealed, .Psychiatric services to evaluate and treat as needed . with order dated 5/18/17. Medical record review of the Diagnostic Problem List dated 12/4/18 revealed, .Anxiety Disorder .Start date 6/12/14 .End date 9/22/17 .[MEDICAL CONDITION] .Start date 12/22/14 .End date 2/20/18 .Generalized Anxiety Disorder .Start date 9/22/17 .Major [MEDICAL CONDITION] .Start Date .9/22/17 .End date .5/14/18 .Adjustment Disorder with Depressed Mood .Start dated .5/14/18 . Interview with MDS Coordinator #2 on 12/04/18 at 2:20 PM, in the MDS office, confirmed the facility failed to submit a PASARR change of status when the resident was diagnosed with [REDACTED]. Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #59's PASARR Level 1 dated 11/5/16 revealed a PASARR Level 1 was submitted on Resident #59 prior to admission to the facility. Continued review revealed the Primary 1 Axis [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #59 had a BIMS of 15 indicating the resident was cognitively intact. Continued review revealed no documentation of a Psychiatric/Mood Disorder of Anxiety. Medical record review of the Psychiatric Consult dated 8/17/18 revealed, .Pt seen for management of mood and anxiety . Continued review revealed .Based on [DIAGNOSES REDACTED]. Medical record review of Resident #59's Annual MDS dated [DATE] revealed the resident had documentation of a new Psychiatric/Mood Disorder of Anxiety. Medical record review of Resident #59's Comprehesive Care plan dated 11/7/18 revealed the resident was care planned for mood as evidence by [DIAGNOSES REDACTED]. Medical record review of the Psychiatric Consult dated 11/7/18 revealed, .Symptom(s) .Challenge(s) Addressed in Today's Session .Anxiety .New/Ongoing Target Sx (symptoms) .Anxiety .[DIAGNOSES REDACTED].Anxiety disorder due to known physiological condition . Medical record review of the Psychiatric Consult dated 11/14/18 revealed .Summary of Session: SW (Social Worker) referred patient d/t (due to) anxiety/depression d/t difficulty adjusting to LTC (long term care) . Interview with MDS Coordinator #2 on 12/5/18 at 10:40 AM, in conference room, confirmed Resident #59 received a new [DIAGNOSES REDACTED]. Continued interview confirmed the facility failed to resubmit a PASARR Level 1 to determine if Resident #59 would be approved for PASARR Level 2 services. Interview with the Director of Nursing (DON) on 12/5/18 at 11:36 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #59 after the resident received a new [DIAGNOSES REDACTED].

Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 resident (#9) of 36 sampled residents. The findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Medication Order dated 12/20/17 revealed a physician's orders [REDACTED]. Medical record review of the Nurse's Notes dated 9/1/18 documented, .placed wanderguard to (R) (right) ankle . Medical record review of the Quarterly ((MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status score of 3, indicating the resident was severely cognitively impaired. Further review revealed Resident #9 required limited assist of one staff member for locomotion on the unit and was not assessed as having as wandering behavior. Medical record review of the Recreation Quarterly Progress Note dated 9/4/18 revealed, .(Resident #9) continues his same daily routine .with much confusion and ambulates around his rooma nd (and) the facility as he likes through the day Pt (patient) .walks around the facility and has to be redirected many times as he will wonder (wander) in and out of other rooms in the facility . Medical record review of Resident #9's Comprehensive Care Plan dated 4/4/18 and updated 9/12/18 revealed .Resident has wandering tendencies . Observation and interview with Certified Nursing Assistant #1 on 12/03/18 at 12:29 PM, in the 2nd floor dining room, revealed Resident #9 confused and wandering. Interview confirmed .He does this all day, he wanders talking . Interview with Licensed Practical Nurse #1 on 12/04/18 at 3:51 PM, on the east hall, revealed Resident #9 wanders daily about the facility. Further interview revealed .He has wandered since admission; it's something he's always done . Interview with MDS Coordinator #1 on 12/05/18 at 10:28 AM, in the MDS office, revealed Resident #9 wanders and was not coded on the MDS as wandering. Further interview confirmed the MDS was not accurate to reflect the resident's wandering behavior.

Based on medical record review and interview, the facility failed to develop and implement a comprehensive care plan to include care of a concussion after a fall for 1 resident (#100) of 2 residents reviewed for falls of 36 residents reviewed. The findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Note revealed Resident #100, on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the emergency room (ER) at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Continued review revealed Resident #100 returned to theER on [DATE] at 12:10 PM, after complaints of increased drowsiness s/p (status [REDACTED]. Medical record review of the Comprehensive Care Plan revealed no care plan on the care and management of concussions for Resident #100. Interview with Minimum Data Set (MDS) Coordinator #2 on 12/5/18 at 2:20 PM, in the MDS office confirmed she failed to develop a care plan for the care of Resident #100's concussion. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to develop and implement a care plan for the care of a concussion following a fall for Resident #100.

Based on medical record review and interview the facility failed to revise a care plan for fall risk and skin integrity following a fall with a laceration for 1 resident (#100) of 36 residents reviewed. The findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Note revealed Resident #100 on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the emergency room (ER) at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Review of the hospital's Discharge Instructions dated 11/24/18 at 6:44 AM, revealed Laceration Care, Adult .if sutures or staples were used: Keep the wound clean and dry .keep the wound completely dry for the first 24 hours or as told by your health care provider, after that time, you may shower or bathe. However, make sure that the wound is not soaked in water until after the sutures or staples have been removed. Clean the wound one time each day .wash the wound with soap and water. Rinse the wound with water to remove all soap. Pat the wound dry with a clean towel. Do not rub the wound . Medical record review of the Baseline Care Plan, undated, for Resident #100 revealed care areas for Fall Risk and Skin/Wound. Further review revealed the Fall Risk Care Plan was updated on 11/24/18 with CNA (Certified Nursing Assistant) instructed to stay with pt (patient) while toileting. Continued review revealed no revision to the Skin/Wound Care Plan and no documentation of the scalp laceration. Medical record review of the Complete Patient Care Plan, dated 11/28/18 revealed care plans for Falls and At Risk for Alteration in Skin Integrity with no revision or documentation of care or treatment of [REDACTED]. Interview with Minimum Data Set (MDS) Coordinator #2 on 12/5/18 at 2:20 PM, in the MDS office confirmed it was her responsibility to develop, revise, and review the care plans and the facility failed to revise the care plans for Resident #100 falls and skin integrity to include the scalp laceration. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to update and revise the care plans on Falls and Skin Integrity for Resident #100 for the care and treatment of [REDACTED].

Based on review of facility policy, review of medical records, observation, and interview, the facility failed to follow hospital discharge instructions following a fall for 1 (#100) resident of 2 residents reviewed for falls of 36 residents sampled. The findings include: Review of the facility policy Transfer Documentation, revised 1/2017, revealed .Responsibilities upon patient's return to the center .physician's orders should accompany the patient from the hospital. admission orders [REDACTED].Begin a new Medication Record using the new physician orders received upon return . Review of the facility policy Return From Transfer/Medical Appointment with Specialist, undated, revealed .Any patient that is transferred to the ER (emergency room ) .the facility will resume previous in-house orders and include any changes from the ER evaluation . Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Notes revealed Resident #100, on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the ER at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Review of the hospital's Discharge Instructions dated 11/24/18 at 6:44 AM, revealed Laceration Care, Adult .if sutures or staples were used: Keep the wound clean and dry .keep the wound completely dry for the first 24 hours or as told by your health care provider, after that time, you may shower or bathe. However, make sure that the wound is not soaked in water until after the sutures or staples have been removed. Clean the wound one time each day .wash the wound with soap and water. Rinse the wound with water to remove all soap. Pat the wound dry with a clean towel. Do not rub the wound . Medical record review of the Daily Skilled Nurse's Note for Resident #100, dated 11/24/18 at 7:26 AM, revealed .returned from hospital .Laceration c (with) 2 sutures to (r) (right) posterior scalp intact .only orders is to remove sutures in 10 days . Medical record review of the 11/2018 and 12/2018 Medication, Treatment and Task Administration Record Report (MAR/TAR) revealed no documentation or observations had been added for the treatment and care of the laceration and sutures to Resident #100's head. Observation of Resident #100 on 12/4/18 at 8:30 AM, in the resident's room, revealed 2 sutures intact to the right posterior side of the head. Interview with the Registered Nurse/Resident Care Coordinator (RN/RCC) #1 and RN #1 on 12/4/18 at 2:25 PM, in the Conference Room, confirmed RN #1 failed to add the laceration/suture care to the MAR/TAR for Resident #100. Interview with Certified Nursing Assistants (CNA) #2 and #3 on 12/4/18 at 2:45 PM, in the third floor lounge, confirmed they were assigned to care for Resident #100 and were not aware Resident #100 had sutures in her scalp. Interview with the Medical Director on 12/4/18 at 3:00 PM, in the 3rd floor chart room, confirmed the facility failed to follow the ER discharge orders for Resident #100. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to place the discharge instructions for the care and treatment of [REDACTED].#100 on the MAR/TAR. Further interview confirmed the facility failed to follow the ER discharge instructions for Resident #100 following a fall with laceration/sutures.

Based on review of nursing standards of care, medical record review, observation, and interview, the facility failed to provide respiratory care to address 1 resident's (#105) decline in respiratory status of 8 residents reviewed for respiratory care of 36 residents reviewed. The findings include: Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition, Lippincott publisher 2010 revealed, Assessing for Heart Failure - Be alert for the following signs and symptoms: GENERAL - Fatigue .Dependent [MEDICAL CONDITION], Weight Gain .Respiratory - Dyspnea on exertion . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing assessment dated [DATE] revealed, A&O x3 (alert and orient to person, place and time) .Respirations even/unlabored with diminished bases (less lungs sounds heard in lower lungs) .Expressed need for therapy before returning home. Medical record review of a Nurse Practitioner's progress note dated 11/26/18 revealed, Pt (patient) seen today following admission .pt reports doing okay, just with little energy .called back to her room later this afternoon because her O2 (oxygen) saturation dropped to 86% on room air (normal O2 saturation value 94-99%) 1) [MEDICAL CONDITIONS] with exertional dyspnea (shortness of breath) will give additional 40 mg (milligrams) [MEDICATION NAME] (diuretic) .now .3) [MEDICAL CONDITION] with exacerbation .Schedule [MEDICATION NAME] QID (respiratory nebulizer treatments 4 times a day) .Aggressive [MEDICAL CONDITION] toilet (medical and nursing measures to address lung function). Encourage pt to splint and cough. Check CXR (chest X-ray) 2 views now . Medical record review of the Nurse Practitioner's progress noted dated 11/27/18 revealed, .9) Volume overload (too much retained fluid) - SP (status [REDACTED]. Medical record review of the Daily Skilled Nurses Notes revealed from 11/28/18-12/1/18 the resident's oxygen saturation averaged 94% with no record of the amount of liters oxygen being delivered per minute when the oxygen level was measured. Medical record review of the Daily Skilled Nurses Note on 12/3/18 at 12:00 PM, revealed no recorded vital signs. Continued review of the one entry for 12/3/18 revealed, Resting in bed at this time. NC (nasal cannula) in place delivering O2. Pt had SOB (shortness of breath) this am (morning) and didn't have NC in. NC placed and O2 sat 91% shortly thereafter. Call light in reach. Will monitor . Medical record review of the Nurse Practitioner's progress noted dated 12/4/18 revealed, Pt seen today for reports of SOB. Pt treated for [REDACTED]. Despite diuretics, her SOB has not improved. O2 demand has increased (need for increased liters of supplemental oxygen) and pt feels as if she cannot get enough air in. Pt does report unilateral LLE (lower leg [MEDICAL CONDITION] in both legs) since admission O2 sat (saturation) 90% on 5 Lpm (5 liters per minute of oxygen by nasal cannula) .1) SOB - obtain .CXR. Give [MEDICATION NAME] 40 mg IM (intramuscular) 1 dose now .2) Acute hypoxemic (low oxygen level) resp (respiratory) failure - now on 5 Lpm (5 liters per minute). Pt's O2 sat during exam was 89-91%. Pt did not require O2 prior to hospitalization . With [MEDICAL CONDITION] will attempt to keep sat >90%. Avoid high O2 flow (amount of oxygen administered per minute) d/t (due to) unknown hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream) hx (history) . Medical record review of the Daily Skilled Nurses Notes from 11/26/18-12/4/18 revealed no record of the resident being assisted to splint and cough. Medical record review of the Baseline Care Plan, undated and unsigned, revealed Care Area .Respiratory .Oxygen 1.5 L (liters per minute) keep sats (oxygen saturation) 90%-92%. Continued review revealed no intervention listed related to the aggressive [MEDICAL CONDITION] toilet prescribed by the Nurse Practitioner (NP) to assist the resident to splint and cough. Observation and interview with the resident on 12/3/18 at 9:00 AM, in her room, revealed she was seated on her bed, appeared short of breath and this increased when she attempted to answer more than a few questions. Observation and interview with the resident on 12/5/18 at 2:00 PM, in her room, revealed she was seated on her bed with unlabored respirations. Interview continued and the resident stated she was .better .up all night off and on going to the bathroom (the same night after receiving the 40 mg of [MEDICATION NAME] IM). Interview with the resident's Licensed Practical Nurse (LPN) #2 on 12/3/18, at 3:00 PM, in the conference room, revealed the LPN restated the information provided on his nursing entry for 12/03/18. In addition, he added the resident had been in the low 80's (referring to oxygen saturation) when she returned from the bathroom without her oxygen). Continued interview confirmed he had not notified the Nurse Practitioner who was onsite of the low oxygen saturation and had not assessed the resident's lung sounds. Interview with the Resident Care Coordinator (RCC) #1 on 12/4/18 at 9:05 AM, at the third floor nursing station, revealed the resident was not weighed on Monday 12/3/18 and stated LPN #2 told the RCC, .She should have been. Interview continued and revealed the NP had not seen the resident on Monday 12/3/18. Further interview confirmed a NP had not seen the resident for the previous 6 days and the resident had not been weighed since 11/30/18. Interview with the NP on 12/4/18 at 8:45 AM, in the third floor nursing station, revealed I have never seen the resident (#105) .plan to assess her this morning . Interview with RCC #2 on 12/4/18 at 1:15 PM, in the conference room, revealed the resident's weight this day was 153 pounds and confirmed this was an increase of 5 pounds from the last weight of 148 pounds, 4 days earlier. Further interview confirmed the weight was to be done every Monday and had not been done as ordered. Continued interview revealed the chest x-ray had been reported and included in the findings The lungs again demonstrate patchy infiltrate in the right base, probably with effusion (fluid)). There is an active process in the left base . Interview with the Director of Nurses (DON) on 12/4/18 at 1:45 PM, in the conference room, revealed the nurses were to take SaO2 (oxygen saturation level in the bloodstream) on all residents as part of the routine vital signs. Continued interview revealed the DON could not provide a formal respiratory care policy. A document titled O2 Saturation Guidelines, undated, was provided for the interview. Further interview confirmed the 3 guidelines provided did not require the information of the amount of oxygen being delivered when oxygen saturation was obtained. Continued interview revealed .a lot of problems with residents' oxygen levels are found by the rehab staff . Further interview revealed Resident #105 had not been fully assessed daily by the nursing staff for her respiratory status and had not been care planned to receive the Aggressive [MEDICAL CONDITION] toilet prescribed by the NP on 11/26/18.

Based on medical record review and interview, the facility failed to provide continuing neurological assessments after a resident on anticoagulant medication fell , resulting in Harm for one resident (#53) of 34 residents reviewed. The findings included: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Medication Administration Record [REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident's score on the Brief Interview for Mental Status (BIMS) was 11/15, indicating moderate impaired cognition. Medical record review of a Post Falls Nursing assessment dated [DATE], revealed Resident #53 was found face down on the floor in her room on 6/27/16 at 7:30 AM, was unable to explain what she was doing at the time of the fall but, .finally said 'I am OK . Vital signs were taken and the physician was notified by phone with no orders received. A personal alarm was attached to alert staff if the resident decided to ambulate without assistance again while in her room. Medical record review of the Neurological Flow Sheet, dated 6/27/16, revealed Form to be used for incidents/accidents with possible head injury: A. Initial assessment followed by: B. Every hour times 3 hours followed by: C. Once per shift for 72 hours . Continued review revealed the neuro checks (a timed series of neurological assessments performed and documented to ensure the injured person has not suffered severe head injury requiring emergency intervention) started with the post fall assessment at 7:30 AM and was repeated at 8:00 AM, 8:30 AM, and 9:00 AM, with no further neuro checks completed. Nurse's Notes on the back of the form revealed, 6/27/16 Unsure of blood from nose was due from fall- on [MEDICATION NAME] (blood thinning medication) but bleeding stopped immediately. Per therapy resident had some nasal bleeding possible due to oxygen usage via nasal canula. Neurochecks DC'd (discontinued) . Medical record review of a Nurse's Note dated 6/27/16 at 4 PM: Fall follow-up from 6/27/16 @ (at) 7:30 AM - awake, alert with confusion noted, has hx (history) of hallucinations and dementia .[DIAGNOSES REDACTED], uses pen and paper for most communication .UTI (urinary tract infection) protocol initiated . Medical record review of the Daily Skilled Nurse's Note dated 6/28/16 7A-7P resident seen by NP (Nurse Practitioner). Send to ER (emergency room ) .Resident presented with decreased mental status 7A-7P. Sent to ER per NP to eval & tx (evaluate and treat). Resident admitted for subdural hematomas . Medical record review revealed a note indicating the resident was sent to theER on [DATE] at 12:45 PM. Medical record review of the hospital Discharge Summary revealed Date of Admission: 06/28/16 .Date of Discharge: 07/01/16 .Admission Diagnosis: [REDACTED].#53 .was trying to get up to go to the bathroom when she had a fall .she had a CT scan (computed tomography), which demonstrated a small subdural hematoma along the frontoparietal falx, roughly 6 mm (millimeters) in thickness as well as a thin density subdural collection over the left posterior frontoparietal lobe roughly 9 mm in thickness .she is alert and oriented x0 (times zero, not alert or oriented) .she does not follow commands .she does spontaneously wave her left lower extremity .was admitted to the Neuro ICU (intensive care unit) .The patient was taking [MEDICATION NAME] .we did obtain a second CT 6 hours after the first one due to use of anticoagulation; at that time, the CT reading showed the subdural hematoma slightly increased .We did obtain a second CT on 6/29/16, approximately 6 hours after. At that time, the CT showed stable right posterior parietal subdural fluid collection and stable falx hematoma. There was no worrisome interval change . Further review revealed the resident was discharged back to the facility on [DATE] with orders not to resume anticoagulation therapy until a repeat CT scan was done in 2 weeks. Interview with the NP on 10/19/16 at 2:10 PM, in the conference room, confirmed I was not consulted until the 28th. I thought she had fallen that morning (morning of 6/28/16). I'm glad I sent her out, on [MEDICATION NAME], on a lot of medicine, her baseline cognition pretty demented all the way along. It would have been appropriate to ask the physician to evaluate anyway given the resident's history. Three .neuro checks is not the normal protocol. In summary, Resident #53, who was receiving anticoagulation therapy, had an unwitnessed fall on 6/27/16 at 7:30 AM, when she was found lying face down with a small amount of bleeding from the nostril. The facility did a total of 4 neuro checks that ended at 9:00 AM, 1 1/2 hours after the fall, with no further neuro checks. The next day, on 6/28/16, the resident was found with altered mental status, sent to the hospital at 12:45 PM, and susequently admitted to the ICU for subdural hematomas.

Based on medical record review and interview, the facility failed to follow the care plan to use a mechanical lift to provide safe transfers, resulting in harm for 1 resident (#213) of 3 residents reviewed for accidents, of 30 residents reviewed. The findings included: Medical record review revealed Resident #213 was admitted to the facility 4/09/09 with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 11/20/14 for Resident #213 revealed .Risk for Falls r/t (related to) muscle weakness, adult failure to thrive, Alzheimer's dementia,[MEDICAL CONDITION]([MEDICAL CONDITION]/stroke) with R (right) sided weakness .Mech (mechanical) lift with 2 (person) assist for transfers . Facility record review of the Initial 24-hour Report dated 2/27/15 revealed .Pt (patient) found to have fx (fracture) of R (right) humerus (upper arm bone) 2/27/15. This was after CNAs (Certified Nurses' Aides) .found arm in different position . Medical record review of the x-ray report dated 2/27/15 at 10:15 AM, revealed .An acute angulated humeral shaft fracture is identified .no significant [MEDICAL CONDITION] changes are seen . Interview on 10/19/15 at 2:50 PM, in the Director of Nursing's (DON) office with the two shower team CNAs (CNAs #1 and #2) who discovered the injury on 2/27/15 revealed We lifted the resident (Resident #213) out of bed and when we got the resident into the shower room and took her gown off her, right arm was very bruised and hanging limp. She usually kept her arms folded and held close to her. We called the nurse and took the resident back to her room and bed. Telephone interview on 10/20/15 at 2:40 PM with the CNA (#3) who was assigned to Resident #213 on 2/26/15 and put Resident #213 to bed at the end of the shift, revealed .resident was in geri-chair, I took off her shirt, put a gown on her and got a male nurse to help me lift her back to bed. We just lifted her the way we always did. She was a small woman. We never used the mechanical lift to lift her, didn't know we were supposed to . Telephone interview with LPN #1 at 5:38 PM revealed I just helped the CNA lift the resident back to bed. There was no lift pad under the resident. We just put our arms under hers, supported her back and slid her into the bed .She was a candidate for a mechanical lift, but I didn't ask, I just helped. Interview with the shower team CNAs on 10/21/15 at 1:50 PM, in the conference room confirmed .we did not use a lift to transfer the resident from the bed to the shower chair, we used a gait belt and pad to scoot resident to the edge of the bed and then into the chair. We didn't see the bruise until we got to the shower room. We took her back to the room and used a sheet to transfer her back to bed. We didn't know we were supposed to use a mechanical lift and didn't know to ask. Interview with the DON on 10/21/15 at 3:10 PM, in the conference room, confirmed a mechanical lift was care planned for Resident #213, and should have been used by staff for the resident for every transfer. Continued interview confirmed the staff failed to follow the care plan when transferring Resident #213 on 2/26-27/15, resulting in harm to Resident #213.

Based on medical record review and interview, the facility failed to use a mechanical lift to provide safe transfers, resulting in harm for 1 resident (#213) of 3 residents reviewed for accidents, of 30 residents reviewed. The findings included: Medical record review revealed Resident #213 was admitted to the facility 4/09/09 with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] and the annual MDS dated [DATE] revealed the resident had severe cognitive impairment, did not speak or walk, and required extensive assistance with all activities of daily living. Medical record review of the Care Plan dated 11/20/14 revealed .Risk for Falls r/t (related to) muscle weakness, adult failure to thrive, Alzheimer's dementia, CVA (cerebral vascular accident/stroke) with R (right) sided weakness .Mech (mechanical) lift with 2 (person) assist for transfers . Facility record review of the Initial 24-hour Report dated 2/27/15 revealed .Pt (patient) found to have fx (fracture) of R (right) humerus (upper arm bone) 2/27/15. This was after CNAs (Certified Nurses' Aides) .found arm in different position . Medical record review of the x-ray report dated 2/27/15 at 10:15 AM, revealed .An acute angulated humeral shaft fracture is identified .no significant degenerative changes are seen . Interview on 10/19/15 at 2:50 PM, in the Director of Nursing's (DON) office with the two shower team CNAs (CNAs #1 and #2) who discovered the injury on 2/27/15 revealed We lifted the resident out of bed and when we got the resident into the shower room and took her gown off her, right arm was very bruised and hanging limp. She usually kept her arms folded and held close to her. We called the nurse and took the resident back to her room and bed. Telephone interview on 10/20/15 at 2:40 PM with the CNA (#3) who was assigned to the resident on 2/26/15 and put the resident to bed at the end of the shift, revealed .resident was in geri-chair, I took off her shirt, put a gown on her and got a male nurse to help me lift her back to bed. We just lifted her the way we always did. She was a small woman. We never used the mechanical lift to lift her, didn't know we were supposed to . Telephone interview with LPN #1 at 5:38 PM revealed I just helped the CNA lift the resident back to bed. There was no lift pad under the resident. We just put our arms under hers, supported her back and slid her into the bed .She was a candidate for a mechanical lift, but I didn't ask, I just helped. Interview with the shower team CNAs on 10/21/15 at 1:50 PM, in the conference room confirmed .we did not use a lift to transfer the resident from the bed to the shower chair, we used a gait belt and pad to scoot resident to the edge of the bed and then into the chair. We didn't see the bruise until we got to the shower room. We took her back to the room and used a sheet to transfer her back to bed. We didn't know we were supposed to use a mechanical lift and didn't know to ask. Interview with the DON on 10/21/15 at 3:10 PM, in the conference room, confirmed the facility failed to use a mechanical lift to provide safe transfers, resulting in harm to Resident #213.

Based on medical record review, observation, and interview, the facility failed to ensure one resident (#1) was provided two-persons to assist with a transfer, resulting in harm for one resident (#1) of five sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident's Brief Interview Mental Status score was 15 (intact cognition) and the resident required assistance of two persons for transfers and bed mobility. Medical record review of a care plan revealed an entry dated October 23, 2013, "...ADL (Activities of Daily Living)...Req (Requires) max (maximum) assist with all adl's...mech. (mechanical) lift for all transfers - 2 staff to assist." Medical record review of a nurse's note dated November 13, 2013, revealed, "7A-7p (7 a.m. - 7 p.m.) alerted by CNA (Certified Nursing Assistant)...to come look at pt's (patient's) L (left) shoulder...my opinion was (the resident) needed an x-ray..." Medical record review of an x-ray report dated November 13, 2013, revealed, "...bony demineralization...Impression: non-displaced fracture lateral aspect of the humeral head. Mild widening of the left AC (Acromioclavicular) joint suggests AC separation." Observation and interview with resident #1 on December 10, 2013, at 12:22 p.m., in the resident's room, revealed the resident seated in a chair and a sling on the left upper extremity. The resident was alert and oriented. When asked about the sling on the left arm, the resident stated, "I broke it. I was on a lift (mechanical device used to transfer). I'm paralyzed on the left. She (staff member/CNA #1) got it (the lift) up too high. I told her to stop and I think she got upset..." Continued interview revealed the resident's son then helped and assisted with the transfer and the resident stated, "...My son helped (CNA #1 ) get me in the bed straight...It (resident's arm) was burning like. I told (CNA #1) it was burning..." The resident stated, "...It kept hurting. They came and took x-rays and they said it was broken..." Interview with CNA #1 on December 10, 2013, at 2:52 p.m., in the conference room, revealed CNA # 1 was aware the resident required the assistance of two for transfer with a mechanical lift. Continued interview revealed CNA #1 transferred the resident with a mechanical lift from a chair to over the bed without another CNA's assistance on November 12, 2013, and a second CNA usually assisted with a transfer by securing the lift pad prior to a transfer and pulling the mechanical lift to the bed. Continued interview revealed CNA #1 "stepped out (of the resident's room) to look for help" with the transfer, and the resident's son said he would help; the resident's son assisted with completion of the transfer. Telephone interview with the resident's physician on December 10, 2013, at 4:28 p.m., revealed, "...someone with bony demineralization-fracture could have occurred during repositioning or transfer-can't say with certainty..." Interview with the Director of Nursing on December 10, 2013, at 4:55 p.m., in the conference room confirmed the facility failed to provide two staff for assistance in transferring Resident #1 on November 12, 2013.