Every finding on record at Silver Bluff

Based on observations and staff interviews, the facility failed to dispose of food stored past the use by date in 1 of 3 refrigerators (walk-in refrigerator). Furthermore, the facility failed to maintain clean air vents located directly above the kitchen's tray line free from gray debris and practice hand hygiene during tray line service for 1 of 4 kitchen staff (Kitchen Staff #1) observed in the kitchen. The deficient practice had the potential to affect food served to residents. Findings included:a. On 1/5/26 at 10:34 AM an observation was conducted in the walk-in refrigerator with the Dietary Manager. An opened 1-gallon container of soy sauce was observed on the top shelf of a storage rack. The container contained a written date 6/11 -12/11. On 1/5/26 at 10:43 AM the Dietary Manager stated the soy sauce useful date range was 6 months after it was opened on 6/11/25. The soy sauce should have been disposed after 6 months (12/11/25).b. On 1/7/26 at 11:31 AM during tray line service Kitchen Staff #1 was observed removing his hat and rubbing his hair with his bare hands. The Kitchen Staff #1 did not wash his hands before putting on a pair of gloves. The continued observation revealed the kitchen staff left the kitchen wearing gloves, entered the dining room area and then returned to the kitchen without washing his hands. Kitchen Staff #1 was plating hot tray liners into plate covers and then onto trays used to plate food. He also was observed touching covered dessert containers used on the tray line. On 1/7/26 at 12:30 PM the Kitchen Staff #1 stated he may have forgotten to wash his hands after he touched his hair while in the kitchen. He stated he knew he needed to wash his hands when entering the kitchen and when changing gloves and he thought he had washed his hands every time he was supposed to.c. On 1/7/26 at 11:45 AM an observation made during tray line service found an air vent located directly above the tray line covered in debris. The air vent was covered in a thick, clumpy, and grayish in color substance.On 1/7/26 at 12:01 PM the Dietary Manager stated the Kitchen Staff #1 should have washed his hands after he touched his hair and each time, he entered the kitchen and changed gloves. Furthermore, the Dietary Manager stated the air vents in the kitchen should be cleaned every 3 to 4 months and did not know when they were last cleaned. She added, maintenance was responsible for cleaning the air vents and she would put in a work order to have them cleaned.The Administrator stated on 1/8/26 at 5:04 PM the food stored past its usable date should have been disposed. The air vents above the tray line needed to be cleaned and maintained and the kitchen staff needed to follow good hand hygiene.

Based on observation, record review, and interviews with the Wound Care Nurse Practitioner (NP), Medical Director (MD) and staff, the facility failed to follow up when a Wound Care NP recommended the staff contact the primary care provider about the condition of the wound and if antibiotics needed to be ordered for a resident who showed symptoms of a wound infection. This deficient practice affected 1 of 2 residents reviewed for pressure ulcers (Resident #11).Findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, type-2 diabetes mellitus, hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (decreased control and strength on one side of the body) following a cerebral infarction affecting left non-dominant side.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment. The MDS showed that she required substantial/ maximal assistance with upper body dressing and was dependent on staff for all other activities of daily living (ADL) tasks and mobility. The MDS documented that she was at risk for developing pressure ulcers. It also documented that she had an unhealed stage 3 pressure ulcer and an unstageable pressure ulcer. The MDS further documented she had a pressure reducing device for the bed.A wound care note by Wound Care NP #2 dated 12/31/25 stated current wounds with decline this week. Treatment plans adjusted. Contact primary care physician (PCP) for possible antibiotic treatment due to positive signs and symptoms of infection to hip.Review of the resident's electronic medical record revealed that no antibiotic orders were entered. The record also showed no documentation in the progress notes indicating that the primary care provider had been contacted.A care plan last revised on 1/6/26 was in place for a pressure ulcer to the right heel, left lower leg, and right hip. The care plan interventions included administering treatments as ordered and to monitor for effectiveness. Staff were directed to assess, record, and monitor wound healing every week and report improvements or declines to the MD.A telephone interview was conducted with Wound Care NP #3 on 1/7/26 at 3:12 PM. He stated he remembered Resident #11 and her DTI (deep tissue injury) (damage to the skin and underlying soft tissues that can quickly become a deep pressure ulcer). He explained how a DTI developed and said that an initial insult to the area, such as a scrape or bump, made the area more sensitive to pressure and increased the risk of developing a DTI. He said that he believed the patient herself may have told him she bumped her hip. He explained you could not always see the trauma or where it started, but things like bumping or scrapping could cause trauma to an area and blood vessels to break under the skin. He said for Resident #11 something caused trauma to her hip and then she developed a DTI. He stated a DTI was what she initially had and that it had been covered with eschar. He explained when a DTI opened, it would then be staged as a pressure injury. Wound NP #3 said when Resident #11's DTI opened, it would be staged as a pressure wound because it was over a bony prominence.On 1/7/26 at 9:23 AM an observation was conducted of Resident #11's right hip wound with Nurse #2. The dressing was saturated with copious purulent brown drainage. The drainage had leaked out of the dressing and was visible on the under-bed pad. A malodorous smell was present. The wound was circular and opened into a visible cavity. A clumped gray piece of eschar was present at the wound opening. Nurse #2 measured the wound as 4 centimeters (cm) in length, 5 cm in width, and 5.5 cm in depth.An interview was conducted with Nurse #2 on 1/7/26 at 9:44 AM. Nurse #2 was the facility's wound care nurse. She said Resident #11's wound was found on 11/20/25 and was covered with black eschar (hard black dead tissue that forms over a deep wound). She believed that Resident #11's wound on her right hip was a pressure ulcer because it was over a boney prominence and there had been no trauma or transfer related trauma that had happened. She was not sure how Wound Care NP #3 had determined it was a transfer trauma wound. Nurse #2 explained Wound Care NP #3 was no longer coming to the facility and that a new Wound Care NP (Wound Care NP #2) had started coming the previous week. Nurse #2 reported she rounded with Wound Care NP #2 during her visit on 12/31/25 and was present when Resident #11's wound was evaluated by Wound Care NP #2. Nurse #2 recalled the odor to Resident #11's wound had been worse last week. Nurse #2 was aware of Wound Care NP #2's progress note from 12/31/25, which mentioned contacting the primary care provider for a possible antibiotic due to symptoms of infection in the right hip wound. Nurse #2 stated she had mentioned this to NP #1 when NP #1 was at the facility on Thursday (1/2/26). She said NP #1 had not thought Resident #1 needed an antibiotic. Nurse #2 reported that NP #1 did not examine Resident #11's wound. She could not explain why NP #1 believed Resident #11 did not need an antibiotic without evaluating the wound.A telephone interview was conducted with NP #1 on 1/7/26 at 10:23 AM. NP #1 stated she had been at the facility on 12/31/25 and again on 1/2/26. She stated she had not been informed and did not recall anyone contacting her about Resident #11's wound status or the need for an antibiotic.A telephone interview was conducted with Wound Care NP #2 on 1/7/26 at 2:56 PM. Wound Care NP #2 explained 12/31/25 had been her first time coming to the facility. She recalled seeing Resident #11 on 12/31/25 and evaluating her wound. She recalled she ordered Santyl (wound treatment used to debride (remove) dead tissue) for the wound care treatment because the wound was covered in eschar, she said the eschar was not stable and needed to come off. She stated Resident #11's wound was bad and that she had asked the Wound Care nurse (Nurse #2) to contact the primary care provider to get her started on an antibiotic. She said there was no doubt in her mind that there was probably some infection going on because of the amount of purulent drainage and the odor. She stated Resident #11 had moderate purulent drainage when she saw her on 12/31/25. Wound Care NP #2 explained that a wound did not heal correctly if there was infection present and that infection could impede healing. She explained that when an antibiotic was needed, her process was to notify the primary care provider and defer to them to decide about the antibiotic because she felt the primary care provider knew more about what was going on with the resident medically. Wound Care NP #2 said Nurse #2 had rounded with her on 12/31/25. She recalled discussing with Nurse #2 that Resident #11 had symptoms of infection and needed follow up with the primary care provider regarding a possible antibiotic. Wound Care NP #2 stated that she had also documented it in her note.On 1/7/26 at 3:50 PM during an interview with the Administrator, Director of Nursing (DON), and Regional Nurse they were made aware by the surveyor of the condition of Resident #11's wound and Wound Care NP #2's progress note from 12/31/25 recommending antibiotics. The Regional Nurse stated that they would update the provider and see if the provider wanted to start antibiotics.The electronic medical record included an order dated 1/7/26 that read, clindamycin (antibiotic) 300 milligrams (mg) by mouth three times a day for wound infection for 10 days. The January 2026 medication administration record (MAR) documented the clindamycin was administered as ordered on 1/7/26 and 1/8/26.A follow up interview was conducted on 1/8/26 at 11:48 with Wound Care NP #2. She reported she had evaluated Resident #11's wound today and that it had looked better today than it had looked last week. She explained the santyl was doing its job to remove the eschar and it looked better because all the eschar was gone and there was less odor. Wound Care NP #2 said Resident #11's wound did not look the way it had looked last week but stated she thought Resident #11 would still benefit from antibiotics because of the drainage. She explained she suspected there was some infection present, although the wound looked better than it had last week. She reported the drainage was brown but not as purulent as it had appeared last week. A telephone interview was conducted with the Medical Director on 1/8/26 at 4:48 PM. The Medical Director stated his last day at the facility was on 12/31/25. He said he had not been contacted about Resident #11's wound or the need for an antibiotic. He explained that if the Wound Care NP had recommended antibiotics, he typically would have started an antibiotic. The Medical Director stated that someone should have followed up about the antibiotic for Resident #11 and made sure it happened.An interview was conducted with the Director of Nursing (DON) and Regional Nurse on 1/8/26 at 2:03 PM. The Regional Nurse stated the information should have been communicated to the primary care provider regarding the possibility of an antibiotic being needed for Resident #11. When asked who was responsible for reviewing the wound care providers notes, the DON stated it was a collective effort by the clinical team and that notes were reviewed in the daily clinical meeting. The DON reported he could not say they reviewed all notes in the clinical meeting but said he thought it was the responsibility of the clinical team to make sure provider notes were reviewed. The DON stated any notes from an outside provider should be reviewed and addressed by the clinical team for the best outcome for the resident. The DON did not remember reviewing Resident #11's wound notes from 12/31/25.An interview was conducted with the Administrator on 1/8/26 at 5:00 PM. The Administrator stated there should have been follow-up with the primary care provider regarding Resident #11 possibly needing an antibiotic. The Administrator said there should be a process for reviewing provider notes for orders.

Based on record review, observations and interviews with staff, resident, Nurse Practitioner and Pharmacist, the facility failed to maintain a medication error rate of less than 5% as evidenced by a medication ordered not to be crushed was administered crushed and medication omissions (3 medication errors out of 34 opportunities), resulting in a medication error rate of 8.82% for 1 of 3 residents (Resident #116) observed during medication pass.The findings included:Resident #116 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia (condition where the prostate gland enlarges) and age-related bilateral cataract.a. The Physician's Orders in Resident #116's electronic medical record indicated an active order dated 11/2/24 for Oxybutynin Chloride XL oral tablet extended release 24 hour 5 milligrams (mg) - give 1 tablet by mouth one time a day for bladder spasms/urgency. Do not crush.On 1/7/26 at 9:04 AM, Medication Aide (MA) #1 was observed as she prepared and administered Resident #116's medications. MA #1 crushed Resident #116's medication which included an Oxybutynin extended-release tablet while stating that Resident #116 preferred to take his medications crushed without applesauce or pudding. MA #1 administered the crushed medications to Resident #116 who swallowed them with a sip of water afterwards.An interview with MA #1 on 1/7/26 at 9:07 AM revealed she did not notice the order for Oxybutynin included instructions to not crush this medication, so she crushed it. MA #1 explained that the instruction to not crush medications was usually in bold letters and it was not for the Oxybutynin order which was why she didn't notice it. MA #1 stated that she did not know why the Oxybutynin could not be crushed.A phone interview with the Nurse Practitioner (NP) on 1/7/26 at 11:01 AM revealed the recommendation for Oxybutynin extended-release tablet was to not crush this medication because it was intended to work over a 24-hour period and if it was crushed, then the medication would have a tendency to hit at one time. The NP stated that she had noted that Resident #116 was getting his medications crushed per his preference, but they could have substituted this medication for a formulation that could be crushed.A phone interview with the Pharmacist on 1/7/26 at 12:13 PM revealed extended-release tablets were not crushable because crushing them would destroy the integrity of the tablet and would release all the medication at one time. She stated that Oxybutynin extended-release tablet should not be crushed.b. The Physician's Orders in Resident #116's electronic medical record indicated an active order dated 7/29/24 for Refresh Tears ophthalmic solution - instill 1 drop in both eyes three times a day for dry eyes, and an active order dated 12/21/24 for Fluticasone-Salmeterol inhalation aerosol (steroid and bronchodilator combination medication) - 1 inhalation orally two times a day for COPD.On 1/7/26 at 9:04 AM, MA #1 was observed as she prepared and administered Resident #116's medications. MA #1 did not administer the Refresh eye drops and the Fluticasone-Salmeterol inhaler to Resident #116.An interview with MA #1 on 1/7/26 at 10:05 AM revealed she did not administer Resident #116's Refresh eye drops and Fluticasone-Salmeterol inhaler because he kept these medications at the bedside and he administered them to himself.An observation and interview with Resident #116 on 1/7/26 at 10:26 AM revealed he did not keep his Refresh eye drops and Fluticasone-Salmeterol inhaler at the bedside and denied administering them to himself.An interview with the Interim Director of Nursing (DON) on 1/7/26 at 12:25 PM revealed Resident #116 did not have physician orders that he could administer medications to himself, and he was not sure why MA #1 thought he kept his inhaler and eye drops at the bedside. The Interim DON stated that MA #1 should have followed the medication pass administration protocol, which was to make sure she gave the right medication, right dosage, right resident, right strength and right product form. He also stated that MA #1 should not have crushed any medication that was not supposed to be crushed.

Based on record review, observations and staff interviews, the facility failed to date an opened insulin pen and discard an expired stock medication available for use in 1 of 5 medication carts (500 hall long-side medication cart). Additionally, the facility failed to store a heparin flush syringe in a locked cart instead of leaving it unsecured on a resident's bedside table (Resident #8).The findings included: 1. An observation of the 500 hall long-side medication cart with Nurse #1 on 1/8/26 at 10:24 AM revealed an opened and undated Novolog flex pen available for use in the top drawer of the medication cart. The insulin pen had a pharmacy label indicating it was filled by the pharmacy on 11/10/25. A review of the manufacturer's instructions for Novolog pen indicated that it lasted 28 days after its first use. The observation further revealed an open bottle of Acidophilus tablets with manufacturer's expiration date of 11/25. There were approximately 40 tablets left in the bottle. Acidophilus is probiotic bacteria naturally found in the human gut and fermented foods. An interview with Nurse #1 on 1/8/26 at 10:28 AM revealed she wasn't sure whether the expiration date was 28 days or 30 days after the Novolog pen was opened, but it should have been dated. Nurse #1 stated that she was not sure when the Novolog pen was opened, but she remembered administering it this morning to a resident and she didn't notice that it wasn't dated when she used it. Nurse #1 stated that the nurses were responsible for checking the medication carts for undated insulin and expired medications. She shared that she did not give any of the Acidophilus tablets, and she didn't have time to check all of the stock medications in the medication cart for expiration dates. Nurse #1 stated that she only checked the stock bottles she got medications out of during her shift. An interview with the Interim Director of Nursing (DON) on 1/8/26 at 12:30 PM revealed the Novolog pen should have been dated when it was opened because it was good for 28 days after opening, and that the expired stock medication should have been discarded. The Interim DON stated that each nurse on the medication cart was responsible for checking the medications and ensuring that the medications they gave to residents were within date. 2. Resident #8 was admitted to the facility on [DATE]. A physician's order dated 12/8/25 for heparin (anticoagulant) lock flush solution 10 unit/milliliter. Use 5 milliliter intravenously every shift for PICC (peripherally inserted central catheter) line patency. Flush PICC line with 10 milliliters saline followed by 5 milliliters (10 units/milliliter). The order was discontinued on 12/15/25. On 1/5/26 at 11:57 AM an observation of Resident #8's room revealed a syringe in a sealed bag. The syringe was located on a shelf next to Resident #8's chair and was labeled heparin (fast-acting anticoagulant (blood thinner) used to treat and prevent blood clots in the body) lock flush solution 5 milliliters, and the syringe was partially full. On 1/5/26 at 12:04 PM Nurse #1 was interviewed and confirmed the syringe contained medication and removed it from Resident #8's room. Nurse #1 stated he had given Resident #8's medication earlier on 1/5/26 and did not see the medication syringe on the shelf. Nurse #1 indicated he did not know who had left the heparin lock flush in the Resident's room. On 1/8/26 at 12:31 PM the Director of Nursing (DON) stated medications should never be left in a Resident's room and he did not know who had left the medication at bedside. On 1/8/26 at 5:06 PM the Administrator stated medications should not be kept at bedside unless a resident had an order for self-administration of medication.

Payor source: MedicaidBased on record review, and resident and staff interviews, the facility failed to hold aspirin (an antiplatelet medication that helps prevent blood clots) which resulted in Resident #55 not being able to have an ordered tooth extraction in November 2025 for 1 of 1 resident reviewed for providing dental services (Resident #55). Findings included:Resident #55 was admitted to the facility on [DATE] with diagnoses of severe protein-calorie deficiency and heart disease.A physician's order for one Aspirin Oral Tablet Chewable 81 milligrams at bedtime was ordered on 4/9/25.Resident #55 was care planned on 4/10/25 for dental health problems related to broken teeth and poor repair. The care plan included Resident #55 had recent tooth pain related to abscess and recurring abscesses. The care plan intervention included reporting bleeding gums and complaints of mouth or tooth pain.Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded him as cognitively intact, received a mechanically altered diet, and had no significant weight loss. The resident had mouth or facial pain and discomfort with chewing.The dental extraction consent form dated 8/25/25 was reviewed. The form included Resident #55's signature giving consent to have extractions and filling completed by the dentist. Additionally, the consent form indicated Resident #55 was taking blood thinner medication and would need the medication held 24-48 hours prior to a procedure. The form indicated the consent form was valid for 1 year after the physicians' signature. The Medical Director signed the consent form dated 8/25/25. A Dentist progress note dated 8/28/25 read Resident #55 was being seen for pain in the lower right quadrant of his mouth. Resident #55 stated he has had pain all over his mouth and wanted his teeth removed and wanted dentures. The Dentist wrote that a full mouth series (x-rays) had been completed and no remaining teeth were restorable. The note added a full mouth extraction would be planned. A physician's order was written on 10/7/25 to hold aspirin oral tablet chewable 81 milligrams from 10/7/25 to 10/10/25.A review of the October 2025 Medication Administration Record revealed aspirin was held from 10/7/25 through 10/10/25.The dentist's progress note dated 10/09/25 read Resident #55 had extractions of 4 teeth.The Social Worker (SW) stated on 1/6/26 at 3:10 PM that she had a follow-up with the dentist at the conclusion of the facility visit on 10/9/25. The dentist told the SW that Resident #55 was scheduled for more extractions on his next visit on 11/20/25. The SW stated she told the former Director of Nursing that Resident #55 would be having extractions on the next dental visit 11/20/25.There were no physicians' orders to hold Resident #55's aspirin in November 2025. A review of the Medication Administration Record for November 2025 revealed the aspirin was not held on 11/18/25, 11/19/25, or 11/20/25.A Dentist progress note dated 11/20/25 read Resident #55 was unable to be seen due to blood thinner (aspirin) not being held. The resident will be seen on the next visit if the blood thinner is held.Resident #55 was interviewed on 1/6/2026 at 10:43 AM. He stated his teeth had been hurting him off and on for a few months and was supposed to have them pulled so he could get dentures. He said when he chewed tougher foods his teeth hurt. Resident #55 stated he had some of his teeth pulled in October 2025 and was supposed to have the rest pulled in November 2025. Resident #55 indicated the November 2025 dentist appointment had to be canceled because the medication was not stopped before the dentist visit. The SW was interviewed on 1/6/26 at 3:10 PM. She stated the dental clinic would send a resident list 7-10 days prior to the facility visit. The list contained which residents would be seen and what they would be seen for. The SW reviewed the list to remove any residents who had been discharged from the facility. Residents who were to have extractions needed to sign a dental extraction form which included a signature from the physician. The dental extraction form included orders to hold blood thinner medications for 24-48 hours prior to tooth extractions and the order was active for 1 year. The SW added Resident #55 had half of his teeth extracted on 10/09/25 and was to have the rest of his teeth extracted on 11/20/25. The SW explained Resident #55 was unable to have his teeth extracted on 11/20/25 because his thinner blood medication had not been held.On 1/8/26 at 3:50 PM the previous Director of Nursing (DON) was interviewed. She stated Resident #55's blood thinner (aspirin) was held for the teeth extractions on 10/09/25. The signed physician's consent form did state the order to hold blood thinners was valid for 1 year. The previous DON stated the consent form was scanned into the resident's chart and the resident's nurses may have forgotten about the consent form being valid for 1 year and were looking for a new order to hold Resident #55's blood thinner. She added the consent form order to hold Resident #55's blood thinner was missed for the 11/20/25 dental visit. The DON added she did not remember the SW telling her about Resident #55's extractions being scheduled for 11/20/25. The former DON did not know when the Dentist was coming back and expected a new physician's order to hold the resident's blood thinner. The former DON stated the nurses would not know when to hold the blood thinner if they did not know when the Dentist was coming to the facility. The Administrator was interviewed on 1/8/26 at 5:08 PM and stated the facility needed to ensure a proper process was in place that included checks and balances for dentist visits so residents would not miss appointments.

Based on observation, staff interviews and record reviews, the facility failed to secure an unopened vial of inhaler and an opened tube of ointment in the medication cart for 1 of 1 room (room [ROOM NUMBER]), failed to date an opened bottle of eye medication and 7 opened pens of insulin for 3 of 6 medication carts (200 halls, 300 halls, and 400 halls), and failed to lock 1 of 6 medication carts during observations for medication storage audits (300 halls). The findings included: a. During a medication storage audit conducted on 11/04/24 at 10:51 AM, 1 vial of unopened ipratropium-albuterol (DuoNeb) solution and an opened tube of zinc oxide ointment were found sitting on Resident #73's bedside table and ready to be used. An attempt to interview Resident #73 on 11/04/24 at 10:52 AM was unsuccessful. She was unable to answer questions. During an interview conducted on 11/04/24 at 10:54 AM, Unit Manager #1 acknowledged that the vial of DuoNeb solution and the tube of zinc oxide ointment should not be left unattended in Resident #73's room. She added Resident #73 had never been assessed for self-administration of medication. She was not the nurse who passed medications in 500 halls in the morning and did not know why both medications were left unattended in Resident #73's room. An interview was conducted with the Staff Development Coordinator on 11/04/24 at 11:21 AM. She explained she did not work in 500 halls on a regular basis. When she passed medication in the morning, she did not notice that 2 medications were left unattended in Resident #73's room. She acknowledged that both medications should be kept in the medication cart. b. The manufacturer's package inserts for latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between the temperature of 36 to 46 Fahrenheit (F) and protected from light. Once it was opened, latanoprost could be stored at room temperature up to 77 F for up to six weeks. A review of manufacturer's package inserts for insulin glargine, Humalog KwikPen, insulin lispro KwikPen, and Levemir FlexPen revealed an unopened pen should be stored under refrigeration between 36 to 46 F and protected from light. Once they were opened, the above insulins could be stored in the refrigerator or at room temperature up to 86 F for up to 28 days, and up to 42 days for Levemir FlexPen. During a medication storage audit conducted on 11/05/24 at 2:03 PM for the medication cart of 300 halls in the presence of Nurse #1, an opened bottle of latanoprost eye drops and an opened pen of insulin glargine were found in the medication cart without an opening date, and they were ready to be used. An interview was conducted with Nurse #1 on 11/05/24 at 2:28 PM. She stated she worked the first shift most of the time and explained the latanoprost eye drops and the insulin glargine were scheduled to be administered on the evening shift. She did not notice the eye drops and insulin were opened without an opening date when she passed medication in the morning. c. A medication storage check was conducted on 11/05/24 at 3:22 PM for the medication cart of 200 halls in the presence of Medication Aide #1 (MA #1). The following insulins were found in the medication cart without an opening date and ready to be used: 1. 1 opened pen of insulin glargine 100 unit/milliliter (ml), with manufacturer's expiration date of 04/30/26. 2. 1 opened pen of Humalog KwikPen 100 unit/ml, with manufacturer's expiration date of 05/31/25. 3. 1 opened pen of Levemir FlexPen 100 unit/ml, with manufacturer's expiration date of 09/30/25. 4. 1 opened pen of insulin lispro 100 unit/ml, with manufacturer's expiration date of 10/31/25. During an interview conducted on 11/05/24 at 3:29 PM, MA #1could not determine how long the insulins had been opened and stored in the medication cart. She explained she was not authorized to administer insulin and therefore rarely checked the insulins to ensure they were dated properly. d. During a medication storage audit conducted on 11/05/24 at 3:42 PM in the presence of MA #2, 2 opened pens of insulin glargine for 2 different residents were found in medication cart for 400 halls without an opening date and ready to be used. An interview was conducted on 11/05/24 at 3:45 PM with MA #2. She stated she did not know who had opened the insulins and acknowledged that all insulins should be dated after they were opened and stored in the medication cart. She explained she was not authorized to administer insulin and therefore she never checked the insulins in her medication cart. During an interview conducted on 11/05/24 at 4:18 PM with the Assistant Director of Nursing (ADON), she stated all the hall nurses were instructed to date medications such as insulins and latanoprost when they were opened. It was her expectation for all the nurses to date latanoprost and insulins when they were opened and stored in the medication cart. She added even though the MAs was not authorized to administer insulin, it was her expectation for the MAs to check the insulins and communicated with the nurse as indicated and as needed. e. A medication storage check was conducted on 11/06/24 at 8:40 AM for the medication cart of 300 halls. Nurse #1 was seen leaving the medication cart interacting with several nurse students about 30 feet away in the hallways. The medication cart was parked unattended in the hallways next to the door of room [ROOM NUMBER]. A bunch of keys were seen sitting on the countertop of the medication cart. At the same time, the medication cart was unlocked as the locking knob was in the up position. Nurse #1 returned to the medication cart approximately 3 minutes later at 8:43 AM. None of the staff or residents were seen standing near the medication cart during the observation. During an interview conducted on 11/06/24 at 8:43 AM, Nurse #1 confirmed that the bunch of keys were for the medication cart and medication storage rooms. She stated that she usually locked the medication cart before leaving it unattended. However, she was constantly disrupted by the nursing students in the morning as they asked questions repeatedly. She acknowledged that the keys for the medication cart and medication storage room should be in her possession at all times and the medication cart should be locked before leaving it unattended. An interview was conducted with the Director of Nursing (DON) on 11/07/24 at 1:55 PM. She stated the incidents could be avoided if nursing staff paid attention when dealing with time or temperature sensitive medications in the facility. It was her expectation for all the nurses or MAs to date insulin pen and latanoprost eye drops when opened a new pen or bottle, and kept residents' room free of unattended medication all the time. An interview was conducted with the Administrator on 11/07/24 at 2:11 PM. He stated it was his expectation for the nursing staff to follow manufacturer's guidelines when handling insulin and latanoprost and kept the facility free of unattended medications in residents' room.

Based on observations, record review, and staff interviews the facility failed to protect a resident's right to be free from physical restraint when Nurse Aide (NA) #2 held Resident #61's wrists/hands in front of her chest during incontinence care when Resident #61 started swinging her arms and kicking her legs. In addition, NA #1 and NA Student #1 observed NA #2 smacking Resident #61 with an open hand on the wrist following the completion of incontinence care. This was for 1 of 3 residents reviewed for physical restraint (Resident #61). The findings included: Resident #61 was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbances. The annual Minimum Data Assessment (MDS) dated [DATE] revealed Resident #61 had severe cognitive impairment. The MDS documented she had physical behaviors directed toward others 1 to 3 days and verbal behaviors directed toward others daily. She was not documented for rejection of care. Resident #61 was documented as being incontinent of bowel/ bladder and dependent on staff for toileting hygiene, personal hygiene, and lower body dressing. Resident #61 had the following care plans in place: A behavior care plan related to dementia with behavioral disturbance revised on 9/3/24. Consisting of behaviors that can be disruptive including, verbally/ physically aggressive behaviors, has displayed yelling/ screaming, tapping/ hitting walls, cursing, and combativeness with staff. The care plan interventions included: -Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. -Stop and allow time to calm down if excessive physical aggression occurs during care. Resident frequently displays physical aggression/combativeness towards staff members during care and does not always understand that staff members are attempting to assist her. During aggression episodes, resident will often exclaim that something is occurring to her, but it is instead what she is doing to others. For example, when resident hits staff members she then yells that she has been hit. This primarily occurs during high contact care with resident. Staff to continue to explain all procedures to the resident before and during provision of care assistance. -Monitor behavior episodes and attempt to identify underlying cause. The Director of Nursing completed the Initial Allegation Report on 9/18/24 regarding an allegation of staff to resident abuse involving Resident #61. The report stated the facility had been made aware that a NA (NA #2) swatted at Resident #61's hand when Resident #61 attempted to hit the NA following incontinence care. Following the incident Resident #61 was assessed by a nurse and did not have any visible marks or injury. The accused employee was suspended pending investigation. The facility reported the allegation of abuse to the police and adult protective services on 9/18/24. There were two witnesses to the alleged abuse incident. A facility investigation of the incident was completed by the Director of Nursing. Through their investigation the facility concluded the abuse allegation was un-substantiated. A typed staff interview form dated 9/18/24 for NA #2 read in part: NA #2 stated while attempting to assist with incontinence care for Resident #61, she became combative after care was completed. I told everyone to step back. I attempted to hold resident's hand and talk to her calmly and she attempted to swing at me and I threw up my hand in defense to protect myself. Me and the other aides backed away and did not touch the resident anymore and left the room. About 30 minutes later I was told to leave because the student said I had swatted the resident on the hand. At no time during the care did I intend to cause the resident harm or hit her. An interview with NA #2 was conducted on 11/6/24 at 1:31 PM. NA #2 said she remembered the incident with Resident #61 which had occurred a little over a month ago. NA #2 explained she had gone with two other staff members to Resident #61's room to provide care. She did not remember the names of the other staff members. NA #2 said Resident #61 was in bed while incontinence care was being provided. She said two of the staff members (NA #1 and NA Student #1) were positioned at Resident #61's legs/ feet toward the bottom of the bed and she had been positioned at the head of the bed during the care. NA #2 stated Resident #61 started swinging her arms and kicking. NA #2 said they walked away and tried to let Resident #61 calm down for 3 to 5 minutes before proceeding with care. NA #2 said after the 3-to-5-minute break she and the other two NAs proceeded to provide incontinence care to Resident #61. She stated Resident #61 started swinging her arms and kicking again. NA #2 stated she was protecting Resident #61's hands from getting hit by holding them and doing defensive moves in a patty cake action while the other NAs completed incontinence care. She described patty cake as smacking hands with the resident. She described defensive moves as putting her arm up to block Resident #61's arm swing. NA #2 indicated no one had told her to hold Resident #61's hands. A typed staff interview form dated 9/18/24 for NA #1 read in part: NA #1 stated while attempting to provide incontinence care for resident (Resident #61) with assistance from nurse aide (NA #2) and student (NA student #1) Resident #61 became combative by swinging arms and kicking and she (NA #1) told everyone to step back and give her (Resident #61) a minute to calm down. After care was completed and we were cleaning up and preparing to leave the room, resident (Resident #61) started swinging her arms and kicking and NA #2 went closer to the resident (Resident #61) and NA #2's arm went up and her hand swatted the back of Resident #61's hand. We finished gathering our supplies and trash and left the room. As we were leaving NA #2 asked if resident (Resident #61) was always that way?. An interview was conducted with NA #1 on 11/6/24 at 1:53 PM. NA #1 stated she remembered the incident of alleged abuse on 9/18/24 involving Resident #61. NA #1 stated she had been training NA #2 on 9/18/24. NA #1 explained she had asked NA student #1 to help with Resident #61's care because she could be feisty during care. She explained feisty as Resident #61 would sometimes try to hit during care. NA #1 said it typically required 2 to 3 NAs to provide care for Resident #61. She explained she had asked another NA to come in to help with care because she was pregnant and knew Resident #61 had behaviors that included kicking. NA #1 said she, NA #2, and NA Student #1 had entered Resident #61's room around 8:30 PM to provide care. She explained the care provided was changing Resident #61 into a gown, changing her brief, and assisting her to bed for the night. She stated Resident #61 became upset during care and she told NA #2 and NA student #1 to take a step back and give Resident #61 a minute to calm down. NA #1 explained everyone stepped back and gave Resident #61 three to five minutes to calm down before reapproaching her for care. When they resumed care with Resident #61 it was herself and NA Student #1 who performed incontinence care for Resident #61 and changed her brief. NA #1 stated NA #2 was sitting on the bedside table located at the head of Resident #61's bed watching the care and initially was not actively participating in the care. Resident #61 started swinging her arms in the air and NA #2 proceeded to hold the lower part of both of Resident #61's hands around her wrists. NA #1 stated after the incontinence care for Resident #61 was completed she and NA student #1 were cleaning up. She said NA #2 was still standing close to Resident #61 holding the resident's hands/wrists. NA #1 further stated Resident #61 swung her arms and NA #2 smacked Resident #61 on the arm near her right wrist. NA #1 recalled Resident #61 did not appear startled, scared, or cry out during the incident. NA #1 stated Resident #61 had not swung her arms in the direction of NA #2 and that she had been swinging her arms in the air. NA #1 recalled after NA #2 swatted Resident #61 on the arm NA #2 walked out of the room and said, is she always like that. She stated the contact NA #2 had with Resident #61 was not defensive or a defensive block. NA #1 said the care was over and NA #2 could have stepped back away from Resident #61 instead of swatting her arm. NA #1 stated NA #2 had smacked Resident #61 with an open hand, and she had not seen a visible mark on Resident #61 where NA #2 had smacked her. The interview further revealed NA #2 had not been asked to hold Resident #61's hands/wrists during care. NA #1 explained Resident #61 did not need to be held down or restrained during care. NA #1 stated NA #2 was not holding Resident #61 down, she was just holding her hands. NA #1 indicated the situation had made her feel uncomfortable. NA #1 said everyone exited the room around 9:00 PM and after exiting Resident #61's room she and NA #2 went to the nurse's station. NA #1 recalled NA #2 did not go into any other resident rooms to provide care. A typed staff interview dated 9/24/24 for NA student #1 read in part: NA student #1, NA #1, and NA #2 were providing care to Resident #61. She (Resident #61) became combative, and we all stepped back. We allowed her some time and then explained everything we were going to do to make her feel more comfortable. She appeared to calm down and we proceeded to continue to provide care. Once we were done providing incontinence care I was collecting the trash from the floor but still standing in the same spot. NA #2 was standing at bedside. Resident (Resident #61) took both hands and pushed at/ towards NA #2. Resident's (Resident #61) hands were balled up. NA #2 brought her hand up in a defensive manner to block the blow, she made contact with Resident #61's hands with her arm and hand. Her (NA #2) hand was open. We all backed away and left the room. An interview was conducted with NA Student #1 on 11/6/24 at 3:41 PM. She stated she remembered the incident on 9/18/24 with Resident #61. NA Student #1 said she went to Resident #61's room with NA #1 and NA #2 around 8:30 PM to assist with getting Resident #61 ready for bed and changing her brief. She explained Resident #61 was usually feisty and was sometimes combative during care. NA Student #1 said during care when they were removing her clothes Resident #61 said no your not doing that. NA Student #1 explained if you talked to Resident #61 during care it distracted her and then she was usually agreeable with care. NA Student #1 stated she and NA #1 transferred Resident #61 to the bed, laid her down on the bed to change her brief, and Resident #61 started to hit and kick. NA Student #1 recalled when Resident #61 started to hit NA #1 said, lets back away and let her cool down. She said they backed away for about 5 minutes and let Resident #61 calm down. NA Student #1 said Resident #61 calmed down a lot and then she and NA #1 resumed care. NA #2 was sitting on the nightstand located at the head of Resident #61's bed watching the care. NA Student #1 further explained once they were almost done changing Resident #61's brief she started trying to hit again. NA Student #1 revealed when Resident #61 started trying to hit NA #2, NA #2 started holding Resident #61 around both of her wrists to keep her from hitting. NA Student #1 explained NA #2 was positioned at the head of Resident #61's bed and was holding her arms away by the wrists while they provided care. She said Resident #61 was not trying to hit or swat at NA #2 at the time. NA student #1 said, she (NA #2) hit her (Resident #61) it was not a defensive block. NA Student #1 said what she witnessed was abuse and she felt it was done aggressively by NA #2. She said there was no change in Resident #61's behavior after the incident and that she did not yell out, or act like she was hurt or scared when the incident occurred. NA student #1 stated she knew what defense was and NA #2's action was not defensive. NA Student #1 recalled everyone exited Resident #61's room around 9:00 PM and NA #2 went to the nurse's station with NA #1 and she did not see NA #2 go into any other resident rooms. The written statement provided by NA Student #1 was reviewed by NA Student #1. NA Student #1 confirmed she had not typed the statement and that the statement had been read to her. NA Student #1 noted she had not re-read the statement and missed that the statement said NA #2 brought her hand up in a defensive manner. NA Student #1 again stated, NA #2's action was intentional and not defensive. During the interview NA Student #1 demonstrated how NA #2 had held Resident #61. She demonstrated Resident #61 had both her arms bent at the elbow and positioned in front of her chest. NA Student #1 showed the placement of NA #2's hands holding Resident #61 around both of her wrists and the base of the hands in front of Resident #61's chest. An interview was conducted with the Charge Nurse on 11/6/24 at 4:56 PM revealed she had been the supervisor on 9/18/24 for the 7:00 PM to 7:00 AM shift. She stated NA #1 reported NA #2 had smacked Resident #61 while helping with care. The Charge Nurse stated she could not remember what time NA #1 had reported the incident to her and she could not remember exactly where NA #1 had reported NA #2 had smacked Resident #61, except she knew it was not on the face or head. The Charge Nurse indicated when NA #1 reported the incident she immediately called the Director of Nursing (DON). The Charge Nurse stated she checked on Resident #61 after the incident. She explained she checked Resident #61's skin all over and did not see any visible marks. The Charge Nurse recalled Resident #61 was unable to tell her what had occurred and Resident #61 did not have any changes in behavior or appear upset or fearful after the incident. A typed interview document for the DON dated 9/18/24 read in part: I received a call at approximately 9:50 PM from the Charge Nurse. She stated she had a report of abuse. NA #1 was placed on the phone and described the incident. She stated while providing care to Resident #61, NA #2 and NA Student #1 were assisting. NA #1 said that while NA Student #1 and her were providing incontinence care NA #2 had been holding residents' (Resident #61) hands to prevent her from striking staff. She said that when they were about finished NA #2 let go of residents (Resident #61) hands and Resident #61 attempted to swing at NA #2. She stated that NA #2 then swatted at residents (Resident #61) hands. I (DON) asked if action was intentional and NA #1 responded yes, that she did feel it was intentional. I spoke with NA #2 who stated she had assisted with resident (Resident #61) care. She stated resident (Resident #61 was combative and she held her hands to prevent resident (Resident #61 from hitting her and other staff. NA #2 stated that when she let go of residents (Resident #61) hands that the resident went to swing at her and she threw out her hand/ arm in defense to block her swing. An interview was conducted with the DON on 11/7/24 at 12:26 PM. The DON stated the Charge Nurse had called her on 9/18/24 around 9:40 PM and reported an allegation of abuse. The DON further stated she spoke on the phone with NA #1 who reported to her NA #2 had swatted Resident #61 during care. The DON spoke with NA #2 and told her there was an allegation of abuse that was going to be investigated, and she needed to leave the facility immediately. The DON reported each NA was spoken to separately about the incident and a reenactment of the incident was conducted with NA #1 and NA Student #1. The DON explained based on the interviews and reenactment of the incident with NA #1 and NA Student #1, the facility determined NA #2's actions had been defensive and that NA #2's contact with Resident #61 had been a defensive block. The DON stated the facility had unsubstantiated the abuse allegation. The DON could not say why NA #1 and NA Student #1 reported during surveyor interviews, they did not feel NA #2's actions were a defensive block and that NA #2's actions were intentional. An interview was conducted with the Administrator on 11/7/24 at 3:10 PM. The Administrator stated the DON had made him aware of the incident on 9/18/24 when it occurred. The Administrator explained the DON had conducted the investigation and reported the findings to him. He stated he had agreed based on what was described that it was not abuse and that it appeared to have been a defensive reaction by NA #1. The Administrator stated the abuse allegation was not substantiated by the facility. The facility provided the following Corrective Action Plan with a correction date of 9/26/24: Corrective action for resident(s) affected by the alleged deficient practice: -On 9/18/2024 approximately thirty minutes following incident around 8:50pm, the Nurse Aide #1 and Nurse Aide Student #1 reported to charge nurse #1 that nurse aid #2 had swatted resident # 61's hand following incontinent care after resident attempted to hit staff. -At approximately 9:40pm, Charge Nurse #1 immediately notified Director of Nursing and suspended nurse aide#1, nurse aide #2 and nurse aide student #1 pending investigation and assessed resident # 61 with no concerns noted. -Resident #61 denied any pain or discomfort. -On 9/18/2024, Resident #61 RP notified. On 9/18/2024 MD was notified with no new orders. -On 9/18/2024 the Director of Nursing immediately reported incident to Administrator and initiated investigation, notified police and Adult Protective Services and sent initial allegation report to state reporting agency. -On 9/18/2024, Director of Nursing interviewed resident #61 and completed body audit with no concerns noted. Director of Nursing spoke with resident #61 family and discussed investigation process. -On (9/18/2024) resident #61 Care Plan updated. -On 9/19/2024, the Director of Nursing interviewed nurse aide #1 and nurse aide #2 separately to get details of the alleged abuse. -On 9/24/2024, the Director of Nursing interviewed nurse aide student #1 and completed reenactment of event. During the interviews, each nurse aide also completed a reenactment of the event. -On 9/25/2024, the Administrator and Director of Nursing concluded the alleged abuse investigation and based on investigation findings unsubstantiated alleged abuse of Resident #61. On 9/25/2024, the Director of Nursing submitted the Investigation Report to the State Survey Agency with findings. Corrective action for residents with the potential to be affected by the deficient practice: -Beginning 9/19/2024 full body audit completed for current residents with BIMS 12 and below with no new skin issues noted. -Safe Check interviews completed for all current residents with BIMS 13 and higher with no issues noted. Staff who worked on the 300 hall were interviewed. Staff not aware of any issues involving any other residents. Measures /Systemic changes to prevent reoccurrence of alleged deficient practice: -On 9/18/2024, the Director of Nursing began in servicing all full-time, part-time, and PRN (as needed) staff (including agency) on ABUSE (preventing, recognizing and reporting) and Dealing with Challenging Behaviors policies. This training included: Abuse Types, reporting abuse allegations immediately to nurse/DON/Administrator, what to do if abuse observed or suspected, assuring resident safety, zero tolerance of retaliation of reporting allegations of abuse, along with notification of local law enforcement, Adult Protective Services, and State Survey Agency. Staff were also asked if they were aware of any abuse occurring to any resident in the facility and what to do if observed or suspected. No staff were aware of any other abuse occurring in facility. The Director of Nursing will ensure that any of the above identified staff (all staff including agency) who does not complete the in-service training by 9/21/2024 will not be allowed to work until the training is completed. This training will be included in new hire orientation for any newly hired staff. -Investigation findings were reviewed in Quality Assurance Meeting on 9/20/2024 with Administrator, Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator with no additional findings. Monitoring Procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements: -Beginning the week of 9/23/2024, the Director of Nursing or designee will monitor ABUSE/CARE CONCERNS using the QA Tool for ABUSE and ADL Care Observations by observing staff perform incontinence care for 5 residents to ensure staff are adhering to Abuse Policy. This will be completed weekly for 4 weeks and monthly for 2 months. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Date of Compliance: 9/26/2024 On 11/7/24, the facility's corrective action plan effective 9/26/24 was validated by the following: The facility held a quality assurance (QA) meeting on 9/20/24 and discussed the abuse allegation related to Resident #61. Review of records revealed the facility had completed body audits for all resident with a BIMS of 12 or below and had completed safe check interviews for all residents with a BIMS of 13 or higher with no issues identified. The facility audit tools for activity of daily living (ADL) observations and quality assurance (QA) recognizing/ reporting abuse audit tools were reviewed. The facility had completed ADL and abuse audits weekly. The facility had held weekly QA meetings to review the audits. Review of training in-service-logs revealed all staff received education on abuse, prevention, recognizing and reporting and dealing with challenging behaviors. Interviews were conducted with licensed nurses, nursing assistants (NAs), and non- nursing department staff. The staff were able to verbalize the different types of abuse and actions to take for reporting abuse. The staff were able to verbalize techniques to manage and deal with challenging behaviors. The education included new staff and contract/agency staff. New staff and contract/ agency staff were not allowed to work until education had been received. The completion date of 9/26/24 for the correctvie action plan was validated.

Based on observations, record review, test tray, and resident, resident representative, and staff interviews, the facility failed to provide palatable food that was appetizing in temperature for 3 of 3 residents reviewed with food concerns (Resident #42, Resident #59, and Resident #103). Findings included: a. Resident #59 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #59 had severely impaired cognition and required set up assistance with eating. An interview on 11/04/24 at 10:15 AM with Resident #59's resident representative revealed the food was often cold at lunch and dinner. b. Resident #103 was admitted to the facility on [DATE]. The annual Minimum Data Set, dated dated dated [DATE] revealed Resident #103 was cognitively intact and required set up assistance with eating. An interview on 11/04/24 at 11:08 AM with Resident #103 revealed he said the food was cold about half the time. c. Resident #42 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #42 was cognitively intact and required set up assistance with eating. An interview on 11/04/24 at 11:42 AM with Resident #42 revealed the food was cold sometimes. An observation of the lunch tray line was conducted on 11/05/24 at 12:45 PM. The test tray was the last tray plated and delivered to the dining room. It was sampled with the Corporate Dietary Manager, facility Dietary Manager, and another facility Dietary Manager at 12:52 PM. The observation revealed the following: the meal plate had no plate warmer under the plate and after the lid was removed, there was no visible steam from the food. When tasted, the pork chop was cold, the beets were cold, and the stuffing was warm. The dessert was pears, and they were not tasted. The overall appearance of the plate was mostly brown. An interview with Corporate Dietary Manager and facility Dietary Manager on 11/05/24 at 12:55 PM confirmed that the food was cold and did not taste appealing. The Corporate Dietary Manager stated she thought the cold food plate was due to the steam table temperature not being set high enough, the lack of food plate warmers, and the lack of insulated meal tray carts. An interview on 11/06/24 at 8:19 AM with the Administrator revealed he was not aware of any concerns related to cold food until yesterday when he talked to the Corporate Dietary Manager.

Based on record review, observation, resident, staff, and family interviews, the facility failed to honor a resident's (Resident #49) right to choose their preferred method of bathing and the resident's right to refuse a shower. On 4-22-23, Resident #49 had refused her shower three times and on the third refusal Nurse #1 was informed of Resident #49's refusal to take a shower. Nurse #1 informed Nursing Assistant (NA) #1 and NA #2 that the resident had to take a shower regardless of Resident #49's refusal. Nurse #1 and 5 NAs (NA #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and stating she did not want to get out of bed and have a shower, out of the bed, into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the likelihood of suffering serious physical and psychosocial harm. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion). This deficient practice was for 1 of 4 residents reviewed for choices. Immediate Jeopardy began on 4-22-23 when six staff members forced Resident #49 out of her bed to receive a shower. Immediate Jeopardy was removed as of 6-10-23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings included: Resident #49 was admitted on [DATE] with multiple diagnoses that included vascular dementia without behavioral disturbances and atrial fibrillation. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was moderately cognitively impaired, and documentation showed that choosing her preference for bathing was very important to Resident #49. Resident #49's activities of daily living care plan initiated on 1-4-2020 and revised on 9-20-22 revealed the resident had an activities of daily living self-care deficit. The goal for Resident #49 was to maintain current level of function with her activities of daily living. The interventions for the goal included Resident #49 required total assistance with bathing and if the resident refuses, allow a few minutes to pass and then re-attempt to get the resident to agree to a shower or bath. Provide the resident with a sponge/bed bath when a full bath or shower cannot be tolerated. There was no documentation regarding Resident #49's preferred bathing choice. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was moderately cognitively impaired and exhibited physical behaviors towards others 1-3 days in the 7 days look back period and had refused care 1-3 days during the 7 days look back period. Resident #49 was documented as needing physical help with two people for bathing and extensive help with two people for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDs also documented Resident #49 received an anticoagulant (medication to inhibit the clotting of blood) 7 out of 7 days during the 7 day look back period. Skin assessments conducted from 4/1/23 through 4/21/23 revealed no bruises were present on Resident #49. Review of Resident #49's medical record revealed a nursing note dated 4-23-23 at 10:37pm written by Nurse #2. The nurse documented she had been called to the resident's room by a family member (daughter) who was questioning what had happened to Resident #49's hand which had a bruise on her left hand. Nurse #2 documented that Resident #49 had told her it happened in the shower a couple of days ago. The facility's final investigation report dated 4-28-23 revealed Resident #49's daughter called the Administrator on 4-25-23 and reported the resident had been abused in the shower on Saturday (4-22-23). The documentation showed the daughter told the Administrator she visited Resident #49 on 4-23-23 and noticed a bruise on the resident's hand. The daughter informed the Administrator that Resident #49 told her staff were pinching her hand during her shower. The daughter also informed the Administrator she had spoken to the charge nurse on 4-23-23 who assessed Resident #49's hand for damage. The investigation report documented Resident #49 had a bruise on the top of her left hand. The investigation report included written statements from staff who had contact with Resident #49 on 4-22-23. Resident #49 was interviewed on 6-5-23 at 10:39am. Resident #49 confirmed she remembered when she sustained a bruise to her hand on 4-22-23. The resident commented, It stayed bruised for a long time. Resident #49 said the girl was trying to force me into the shower chair and was squeezing my hand. I told her to stop because she was hurting me, but she did not. She also stated she was fighting with the staff because she did not want to get a shower. Resident #49 discussed that she preferred to get bed baths. The resident would not discuss how she felt during the incident on 4-22-23 but instead kept stating I don't want to get anyone fired. Resident #49 discussed telling a family member (her daughter) on 4-23-23 what happened and stated she did not tell any other staff because she was concerned about the staff's jobs. She stated she had not received any other bruises since 4-22-23. Upon observation of the resident, she was observed not to have any bruising to her hands. Resident #49 was observed on 6-5-23 at 10:39am. The resident was observed to be lying in bed. Her clothes were noted to be clean, there were no odors observed, her hair was observed to flow down to the middle of her back and was clean but uncombed. A telephone interview occurred with Resident #49's daughter on 6-6-23 at 11:35am. The daughter discussed visiting the resident on 4-23-23 and noticed a bruise on the resident's hand that was black and blue in color. She stated when she asked Resident #49 what happened the resident told her staff had given her (resident) a shower yesterday (4-22-23). The daughter further discussed Resident #49 telling her she (the resident) was combative because she did not want a shower, so the resident told the daughter that staff held her hand down and pinched her hand. The daughter said she informed Nurse #2 of the bruise to Resident #49's hand and stated the nurse took a picture of the bruise and told her the staff would monitor the area. The daughter stated she never told staff to force the resident to have a shower. She explained she told staff to encourage the resident to take a shower but if the resident refused it was ok. She explained she knew the resident did not like getting a shower and preferred to have bed baths. The daughter stated on 4-23-23 during the visit that the resident told her she did not think staff liked her. NA #1's written statement dated 4-26-23 related to the incident on 4-22-23 indicated that she assisted with transferring Resident #49 from the bed to the wheelchair so she could be brought to the shower room. The statement further indicated that she did not aid with giving Resident #49 the shower. NA #1 was interviewed on 6-6-23 at 12:46pm. NA #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #1 was asked to clarify her statement and explain Resident #49's behaviors as well as staff's course of action. NA #1 stated Resident #49 was real bad to refuse showers. She discussed that she did not know if the resident's preference in bathing was written anywhere but stated she usually asked Resident #49 if she wanted a shower or bed bath. She further discussed the resident being allowed to refuse a shower but not all the time. NA #1 explained Resident #49 was allowed to refuse one shower a week but the second scheduled shower, the resident was not allowed to refuse. NA #1 explained on 4-22-23 Resident #49 refused her shower 2-3 times and after the last refusal, she informed Nurse #1 that the resident was refusing her shower. The NA stated Nurse #1 told her to get the resident up and take her to the shower anyway. She stated there were six staff in the room (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) and that it took four staff (the NA could not remember which staff) to sit Resident #49 on the edge of the bed. NA #1 explained during this time, the resident was throwing her hands around, pushing away from staff and putting her arms up guarding herself. The NA stated once Resident #49 was talked into receiving a shower, the resident was no longer combative. NA #1 explained Resident #49 would stick her right hand through the side rails and bang her hand over the bed table when she wanted something. The NA stated she worked with Resident #49 on 4-20-23 and the resident did not have a bruise on her hand and said she did not see if Resident #49 had a bruise on her left hand during the transfer on 4-22-23. Nurse #1's written statement that was undated following the incident on 4-22-23 read; I was called down to the resident's room to help them get her up for a shower. She was refusing as she always does. I told her [her son] wanted her to get a shower. She told us [her son] was not the boss of her. We (the CNAs and myself) assisted [Resident #49] to sitting on her bed, then put her on the shower chair. She was not happy getting up, but smiling and apologizing when her shower was done. During an interview with Nurse #1 on 6-6-23 at 1:17pm, Nurse #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. The nurse was asked to discuss Resident #49's behavior and explain what happened when the resident refused her showers. The nurse confirmed she was the charge nurse on 4-22-23 but stated she did not remember the incident. Nurse #1 stated if it was a shower day for Resident #49 then the resident would have been combative by flailing her hands and arms but said usually once the resident was assisted by staff into a seated position on the edge of the bed the resident would stop being combative. After reading her written statement for the 4-22-23 incident that she provided to the facility during their investigation, she stated she remembered being told Resident #49 was refusing her shower and she went to the resident's room to speak with her along with five NAs (NA #1, NA #2, NA #3, NA #4, and NA #5). Nurse #1 was unable to explain why six staff members went to Resident #49's room. The nurse stated once Resident #49 was placed in the shower chair, the resident stopped being combative. Nurse #1 explained typically if a resident refused a shower three times, the resident would be provided a bed bath but stated with Resident #49, she would sometimes be forced to get a shower because the resident's hair was long and became matted if she did not receive a shower. She explained the facility had washing caps that could be used to wash the resident's hair but stated they did not work well. She further stated the family had told staff they wanted the resident to have at least one shower a week. Review of NA #5's written statement dated 4-26-23 following the incident on 4-22-23 read; Resident #49 did not want to take her shower but me and [Nurse #1] got her to go take it. The bruise on her hand is where she puts her hand through the rail on the bed all the time. She keeps a bruise on that hand a lot from the bed rails. A telephone interview occurred with NA #5 on 6-6-23 at 3:01pm. NA #5's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #5 was asked to discuss Resident #49's behavior, what happens when the resident refused a shower, and the bruise Resident #49 sustained to her left hand. The NA confirmed she assisted with getting Resident #49 out of bed for a shower on 4-22-23. She stated she remembered the resident was combative because the resident did not want to get out of bed and take a shower. NA #5 stated, while trying to get Resident #49 into the shower chair, the resident attempted to hit one of the NAs. She stated she could not remember which one, but it was one of the NAs standing behind the resident. The NA stated there were six staff members (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) in the room and she could not remember who was standing behind the resident. NA #5 explained Resident #49 was allowed to refuse one shower a week but then the resident will be forced the next shower day. She explained if Resident #49 refused the shower, staff tried to talk her into receiving a shower. She further explained that if she was not able to be talked in to receiving her shower, the resident was forced to get up out of the bed to take a shower. The NA discussed typically residents were allowed to refuse a shower four to five times on their shower day but then the nurse on duty had to be informed of the refusal and it was up to the nurse on duty to decide if the resident needed to be forced to get up and receive a shower. She stated she could not remember if Resident had a bruise on her left hand on 4-22-23. NA #2's written statement dated 4-25-23 following the incident on 4-22-23 read; Per [NA #2] I did not help to give [Resident #49] her shower on Saturday. I did assist with getting her back into bed after the shower. She was fine with me and was not being combative. When asked about the bruise on resident's hand, [NA #2] told interviewer that [Resident #49] had that bruise before Saturday. During a telephone interview with NA #2 on 6-6-23 at 3:34pm, NA #2's provided statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #2 was asked if she assisted with Resident #49's transfer prior to the shower, resident's behavior, and what happened if Resident #49 refused a shower, as well as the bruise on Resident #49's hand. NA #2 stated she assisted in transferring Resident #49 from the bed to the shower chair on 4-22-23. NA #2 discussed Resident #49 telling the staff she did not want a shower and had been combative until she was placed in the shower chair. The NA stated she could not remember how many staff were in the room but said there were a lot of us. She was unable to explain why there were so many staff in the room. She also discussed Resident #49 never wanting to get out of bed and usually when she refused her shower a bed bath was provided. NA #2 explained she did not think the resident's preference for bathing was written anywhere but said she usually asked the resident if she wanted a bed bath or shower. The NA stated she did not know why she was being made to get a shower on 4-22-23. NA #2 stated she did not see a bruise on Resident #49's hand when transferring the resident into the shower chair. She stated she said in her written statement Resident #49 had the bruise before Saturday (4-22-23) because the resident always keeps a bruise on her hand. Review of NA #3's written statement dated 4-26-23 to the facility following the incident on 4-22-23 read; [NA #5, NA #4, NA #2, Nurse #1] and myself all assisted in getting her from the bed to the shower chair in her room. She didn't want to go at first but did fine with all of us helping her in the chair. [NA #4] and I pushed her in the shower room and began her shower and she was thanking us for bathing her and she even apologized for being an old fart (her words) and not wanting to take a shower. We dressed her and took her back to the room and she wanted to go back to bed so we assisted her in that. We hooked up her oxygen and she was good. NA #3 was interviewed by telephone on 6-6-23 at 7:12pm. NA #3's statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior. NA #3 explained Resident #49 was scheduled for a shower on 4-22-23 but the resident had been refusing. She said it took five people (Nurse #1, NA #1, NA #2, NA #4, and NA #5) plus herself to get Resident #49 out of the bed because the resident was pushing them away and not wanting to get up. NA #3 explained Resident #49's preference for bathing was not documented anywhere and said she usually just asked the resident if she wanted a bath or shower. Na #4's written statement dated 4-27-23 following the incident on 4-22-23 read; On Saturday we asked [Resident #49] if she was ready for a shower and she didn't want to get out of bed but then finally said she was ready but still gave us a hard time to get out of bed so I went to ask the other CNAs [NA #5, NA #1, NA #3] if they could help because she was screaming at me, at that time [NA #5] went and got the charge nurse [Nurse #1] to help. They got [Resident #49] up put of the bed and into the shower chair and we wheeled her down to the shower room and me and [NA # 3] gave her a shower. She was fine in the shower and kept saying how sorry she was for giving us a hard time getting out of bed. She was calm and gentle while in the shower. We washed and dressed her and got her back in the room and she got her toenails cut by [NA #2] and [NA #2] had helped me get her in the bed and she was fine and helped us and said thank you. An interview with NA #4 occurred on 6-7-23 at 9:01am. NA #4's written statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior prior to the shower. NA #4 stated on 4-22-23 she asked Resident #49 if she wanted a shower and said the resident was agreeable to receiving a shower. She stated she left the resident's room to ask for more help because she was not familiar with the resident and could not transfer the resident on her own. NA #4 was unable explain why her written statement was different. She stated during the transfer Resident #49 was pushing against them and fighting. NA #4 explained she never heard the resident say she did not want a shower. The previous Social Worker (SW) was interviewed by telephone on 6-6-23 at 4:44pm. The previous SW stated she had conducted the investigation for the abuse allegation towards Resident #49 on 4-25-23 after the Administrator received a call from Resident #49's daughter, saying the resident had been roughed up by staff in the shower on 4-22-23. She stated she first questioned staff and then questioned Resident #49 about the incident on 4-22-23. She stated the staff were consistent in their statements that Resident #49 was combative getting into the shower chair because the resident did not want a shower. The previous SW stated she had not questioned staff on their response when the resident was refusing her shower or when the resident had been combative. She explained once Resident #49 was refusing her shower and had become combative, the staff should have walked away instead of forcing her into the shower. Resident #49's son who was the resident's Power of Attorney (POA), was interviewed by telephone on 6-7-23 at 9:30am. The son discussed Resident #49 being difficult at times and being strong willed but stated he never told staff to force the resident to get a shower. The son explained he knew the resident did not like showers and preferred to stay in the bed to receive bed baths. He stated he had spoken with staff to encourage Resident #49 to take a shower but said he told the staff if the resident refused to let her refuse. During an interview with NA #7 on 6-7-23 at 2:06pm, she stated resident preferences for bathing were not documented anywhere. NA #7 discussed when she was hired at the facility a few months ago, she was informed by staff (unable to recall who) residents could not just receive bed baths. NA #7 explained she asked the residents if they would like a shower or bed bath. She stated if a resident refused their shower three times, she informed the nurse and the nurse spoke with the resident. The NA stated she never felt like she was forcing a resident to take a shower. The Administrator was interviewed on 6-7-23 at 3:01pm. He stated, forcing a resident was abusive and if he had known he would have stopped it from happening. The Administrator was notified of the Immediate Jeopardy on 6-7-23 at 3:01pm. The facility provided the following Credible Allegation of Immediate Jeopardy (IJ) removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. o This deficient practice at tag F561 impacts Resident #49. o This deficient practice at tag F561 could potentially impact all residents. o During the admissions process, the admitting nurse asks about bathing preferences which is acknowledged and incorporated in their plan of care. o All interviewable residents will be interviewed by 11:59 PM on 06/09/2023 to ensure that their bathing wishes are being followed. The interviews will be conducted by the Administrator, Director of Nursing (DON), or trained designee. There have been no complaints or concerns voiced to date of their bathing schedule. To ensure that there are no complaints or concerns, the facility (Director of Nursing or Administrator or trained designee) notified the responsible parties of non-interviewable residents via phone messaging system to contact the Administrator or Director of Nursing if they have any concerns about their loved ones' shower or bathing schedules. This also included a survey to choose method of bathing. This was completed at 9:24 AM on 6/9/2023. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. o The Chief Executive Operator (CEO), Administrator, Director of Nursing (DON) or trained designee will educate 100% of all staff regarding Tag F561 by 12:00 PM on 06/09/2023, or the staff will be removed from the schedule and not allowed to work until they have been educated. This includes contract and agency staff members. The educate will include: o Residents' rights policy and procedure. o Allowing the resident to choose bathing options, including bed baths, showers, tub, and refusal all together. o How to offer the resident options on bathing. o Understanding that the resident has the right to decline all bathing. o Understanding that forcing care is abuse and can lead to harm to the patient. o Staff understanding the methods of offering bathing alternatives (examples include shower, bed baths, sink baths, bathtubs, and refusing bathing) to meet the residents' needs. o Reporting refusal of care to the charge nurse so the nurse can take extra measures to have alternative means (examples: psychiatric care referrals, notifying families for involvement, notifying physician for input on care). o 100% of staff will be educated by 12:00 PM on Friday, June 9th, 2023, or they will be removed from the schedule. Alleged date of IJ removal: June 10, 2023 On 6-12-23, the facility's plan for Immediate Jeopardy removal effective 6-10-23 was validated by the following: documentation and interviews with residents and staff. Review of the in-service sign-in sheets revealed all staff and all departments received education which included residents' right to refuse care and how to manage residents who refused care. Residents interviewed revealed all residents reported they had not been forced to do anything they did not wish to do or have care provided against their will. The staff interviewed all stated residents had the right to choose and/or refuse care and should not be forced against their will. The facility's Immediate Jeopardy removal date of 6-10-23 was confirmed.

Based on record review, staff, family and resident interviews, the facility failed to protect Resident #49's right to be free from physical and emotional abuse for one of two sampled residents reviewed for abuse. On 4-22-23 Resident #49 had refused a shower three times and on the third refusal, six staff members (Nurse #1, Nursing Assistant (NA) #1, NA #2, NA #3, NA #4, and NA #5) proceeded to force Resident #49, who was combative and pushing staff away, out of bed and into a shower chair and into the shower. Resident #49 sustained a bruise to her left hand and had the high likelihood of suffering other serious physical and psychosocial harm. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion). Immediate Jeopardy began on Saturday 4-22-23 when six staff members forced Resident #49 out of her bed to receive a shower with the resident sustaining a bruise to her hand and feeling that staff did not like her. Immediate Jeopardy was removed as of 6-10-23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Findings included: Resident #49 was admitted on [DATE] with multiple diagnoses that included vascular dementia without behavioral disturbances, atrial fibrillation and chronic respiratory failure. Physician order dated 11-24-20 revealed Resident #49 was to receive Eliquis (medication to prevent blood clots) 5 milligrams (mg) twice a day. Resident #49's activities of daily living care plan initiated on 1-4-2020 and revised on 9-20-22 revealed the resident had an activities of daily living self-care deficit. The goal for Resident #49 was to maintain current level of function with her activities of daily living. The interventions for the goal included Resident #49 required total assistance with bathing and if the resident refuses, allow a few minutes to pass and then re-attempt to get the resident to agree to a shower or bath. Provide the resident with a sponge/bed bath when a full bath or shower cannot be tolerated. There was no documentation regarding Resident #49's preferred bathing choice. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was moderately cognitively impaired and exhibited physical behaviors towards others 1-3 days in the 7 days look back period and had refused care 1-3 days during the 7 days look back period. Resident #49 was documented as needing physical help with two people for bathing and extensive help with two people for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS also documented Resident #49 received an anticoagulant (medication to inhibit the clotting of blood) 7 out of 7 days during the 7 day look back period. Skin assessments conducted from 4/1/23 through 4/21/23 revealed no bruises were present on Resident #49. Review of Resident #49's medical record revealed a nursing note dated 4-23-23 at 10:37pm written by Nurse #2. The nurse documented she had been called to the resident's room by a family member (daughter) who was questioning what had happened to Resident #49's hand which had a bruise on her left hand. Nurse #2 documented that Resident #49 had told her it happened in the shower a couple of days ago. The initial investigative report completed by the facility's previous Social Worker (SW) dated 4-25-23 revealed the facility had received a phone call from Resident #49's daughter who told the facility the resident had been abused in the shower on Saturday (4-22-23). According to the report the daughter informed the facility that Resident #49 had told her staff were pinching her hand during her shower. The previous SW documented per the nursing assessment Resident #49 was not in any acute pain from the bruising and the resident did not report any mental anguish from the incident. The facility's final investigation report dated 4-28-23 revealed Resident #49's daughter had called the Administrator on 4-25-23 and reported the resident had been abused in the shower on Saturday (4-22-23). The documentation showed the daughter told the Administrator she had visited Resident #49 on 4-23-23 and noticed a bruise on the resident's hand. The daughter informed the Administrator that Resident #49 had told her staff were pinching her hand during her shower. The daughter also informed the Administrator she had spoken to the charge nurse on 4-23-23 who assessed Resident #49's hand for damage. The investigation report documented Resident #49 had a bruise on the top of her left hand. The investigation report included written statements from staff who had contact with Resident #49 on 4-22-23. Resident #49 was interviewed on 6-5-23 at 10:39am. Resident #49 confirmed she remembered when she sustained a bruise to her hand on 4-22-23. The resident commented, It stayed bruised for a long time. Resident #49 said the girl was trying to force me into the shower chair and was squeezing my hand. I told her to stop because she was hurting me, but she did not. She also stated she was fighting with the staff because she did not want to get a shower. Resident #49 discussed that she preferred to get bed baths. The resident would not discuss how she felt during the incident on 4-22-23 but instead kept stating I don't want to get anyone fired. Resident #49 discussed telling a family member (her daughter) on 4-23-23 what had happened and stated she did not tell any other staff because she was concerned about the staff's jobs. She stated she had not received any other bruises since 4-22-23. Upon observation of the resident, she was observed not to have any bruising to her hands. Resident #49 was observed on 6-5-23 at 10:39am. The resident was observed to be lying in bed. Her clothes were noted to be clean, there were no odors observed, her hair was observed to flow down to the middle of her back and was clean but uncombed. A telephone interview occurred with Resident #49's daughter on 6-6-23 at 11:35am. The daughter discussed visiting the resident on 4-23-23 and noticed a bruise on the resident's hand that was black and blue in color. She stated when she asked Resident #49 what had happened the resident told her staff had given her (resident) a shower yesterday (4-22-23). The daughter further discussed Resident #49 telling her she (the resident) was combative because she did not want a shower, so the resident told the daughter that staff had held her hand down and pinched her hand. The daughter said she informed Nurse #2 of the bruise to Resident #49's hand and stated the nurse took a picture of the bruise and told her the staff would monitor the area. The daughter stated she had never told staff to force the resident to have a shower. She explained she told staff to encourage the resident to take a shower but if the resident refused it was ok. She explained she knew the resident did not like getting a shower and preferred to have bed baths. The daughter stated on 4-23-23 during the visit that the resident told her she did not think staff liked her. NA #1's written statement dated 4-26-23 related to the incident on 4-22-23 indicated that she assisted with transferring Resident #49 from the bed to the wheelchair so she could be brought to the shower room. The statement further indicated that she did not aid with giving Resident #49 the shower. NA #1 was interviewed on 6-6-23 at 12:46pm. NA #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #1 was asked to clarify her statement and explain Resident #49's behaviors as well as staff's course of action. NA #1 stated Resident #49 was real bad to refuse showers. She discussed she did not know if the resident's preference in bathing was written anywhere but stated she would usually ask Resident #49 if she wanted a shower or bed bath. She further discussed the resident being allowed to refuse a shower but not all the time. NA #1 explained Resident #49 was allowed to refuse one shower a week but the second scheduled shower, the resident was not allowed to refuse. NA #1 explained on 4-22-23 Resident #49 had refused her shower 2-3 times and after the last refusal, she had informed Nurse #1 that the resident was refusing her shower. The NA stated Nurse #1 told her to get the resident up and take her to the shower anyway. She stated there were six staff in the room (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) and that it took four staff (the NA could not remember which staff) to sit Resident #49 on the edge of the bed. NA #1 explained during this time, the resident was throwing her hands around, pushing away from staff and putting her arms up guarding herself. The NA stated once Resident #49 was talked into receiving a shower, the resident was no longer combative. NA #1 explained Resident #49 would stick her right hand through the side rails and bang her hand over the bed table when she wanted something. NA #1 stated when the resident was combative, she would try to speak with the resident to calm her or she would inform the nurse on duty. The NA stated she did not see if Resident #49 had a bruise on her left hand during the transfer on 4-22-23. Nurse #1's written statement that was undated following the incident on 4-22-23 read; I was called down to the resident's room to help them get her up for a shower. She was refusing as she always does. I told her [her son] wanted her to get a shower. She told us [her son] was not the boss of her. We (the CNAs and myself) assisted [Resident #49] to sitting on her bed, then put her on the shower chair. She was not happy getting up, but smiling and apologizing when her shower was done. During an interview with Nurse #1 on 6-6-23 at 1:17pm, Nurse #1's written statement related to the 4-22-23 incident with Resident #49 was reviewed. The nurse was asked to discuss Resident #49's behavior and explain what happened when the resident refused her showers. The nurse confirmed she was the charge nurse on 4-22-23 but stated she did not remember the incident. Nurse #1 stated if it was a shower day for Resident #49 then the resident would have been combative by flailing her hands and arms but said usually once the resident was assisted by staff into a seated position on the edge of the bed the resident would stop being combative. After reading her written statement for the 4-22-23 incident that she provided to the facility during their investigation, she stated she remembered being told Resident #49 was refusing her shower and she went to the resident's room to speak with her along with five NAs (NA #1, NA #2, NA #3, NA #4, and NA #5). Nurse #1 was unable to explain why six staff members went to Resident #49's room. The nurse stated once Resident #49 was placed in the shower chair, the resident stopped being combative. Nurse #1 explained typically if a resident refused a shower three times, the resident would be provided a bed bath but stated with Resident #49, she would sometimes be forced to get a shower because the resident's hair was long and became matted if she did not receive a shower. She explained the facility had washing caps that could be used to wash the resident's hair but stated they did not work well. She further stated the family had told staff they wanted the resident to have at least one shower a week. Review of NA #5's written statement dated 4-26-23 following the incident on 4-22-23 read; Resident #49 did not want to take her shower but me and [Nurse #1] got her to go take it. The bruise on her hand is where she puts her hand through the rail on the bed all the time. She keeps a bruise on that hand a lot from the bed rails. A telephone interview occurred with NA #5 on 6-6-23 at 3:01pm. NA #5's written statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #5 was asked to discuss Resident #49's behavior, what happens when the resident refused a shower, and the bruise Resident #49 sustained to her left hand. The NA confirmed she assisted with getting Resident #49 out of bed for a shower on 4-22-23. She stated she remembered the resident was combative because the resident did not want to get out of bed and take a shower. NA #5 stated, while trying to get Resident #49 into the shower chair, the resident attempted to hit one of the NAs. She stated she could not remember which one, but it was one of the NAs standing behind the resident. The NA stated there were six staff members (Nurse #1, NA #1, NA #2, NA #3, NA #4, and NA #5) in the room and she could not remember who was standing behind the resident. NA #5 explained Resident #49 was allowed to refuse one shower a week but then the resident will be forced the next shower day. She explained if Resident #49 refused the shower, staff tried to talk her into receiving a shower. She further explained that if she was not able to be talked in to receiving her shower, the resident was forced to get up out of the bed to take a shower. The NA discussed typically residents were allowed to refuse a shower four to five times on their shower day but then the nurse on duty had to be informed of the refusal and it was up to the nurse on duty to decide if the resident needed to be forced to get up and receive a shower. She stated she could not remember if Resident had a bruise on her left hand on 4-22-23. NA #2's written statement dated 4-25-23 following the incident on 4-22-23 read; Per [NA #2] I did not help to give [Resident #49] her shower on Saturday. I did assist with getting her back into bed after the shower. She was fine with me and was not being combative. When asked about the bruise on resident's hand, [NA #2] told interviewer that [Resident #49] had that bruise before Saturday. During a telephone interview with NA #2 on 6-6-23 at 3:34pm, NA #2's provided statement related to the 4-22-23 incident with Resident #49 was reviewed. NA #2 was asked if she assisted with Resident #49's transfer prior to the shower, resident's behavior, and what happened if Resident #49 refused a shower, as well as the bruise on Resident #49's hand. NA #2 stated she assisted in transferring Resident #49 from the bed to the shower chair on 4-22-23. NA #2 discussed Resident #49 telling the staff she did not want a shower and had been combative until she was placed in the shower chair. The NA stated she could not remember how many staff were in the room but said there were a lot of us. She was unable to explain why there were so many staff in the room. She also discussed Resident #49 never wanting to get out of bed and usually when she refused her shower a bed bath was provided. NA #2 explained she did not think the resident's preference for bathing was written anywhere but said she usually asked the resident if she wanted a bed bath or shower. The NA stated she did not know why she was being made to get a shower on 4-22-23. NA #2 stated she did not see a bruise on Resident #49's hand when transferring the resident into the shower chair. She stated she said in her written statement Resident #49 had the bruise before Saturday (4-22-23) because the resident always keeps a bruise on her hand. Review of NA #3's written statement dated 4-26-23 to the facility following the incident on 4-22-23 read; [NA #5, NA #4, NA #2, Nurse #1] and myself all assisted in getting her from the bed to the shower chair in her room. She didn't want to go at first but did fine with all of us helping her in the chair. [NA #4] and I pushed her in the shower room and began her shower and she was thanking us for bathing her and she even apologized for being an old fart (her words) and not wanting to take a shower. We dressed her and took her back to the room and she wanted to go back to bed so we assisted her in that. We hooked up her oxygen and she was good. NA #3 was interviewed by telephone on 6-6-23 at 7:12pm. NA #3's statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior. NA #3 explained Resident #49 was scheduled for a shower on 4-22-23 but the resident had been refusing. She said it took five people (Nurse #1, NA #1, NA #2, NA #4, and NA #5) plus herself to get Resident #49 out of the bed because the resident was pushing them away and not wanting to get up. Na #4's written statement dated 4-27-23 following the incident on 4-22-23 read; On Saturday we asked [Resident #49] if she was ready for a shower and she didn't want to get out of bed but then finally said she was ready but still gave us a hard time to get out of bed so I went to ask the other CNAs [NA #5, NA #1, NA #3] if they could help because she was screaming at me, at that time [NA #5] went and got the charge nurse [Nurse #1] to help. They got [Resident #49] up put of the bed and into the shower chair and we wheeled her down to the shower room and me and [NA # 3] gave her a shower. She was fine in the shower and kept saying how sorry she was for giving us a hard time getting out of bed. She was calm and gentle while in the shower. We washed and dressed her and got her back in the room and she got her toenails cut by [NA #2] and [NA #2] had helped me get her in the bed and she was fine and helped us and said thank you. An interview with NA #4 occurred on 6-7-23 at 9:01am. Na #4's written statement related to the 4-22-23 incident with Resident #49 was reviewed. She was asked to clarify Resident #49's behavior prior to the shower. NA #4 stated on 4-22-23 she had asked Resident #49 if she wanted a shower and said the resident was agreeable to receiving a shower. She stated she left the resident's room to ask for more help because she was not familiar with the resident and could not transfer the resident on her own. NA #4 was unable explain why her written statement was different. She stated during the transfer Resident #49 was pushing against them and fighting. NA #4 explained she never heard the resident say she did not want a shower. Nurse #2 was interviewed by telephone on 6-6-23 at 2:17pm. The nurse explained on 4-23-23, Resident #49's family member had asked her how the resident received a bruise to her left hand. Nurse #2 stated she assessed the area and saw the resident had a bruise to her left hand and thought Resident #49 might have had blood work completed. The nurse stated once she saw there was no documentation of blood work being completed, she informed the family member staff would monitor the site and stated she took a picture of the bruise. Nurse #2 discussed being told by the family member, that Resident #49 had told her the bruise had occurred with staff while she was in the shower. The previous Social Worker (SW) was interviewed by telephone on 6-6-23 at 4:44pm. The previous SW stated she had conducted the investigation for the abuse allegation towards Resident #49 on 4-25-23 after the Administrator had received a call from Resident #49's daughter, saying the resident had been roughed up by staff in the shower on 4-22-23. She stated she first questioned staff and then questioned Resident #49 about the incident on 4-22-23. She stated the staff were consistent in their statements that Resident #49 was combative getting into the shower chair because the resident did not want a shower. The previous SW stated she had not questioned staff on their response when the resident was refusing her shower or when the resident had been combative. She explained once Resident #49 was refusing her shower and had become combative, the staff should have walked away instead of forcing her into the shower. The Administrator was interviewed on 6-7-23 at 3:01pm. He stated, forcing a resident was abusive and if he had known he would have stopped it from happening. The Administrator was notified of Immediate Jeopardy on 6-7-23 at 3:01pm. The facility provided the following Credible Allegation of immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. o This deficient practice cited at tag F600 had a high likelihood of resulting in serious physical and psychosocial harm for Resident #49. o Initial Report was filed at 3:43 PM on 04/25/2023. o Adult Protective Services (APS) notified on 4/26/2023. o Date of final investigation submission was 4/28/2023 at 2:24 PM. o Police Notified 5/4/2023. o This deficient practice at tag F600 could potentially impact all residents. o Resident #49 has shown no signs or symptoms of psychosocial harm as of 6/8/2023. No signs or symptoms of psychosocial harm were documented from the below assessments: o Resident #49 was visited by Administrator on 4/25/2023. o Resident #49 was visited by Licensed Clinical Social Worker (LCSW) on 4/25/2023. o Resident #49 was assessed by Registered Nurse (RN) on 5/11/23. o Resident #49 was visited by LCSW on 5/12/2023. o Resident #49 was visited by Psychiatric NP on 5/12/2023. o Resident #49 was assessed by Licensed Practical Nurse (LPN) on 5/13/23. o Resident #49 was visited by Palliative Care Nurse NP on 5/24/23. o Resident #49 was visited by LCSW on 5/26/2023. o Resident #49 was visited by Nurse Practitioner (NP) 5/31/2023. o All residents with a Brief Interview for Mental Status (BIMs) below 8 (who had a shower on the allegation date) had skin assessments completed with no relevant findings during the initial investigation. This was completed by RN Charge Nurse on 4/26/2023. o All residents with a BIMs 8 or above (who had a shower on the allegation date) were interviewed and there were no relevant findings during the initial investigation. The Social Services Director interviewed the residents on 4/26/2023. o The facility will interview all residents with a BIMs of 8 or above regarding Abuse by 11:59 PM on 06/09/2023. The interviews will be conducted by the Administrator or Director of Nursing (DON) or trained designee. o The facility will conduct skin assessments on all residents with a BIMs below 8 by 11:59 PM on 06/09/2023. The Director of Nursing or other licensed nurses as designated by the DON will be responsible for the skin assessments. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. o The Chief Executive Operator (CEO), Administrator, Director of Nursing (DON) or trained designee will educate 100% of staff regarding Tag F600 by 12:00 PM on 06/09/2023, or the staff will be removed from the schedule and not allowed to work until they have been educated. This includes contract and agency staff members. The educate will include: o Understanding and identifying the types of abuse. o The reasonable person concept in regard to abuse. o How to manage and address residents who refuse care. o How to address and handle residents with combative behaviors o Understanding that forcing care is abuse and can result in serious injury. o Understanding that the resident has a right to be free from abuse. o 100% of staff will be educated by 12:00 PM on Friday, June 9th, 2023, or they will be removed from the schedule. Alleged date of IJ removal: June 10, 2023 On 6-12-23, the facility's plan for Immediate Jeopardy removal effective 6-10-23 was validated by the following: documentation and interviews with the residents and staff. Review of the in-service sign in sheets revealed all staff and all departments received education which included understanding and identifying the various types of abuse, residents' right to be free from abuse, and how/who/when to report concerns of abuse. Review of the facility documentation revealed skin audits were completed 06/09/23 on all cognitively impaired residents with no concerns or new skin abnormalities identified and staff interviews completed 06/09/23 with all alert and oriented residents revealed no concerns of abuse. Residents interviewed revealed no concerns of abuse. Residents all reported they felt safe residing in the facility. Staff interviewed from various departments and shifts all confirmed they received in-service education and were able to verbalize the types of abuse, what constituted abuse, and when and who to report any concerns. The facility's Immediate Jeopardy removal date of 6-10-23 was confirmed.

Based on record review, staff, and family interviews the facility failed to follow their abuse policy in the areas of identification, immediately reporting an allegation of abuse to the Administrator, and reporting an allegation of abuse to the state agency within two hours. This occurred for 1 of 2 residents (Resident #49) reviewed for reporting. Findings included: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating policy and procedure revised on 9-2022 revealed in part; If resident abuse is suspected, the suspicion must be reported immediately to the Administrator. The Administrator immediately reports the suspicion to the agency within two hours of an allegation involving abuse. A telephone interview occurred with Resident #49's daughter on 6-6-23 at 11:35am. The daughter explained she had visited the resident around supper time on 4-23-23 and saw the bruise on her hand. She stated when she asked Resident #49 what had happened, the resident told her staff had held her hand down and pinched her hand on 4-22-23 because she did not want to get a shower and she was being combative. The daughter discussed informing Nurse #2 before supper on 4-23-23 that Resident #49 had a bruise on her hand and that the resident had told her staff had done it to her while she was in the shower. She stated Nurse #2 looked at the area, took a picture and told her staff would monitor the bruise. A review of a nursing note written by Nurse #2 on 4-23-23 at 10:37pm documented she was called to Resident #49's room by a family member (Resident #49's daughter) who was questioning what happened to the resident's hand which had a bruise to the left hand. The note documented the resident told Nurse #2 that the bruise happened in the shower a couple of days ago. Nurse #2 was interviewed by telephone on 6-6-23 at 2:17pm. Nurse #2 confirmed she was the charge nurse on 4-23-23. She explained she had been called to Resident #49's room around 5:00pm by the resident's daughter who wanted to know what happened to the resident's hand. The nurse said she assessed the area and found a bruise on Resident #49's left hand. Nurse #2 stated the daughter had told her Resident #49 had said the bruise occurred while she was in the shower with staff. The nurse discussed the protocol if an allegation of abuse was made. She stated she would have done an incident report and notified the Administrator immediately. Nurse #1 stated she did not follow protocol because she did not think it was abuse. The facility's initial report conducted by the facility's previous Social Worker dated 4-25-23 revealed the incident occurred on 4-22-23 but the facility was not made aware of the incident until 4-25-23 when Resident #49's daughter called the facility and reported the resident had been abused in the shower on 4-22-23. The initial investigation also revealed Resident #49's daughter informed the Administrator on 4-25-23 that she had visited the resident on 4-23-23 and had spoken to the charge nurse on duty (Nurse #2) who had assessed Resident #49's hand for damage. The facility's investigation report was completed on 4-28-23. The previous Social Worker (SW) was interviewed by telephone on 6-6-23 at 4:44pm. The SW confirmed she was the person responsible for conducting the investigation and that the investigation began on 4-25-23 when the Administrator had received a call from Resident #49's daughter alleging the resident had been roughed up in the shower. She stated it was at that time she learned the initial allegation of abuse had been made to Nurse #2 on 4-23-23. She also stated she was aware the allegation should have been reported immediately to the Administrator by Nurse #2 on 4-23-23 and a report turned into the agency within two hours. During an interview with the Administrator, Director of Nursing (DON), and the facility's owner on 6-7-23 at 3:40pm, the DON stated Nurse #2 had used her professional judgement on 4-23-23 regarding if the bruise on Resident #49's hand was abuse and did not need to report the incident.

Based on observations, record review and resident and staff interviews the facility failed to provide protection for residents during the investigation of an allegation of abuse for 1 of 2 residents (Resident #18) reviewed for abuse. Findings included: A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised September 2022 revealed in part: Investigating Allegations: 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Resident #18 was admitted to the facility on [DATE] with a diagnosis of osteoarthritis (the wearing down of protective tissue at the end of bones). A review of Resident #18's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She required the extensive assistance of 2 people for bathing and dressing. A nursing progress note dated 6/2/23 at 4:53 PM written by Nurse #3 revealed she was called to Resident #18's room to look at a bruise on Resident #18's right forearm. It further revealed Resident #18 had thin skin and the bruise looked superficial. The area was assessed and the Director of Nursing (DON), the Administrator and Resident #18's Physician Assistant (PA) were notified of the bruise. Resident #18 reported to Nurse #3 that she got the bruise yesterday during her bed bath when She grabbed my arm to pull me forward. A progress note dated 6/2/23 at 5:39 PM written by the Administrator revealed in part that a Nurse Aide (NA) made management aware of a complaint from Resident #18 regarding a bruise. The police and Adult Protective Services (APS) were notified. An initial allegation report was faxed to the State. On 6/5/23 at 2:42 PM Resident #18 was observed to have a flat oval shaped reddish-purple area to her right forearm. An interview with Resident #18 at that time indicated it had been caused by an NA when she grabbed her arm and jerked it to try to raise her up to put her gown on after her bath the other day. She stated there were 2 NAs that helped with her bath, and they were rushing. She went on to say the tall one pulled her brief too tight. She stated when she told that NA it was too tight, she looked mad and left the room. Resident #18 went on to say she felt the remaining NA jerked her arm deliberately causing the bruise. She further indicated she did not know the names of the NAs, but she would remember their faces if she saw them again. Resident #18 stated she had reported this, and the Director of Nursing had come to look at the area on her arm. She went on to say she really couldn't say how this made her feel. On 6/8/23 at 8:54 AM in a follow-up interview Resident #18 stated she felt safe in the facility. She went on to say while she couldn't always remember names, she could remember faces. She stated she had not seen the NAs involved with her bath the day she was bruised again. On 6/6/23 at 12:31 PM an interview with Nurse #3 indicated Resident #18 reported to her on 6/2/23 that she got a bruise on her right forearm the previous day during her bed bath on the 7AM to 3PM shift when an NA pulled her forward to pull her shirt down. Nurse #3 stated Resident #18 did not indicate to her whether this occurred accidentally or not. She went on to say she did not ask Resident #18 whether she felt it was an accident because she did not want to ask any leading questions. She further indicated Resident #18 had not expressed any concerns to her regarding the way staff treated her. Nurse #3 stated NA #1 and NA #9 assisted Resident #18 with her bed bath on the 7AM-3PM shift on 6/1/23. On 6/6/23 at 12:56 PM an interview with NA #1 indicated she and NA #9 assisted Resident #18 with a bed bath on 6/1/23 on the 7AM to 3PM shift. She stated she had been on Resident #18's left throughout the bath and NA #9 had been on Resident #18's right. She went on to say neither had pulled Resident #18's arms to raise her up to put her gown on. She further indicated they had slipped the gown over Resident #18's head and rolled her from side to side to pull it down. NA #1 stated they used the pad to pull Resident #18 up in bed. She went on to say she left Resident #18's room to take out the dirty sheets. She further indicated Resident #18 had not expressed any concerns about the care she or NA #9 provided that day. On 6/6/23 at 1:43 PM an interview with NA #9 indicated she and NA #1 assisted Resident #18 with a bed bath on 6/1/23 on the 7AM-3PM shift. She stated she had been on Resident #18's right side during the bath. She went on to say Resident #18 already had her gown on, but she had to lean her forward to pull her up. NA #1 stated she scooped her arm under Resident #18's arm to do this. She further indicated Resident #18 had not expressed any pain or concerns to her when she did this. On 6/6/23 at 1:53 PM an interview with the DON indicated Resident #18 reported to NA #10 on 6/2/23 on the 3PM to 11PM shift that she had a bruise on her right arm from the way staff treated her during her bath. She went on to say NA #10 immediately reported this to her. She further indicated when she spoke with Resident #18 on 6/2/23, Resident #18 had initially been confused about when the incident occurred, but the more she spoke with her, Resident #18 had been able to pinpoint the incident as occurring on 6/1/23 when she received her bath before 3PM. The DON stated Resident #18 reported that one of the NAs present during her bath had been mad and walked out. She further indicated Resident #18 reported to her that the NA that remained had also been mad. The DON stated Resident #18 told her she felt the remaining NA bruised her on purpose. The DON described the bruise as oval, light pink in color and appearing superficial. She stated there had been no finger marks. She went on to say Resident #18 had not complained of pain. She further indicated while she thought she narrowed the staff involved down to NA #1 and NA #9; she had not been sure. She further indicated she had looked to see if NA #1 and NA #9 were still working on the hall on 6/2/23 when she became aware of the allegation so she could speak to them, but they had not been. The DON stated she immediately reported this to the Administrator on 6/2/23 as an allegation of abuse. On 6/6/23 at 2:11 PM an interview with the Administrator indicated Resident #18 reported to NA #10 on 6/2/23 that the two girls who gave her bath the previous day hurt her. He went on to say he spoke with Resident #18 on 6/2/23 and observed the bruise himself. He stated the bruise on her right forearm appeared superficial and there were no hand or finger marks. He went on to say Resident #18 told him during this bath one of the NAs left the room and the NA that remained asked if she was leaving her. He stated Resident #18 told him the remaining NA raised her up to pull her shirt down and as she was letting her back down the NA's hand caused the bruise. He further indicated Resident #18 had been sure the bruise had been caused deliberately. The Administrator stated Resident #18 told him she was sure that NA knew what she was doing. He went on to say Resident #18 had not been able to provide him with the names of the staff involved. He further indicated normally when there was an allegation of abuse, he would suspend the staff involved immediately pending the investigation, but he had not done that this time. He stated he had not suspended anyone because he did not know for certain which staff were involved as Resident #18 had not been able to provide any names. He went on to say he had not spoken with NA #1 or NA #9 until today. He stated the investigation was still ongoing. On 6/6/23 a review of the timecard information for NA #1 and NA #9 provided by the facility revealed NA #1 was present in the facility working on 6/1/23 from 7:54 AM through 2:58 PM, was not present working in the facility on 6/2/23 through 6/4/23 and was present in the facility working on 6/5/23 from 7:15 AM through 2:49 PM and 6/6/23 from 7:09 AM through 2:42 PM. It further revealed NA #9 was present in the facility working on 6/1/23 from 8:19 AM through 2:55 PM, was not present working in the facility on 6/2/23 through 6/4/23 and was present in the facility working on 6/5/23 from 7:09 AM through 3:17 PM and 6/6/23 from 7:15 AM through 2:43 PM. On 6/6/23 at 3:13 PM an interview with NA #10 indicated on 6/2/23 Resident #18 showed him a bruise and told him that 2 ladies the previous evening were getting her ready for bed when one got flustered and lifted her up when they were trying to get her gown pulled down in the back and that caused the bruise. He stated he took this as an allegation of abuse and immediately informed the DON. On 6/7/23 at 9:31 AM a telephone interview with NA #11 indicated on 6/2/23 she observed a bruise on Resident #18's right arm. She stated Resident #18 told her that she had gotten this the previous day when 2 NAs were bathing her. She further indicated Resident #18 had not been able to provide any names. NA #11 went on to say Resident #18 told her the tall NA had gotten upset and left the room and while that NA was gone the other NA tried to lift her up causing the bruise. NA #11 stated NA #10 had immediately gone to report this to the DON.

Based on observations, record review, and staff interviews, the facility failed to (1) perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound, and before applying a clean dressing to a wound and (2) provide a clean field for wound care materials for 1 of 1 staff member observed for wound care (Nurse #4). Findings included: Review of a facility policy titled Wound Care revised in October 2010 read in part in steps #3 through #5 Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hand thoroughly. Put on gloves. Step #12 read in part Be certain all clean items are on clean field. An interview on 6/07/23 at 2:28 PM with Nurse #4 revealed he was the Infection Control Preventionist and Wound Treatment Nurse. An observation on 6/07/23 at 2:28 PM with Nurse #4 for wound care on Resident #82's right shin skin tear. Nurse #4 was observed to place wound care supplies on the overbed table without sanitizing it or placing a protective barrier. Nurse #4 brought wound care supplies (wound cleanser bottle, camera, foam border gauze package, gauze package, permanent marker, calcium alginate dressing package, scissors) in the resident's room and placed them on the overbed table, sanitized his hands and applied clean gloves. He then removed the old skin tear dressing which had a moderate amount of serous drainage, sprayed wound cleanser on the wound, and wiped the wound with gauze. He then took a picture of the skin tear with the camera, used scissors to cut the calcium alginate to wound size, placed it on the wound, and applied the foam border dressing on top of the calcium alginate, used the permanent marker to write the date on the foam border dressing. Nurse #4 pulled the resident's sock up and her pants leg down. He was observed to wear the same pair of gloves during the entire wound care process. During an interview with Nurse #4 on 6/07/23 at 2:40 PM he stated he was unaware of the need to have an infection control barrier on the resident's overbed table surface where he placed the wound care supplies, the need to perform hand hygiene or change gloves during the wound care process. An interview with the Director of Nursing on 6/07/23 at 3:03 PM revealed she believed that Nurse #4 had just made an error during the wound care observation. She stated he must have just blanked on the correct infection control process for wound care. An interview with the Administrator on 6/08/23 at 8:30 AM revealed he thought that Nurse #4 was nervous to observed during wound care but stated he should have followed infection control policy.

Based on observations, record review, and staff interviews, the facility failed to post complete and accurate daily nurse staffing information for 2 of the 5 days reviewed (6/06/23 and 6/07/23). Findings included: The daily nurse staffing information posted was observed on 6/06/23 at 9:30 AM. The posting revealed no total staff hours for nursing assistants or nurses for any shift. The daily nurse staffing information posted was observed on 6/07/23 at 10:45 AM. The posting revealed no total staff hours for nursing assistants or nurses for any shift. An observation and interview on 6/07/23 at 10:54 AM with the Director of Nursing revealed that she posted the daily nurse staffing information at the nurses' station. She stated she was aware of the requirement to post the total staffing hours by position and shift. She was unaware that the current information posted did not include the total hours. She stated it must have happened when the facility switched staffing software systems and she had not noticed it did not include the required information. An interview on 6/07/23 at 11:10 AM with the Administrator revealed he was unaware of that the posted nursing staff information did not include the required total number of hours for nursing assistants and nurses.

Based on record review and staff interviews the facility failed to provide treatment and dressing changes for a skin tear for 1 of 3 residents reviewed for wounds (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with cumulative diagnoses of Alzheimer's dementia and acute respiratory failure with hypoxia and pneumonia. Resident #1's admission Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired and required extensive assistance with all aspects of daily living, except eating. MDS did not indicate any pressure ulcer/injury. Review of wound assessment note dated 11/21/22 documented by Nurse #1, indicated a new, open, acute wound to Resident #1's sacrum/buttocks. The wound was 0.5cm (centimeter) x 0.5cm with no redness or exudate observed. No undermining or tunneling. Surrounding skin was clear. Periwound temperature was consistent with surrounding skin. No pain with dressing application. This is a new wound. Additions added to treatment, see physicians order. Incontinent of bladder, continent of bowel. An interview with Nurse #1 on 3/7/23 at 11:20am indicated she discovered the skin tear on Resident #1's right buttock on 11/21/22, cleaned it and applied a foam dressing per facility skin tear wound protocol and recorded it on the wound assessment document. She further explained the facilities process of entering the new wound into the electronic medical record to notify the wound nurse of any new treatments and notify the physician of new standing orders to be signed. She then indicated that she clearly had not remembered to implement these standing orders or to inform the next shift of her findings. Review of the 11/1/22 through 11/30/22 Physician orders showed no standing order initiated for wound care to Resident #1's sacrum/buttocks. Record review of 11/1/22 through 11/30/22 Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed no treatment orders for wound care to Resident #1's sacrum/buttocks. Interview with facility Wound Nurse on 3/6/23 at 4:38pm indicated he did not recall Resident #1. Referencing his wound report documentation, he reported that Resident #1 did not have any wound care orders. He reported the standing order for a skin tear wound was a generic cleaner and a foam dressing, cleaned and dressing changed daily. He explained the process of their program, when the wound had been entered into their program, it added the standing orders for skin tear treatment to the TAR and alerts the MD to any new standing orders to be signed. He reported he would then print the daily wound report and any new wounds requiring treatments would be added. Review of wound assessment dated [DATE] documented by Nurse #1 revealed, skin tear to right buttock, category II, acquired in house on 11/21/22. Area: 18.5 cm (squared); L (length) 4.7 cm; W (width) 5.6 cm; 80% wound covered with epithelial, no evidence of infection; light drainage sanguineous/bloody, no odor; edges non-attached, edge appears as a cliff with surrounding tissue erythema/fragile, no warmth to surrounding skin; Dressing appearance is intact/saturated, cleansed with generic wound cleaner & foam dressing applied. Interview with Nurse #1 on 3/7/23 at 11:20am also revealed she had been assigned to Resident #1 on 11/30/22 but did not recall being asked anything concerning his wound or dressing needs from the family. However, she did assess his wound on 11/30/22, documented it as skin tear, measured it, cleaned it and applied a new foam dressing. Interview with the Director of Nursing (DON) on 3/7/23 at 1:45pm, revealed she was unaware of Resident #1 having an acute wound to his buttock and further revealed that she expected the standing order to have been written and transcribed to the TAR to ensure ongoing care from other shifts, and the wound nurse to have been notified for wound care follow up.

Based on observations, record review, and staff interviews, the facility failed to change soiled linen for 1 of 1 resident reviewed for a clean and homelike room (Resident #6). The findings included: On 06/11/18 at 3:12 PM the blanket on top of Resident #6's bed was observed with brown colored smears approximately 2 inches wide and 3 inches long. The smears were located on the right top edge of the blanket at the foot of the resident's bed and were visible from the hallway. On 06/12/18 at 8:07 AM Resident #6's bed was observed unmade. The same brown colored smears were observed in the same location on the resident's blanket. At 1:32 PM on 06/12/18 the resident's made bed was observed with the same brown colored smears in the same location on the resident's blanket. The smears were visible from the hallway. An interview with Nursing Assistant (NA) #2 on 06/12/18 at 2:07 PM revealed she made Resident #6's bed today. NA #2 explained she did notice the brown colored smears on the blanket but thought they were stains that were sometimes found on facility blankets. The NA added she did not change the blanket when she made Resident #6's bed today. An interview with the Director of Nursing (DON) on 06/12/18 at 2:15 PM revealed she expected NAs to change the blankets on residents' beds if they appeared soiled.

Based on observations, record review, and staff interviews, the facility failed to follow instructions regarding not to crush an extended relief medication for 1 of 7 residents observed receiving medications (Resident #67). The findings included: Resident #67 was admitted to the facility 03/06/14 with [DIAGNOSES REDACTED]. A review of Resident #67's medical record revealed a physician's orders [REDACTED]. On 06/13/18 at 8:36 AM, Nurse #3 was observed preparing medications for Resident #67. Medications which included aspirin, [MEDICATION NAME], and Senna were placed in a medication cup. Two capsules of [MEDICATION NAME] were opened and the contents (small individual sprinkles) were emptied into the cup. All these medications were placed in a pouch. The nurse was observed placing the pouch in a pill crusher and crushing all the medications together. The contents of the pouch were placed in a medication cup with applesauce. During an interview at this time, Nurse #3 stated this was the way she always administered Resident #67's [MEDICATION NAME]. Nurse #3 noted the order for the administration of [MEDICATION NAME] on the electronic Medication Administration Record [REDACTED]. Nurse #3 explained she thought that meant not to crush the capsules. Nurse #3 was observed administering the medications as she had prepared them. An interview was conducted via phone with the facility's Pharmacy Consultant (PC) on 06/13/18 at 10:11 AM. The PC explained the [MEDICATION NAME] sprinkles were coated so that they were released in the body at different times providing extended coverage. She added crushing the sprinkles would make all the [MEDICATION NAME] medication act at once instead of being extended over a period of time. The PC stated she had reviewed [MEDICATION NAME] blood levels that were obtained 11/30/17, 03/01/18, and 06/11/18. She added all the levels were within normal limits. The PC further stated the physician should be notified in case changes in the dosage needed to be made. An interview was conducted with the Psych Physician Assistant (PPA) on 06/13/18 at 1:03 PM. The PPA stated she was unaware of Resident #67's [MEDICATION NAME] being crushed. She stated due to the sprinkles being coated so the medication was released throughout the day could make a difference in the effectiveness of the [MEDICATION NAME]. The PPA did not think any harm was done to the resident at this time but the resident should be monitored. An interview was conducted with the Director of Nursing (DON) on 06/13/18 at 4:30 PM. The DON stated she would be sure the physician was notified of the medication error and the nurse was reeducated. The DON added extended release medications should never be crushed.

Based on observations, record review and staff interviews the facility failed to clean 1 of 1 kitchen ice machines used to provide ice for residents. The findings included: During the initial tour of the kitchen on 06/11/18 beginning at 8:25 AM, an observation of the ice machine located in the kitchen revealed a pink tinged substance located on the white plastic seal under the ice machine lid. The pink tinged substance was observed to be easily removed by the Director of Operations (DO) with a paper towel. Record review of the (YEAR) Dietary Services Ice Machine log indicated the ice machine is cleaned monthly with the most recent cleaning on 05/17/17. The log further revealed a deep clean occurs quarterly which included internal cleaning and sanitizing of the ice machine along with a filter change with the most recent cleaning on 03/12/18. During a joint interview with the DO and the Dietary Manager (DM) on 06/14/18 at 10:42 AM, the DO stated the kitchen area was very humid and it had almost been a month since the cleaning had been completed on the ice machine. The DO stated the ice machine probably needed to be cleaned every 2 weeks instead of monthly because of the humidity. During an interview with the Administrator on 06/14/18 at 6:40 PM, she stated her expectations were for the ice machine to be cleaned routinely.

Based on observations and staff interviews the facility failed to properly store food and clean bins housing dried food products in the facility kitchen. The findings included: 1. During the initial tour of the facility kitchen on 03/07/16 from 9:05 AM-10:00 AM the following concerns were identified: a. An opened, one gallon container of 2% milk was stored on shelving in the reach in refrigerator. The manufacturer expiration date on the container of milk was 02/27/16. The kitchen manager reported the reach in refrigerator was checked on a daily basis by staff and any outdated items were removed. The kitchen manager stated the outdated milk must have been missed by staff when the reach in refrigerator was checked. b. Individual cartons of milkshakes were stored in three separate cardboard boxes in the reach in refrigerator. One box had approximately 21 thawed strawberry milkshakes, another had approximately 63 thawed chocolate milkshakes and a third had approximately 25 thawed strawberry milkshakes. The manufacturer label on the milkshakes noted the milkshakes were good for 14 days after thawed. There was no indication on the milkshakes or the cardboard box which contained the milkshakes to indicate when they had been thawed. The kitchen manager stated dietary staff were supposed to date the cardboard box when the milkshakes were pulled and could not explain why that had not been done. c. Inside the walk in freezer the following was observed: A plastic bag containing grated cheese was stored open to air and the exposed grated cheese was crystallized. A plastic bag of individual dinner rolls was stored open to air with product exposed. A plastic bag housing individual beef patties was stored open to air with product exposed. A plastic bag containing sliced okra was stored open to air and the exposed okra was crystallized. The kitchen manager stated dietary staff were supposed to seal bags prior to placing them back in the freezer. The kitchen manager could not explain why the cheese, rolls, beef patties and okra had been stored open to air. d. A five pound container of sour cream with a manufacturer best by date of 02/15/16 was stored on shelving in the walk in refrigerator. A portion of cheese was wrapped in plastic wrap and stored inside a plastic bin housing cheese products in the walk in refrigerator. The cheese was not labeled or dated. The kitchen manager stated the walk in refrigerator was checked daily by dietary staff for any outdated products and to ensure products were properly labeled and dated. The kitchen manager could not explain why the sour cream had not been removed from the walk in refrigerator or why the cheese was not labeled or dated. e. Three rolling bins containing dried product were observed stored under a food preparation table in the kitchen. The bins housed corn meal, flour and sugar. The top of each of the rolling bins (which included the lid) had a considerable build-up of dried, sticky debris covering a significant portion of the top of the container. f. A dietary aide was observed bringing two cans of mixed fruit into the food preparation area. The dietary aide stated she removed the cans from the dry storage area and was going to use them for the lunch meal. One of the cans of mixed fruit had significant dents on both the top and bottom of the can which involved the rim area. The dietary aide was observed to open the dented can and began to portion out individual servings of fruit from the can. The concern was reported to the kitchen manager and the individual servings that had been portioned out as well as the remaining fruit content in the dented can was discarded. The kitchen manager stated dented cans were stored in a particular area in dry storage and were not to be used. The kitchen manager spoke to the dietary aide and reported the aide stated she did not notice the can was dented. 2. On 03/10/16 at 11:00 AM the three rolling bins containing dried product were again observed stored under a food preparation table in the kitchen. The bins housed corn meal, flour and sugar. The top of each of the rolling bins (which included the lid) had a considerable build-up of dried, sticky debris covering a significant portion of the top of the container. The Food Service Director (FSD) was present at the time of the observation and reported the bins were scheduled to be cleaned each Monday. The FSD stated he was not sure if the bins had been cleaned on 03/07/16 (a Monday) and noted they needed to be cleaned.

Based on observations, record reviews and staff interviews the facility failed to thoroughly investigate and submit 24 hour and 5 working day reports to the North Carolina Health Care Personnel Registry (state agency) for 1 of 1 residents with bruising, swelling and a [MEDICAL CONDITION] of unknown origin. (Resident #142) The findings included: The facility undated Abuse Nursing Policy and Procedure included the following: Reporting of Alleged Violations Involving Mistreatment, Neglect or Abuse, including Injuries of Unknown Source and Misappropriation of Resident Property: -All injuries of unknown source will be reported immediately to the Administrator. -The Administrator or designee will immediately notify the complaint investigation intake and referral unit and the legal representative and/or interested family member of the incident and pending investigation. -The initial report must be telephoned in or faxed within 24 hours of the incident. Investigations of Alleged Violations: -All alleged violations involving mistreatment, neglect or abuse including injuries of unknown source and misappropriation of resident property, are recorded on an assessment form and reported to the Administrator or his/her designee. This assessment will be completed by the Director of Nursing (DON), the Social Service Director or their designee. -Interviews will be conducted of all pertinent parties. Signed statements will be taken from those persons who saw or heard information pertinent to the incident. Statements will be gathered from the suspect, person making accusations, resident involved, reliable residents who may have witnessed the incident, and any other person who may have some information. Investigation of Injuries of Unknown Source: -Interviews will also be conducted when a resident has an injury from an unknown source. Signed statements will be gathered from : staff who cared for the resident just prior to and just after injury; other reliable residents in the vicinity nearby area; family or visitors who may have noticed anything. -Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source of injury can be identified based on the resident's behavior. (i.e. how they move their arms, walk, push a wheelchair, behave, etc.) -The chart will be reviewed for any pertinent information which could help the investigation. Written Report to the State Agency: -A written report will be submitted to the Administrator and the State Agency within five working days of the incident. -This report will contain all of the investigative information, description of the injury; signed statements from the pertinent parties; information gathered from the investigation; and the results of the investigation. Resident #142 was admitted to the facility 05/28/14 with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #142 assessed her with severe cognitive impairment. The Care Area Assessment (CAA) for Activities of Daily Living (ADL) associated with the annual 08/07/15 MDS assessment for Resident #142 noted, Resident requires extensive to total assistance from staff for completion of all ADL tasks. She is transferred with a mechanical lift and is totally dependent for eating. She is up in chair and takes her meals in the dining room. Staff members attempt to anticipate and provide for resident's ADL needs on a routine and as needed basis. The care plan for Resident #142 noted review dates of 11/06/15 and 02/05/16. Problem areas in the care plan for Resident #142 included the following: -Has impaired cognitive function/dementia or impaired thought processes related to disease process, dementia. -Resident is at risk for fall related injury secondary to use of [MEDICAL CONDITION] medications, altered cognition and poor safety awareness -Has an ADL self care performance deficit related to dementia, limited mobility, disease process. -Is resistive to care related to dementia. At times she resisted personal care such as showers. -Has potential to demonstrate physical behaviors related to dementia. Poor impulse control by reaching out at times and inappropriately pinching others. Resident tends to only pinch staff members. Review of nurses notes in the medical record of Resident #142 included the following: 11/07/15 11:30 AM I was alerted by nursing staff that resident had fallen out of chair. Resident was evaluated for injuries. Helped into her chair. Vital signs taken. Resident showed no signs/symptoms of distress. 11/12/15 10:39 PM-Called to resident's room by hall nursing assistant during rounds resident was combative slapping at nursing assistant, scratching and pinching. Nursing assistant noticed a skin tear to the top of the right hand. Areas cleansed with wound cleanser. Resident resting quietly in bed with eyes closed. 11/13/15 4:28 AM Labs. Drawn and specimen to lab. Resident tolerated well. 11/13/15 6:30 AM Called to resident's room by nursing assistants during morning round resident noted to have a large bruised area to her upper left inner and top thigh area. Bruise is purple in center with yellowing edges noted. Area is swollen and red around it. Left hip area is swollen as well. 11/13/15 6:32 AM Date wound identified 11/13/15. Wound location upper left thigh/hip. Wound bruise 5 inches X 6 inches. Surrounding skin [MEDICAL CONDITION]. Periwound temp warmer than surrounding skin. 11/13/15 9:58 AM X-ray of left hip and femur due to pain and bruising. 11/13/15 1:51 PM Nurse Practitioner reviewed left hip and femur X-ray positive for fracture. New orders for Occupational Therapy to evaluate and treat for staff education related to positioning and transfers due to left [MEDICAL CONDITION]. 11/13/15 4:56 PM Ice pack to left hip/thigh for 20 minutes every four hours as needed for 48 hours. [MEDICATION NAME] every 6 hours as needed for pain. Bed rest, do not transfer. Review of radiology report from 11/13/15 noted, Acute [MEDICAL CONDITION] neck in the intertrochanteric region. Osteopenia is noted. Physician/nurse practitioner progress notes in the medical record of Resident #142 included the following: 08/26/15-Total care for all ADLs. Functional [MEDICAL CONDITION] related to advanced dementia. Geri Chair for mobility. No current skin issues. Appears comfortable. 10/26/15-Requires extensive assist with ADLs. No falls or acute illness. 11/13/15-Seen today per nurse request due to swelling and bruising of left hip area and external rotation of left leg noted this AM by staff. No recent fall or injury reported. In bed with head elevated eating her lunch. Not in any acute distress. Unable to obtain review of symptoms from resident due to dementia and delusions. [MEDICAL CONDITION] and mild bruising to left hip area, tender to touch or movement. No other issues reported. Left [MEDICAL CONDITION], bed rest. Unable to verbalize level of pain. [MEDICAL CONDITION] to left hip and upper thigh, outward rotation of proximal femur. No recent fall or injury reported. X-ray shows osteopenia. Resident is non ambulatory. No treatment indicated due to multiple comorbidities and late stage dementia. Comfort focused care. 11/17/15-Left hip with ecchymosis, external rotation. It turns out that there was an omission in the official document and patient did have a fall the previous week that was never recorded or reported to myself or the nurse practitioner. X-ray was diagnostic. Agree with bed rest and pain control. Review of the medical record of Resident #142 noted post incident follow-up reviews were completed after the fall on 11/07/15. These were dated 11/08/15 and 11/12/15 and indicated there were no complications related to the 11/07/15 fall. Review of the medical record noted a skin assessment had been completed on 11/11/15 for Resident #142 and there were no problems identified. Nurse #3 that completed the skin assessment on 11/11/15 was interviewed on 03/10/16 at 2:47 PM and stated if there were no concerns noted during the skin assessment then nothing was documented. On 03/09/16 at 11:00 AM the Director of Nursing (DON) stated the facility reviewed all fall and incident investigations to determine any changes to interventions to prevent falls. In a follow-up interview on 03/09/16 at 11:32 AM the incident reports for Resident #142 dated 11/07/15, 11/12/15 and 11/13/15 were provided for review. The DON stated the incident report was inclusive of all information involved in the investigation, including any staff interviews. Review of the incident reports included the following: 11/07/15-11:30 AM I was alerted by nursing staff that resident had fallen out of chair. Resident was evaluated for injuries. Helped into her chair. Vital signs taken. Resident showed no signs/symptoms of distress. A post fall assessment dated [DATE] at 11:30 AM noted a fall without injury with interventions to remind the resident to call for help. There were no staff interviews attached to the investigation. 11/12/15-10:30 PM Called to resident's room by hall nursing assistant during rounds resident was combative slapping at nursing assistant, scratching and pinching. Nursing assistant noticed a skin tear to the top of the right hand. Area cleansed with wound cleanser, edges were approximated will and skin tear protocol implemented. There were no staff interviews attached to the investigation. 11/13/15-6:22 AM Called to resident's room by nursing assistants during morning round resident noted to have a large bruised area to her upper left inner and top thigh area. Bruise is purple in center with yellowing edges noted. Area is swollen and red around it. Left hip area is swollen as well. Resident assessed for pain/discomfort routine Tylenol given per order. Resident repositioned in bed. Will notify physician. There were no staff interviews attached to the investigation. Notation from the incident review committee noted the 11/07/15, 11/12/15 and 11/13/15 were reviewed in the 11/19/15 meeting with documentation which included: 11/19/15-Review of the 11/07/15 fall noted, Per fall review committee: Resident has left hip/femur fracture. Occupational therapy for positioning, bed rest, routine and as needed pain medications. 11/19/15-Review of the 11/12/15 skin tear noted, Per incident review committee: Resident combative, has fragile skin. No abuse suspected. Will monitor in Treatment Administration Record. 11/19/15-Review of the 11/13/15 bruise noted, Per fall committee: Left hip/femur fracture. Occupational therapy for positioning, bed rest, routine and as needed pain medication. On 03/09/16 at 2:53 PM the DON stated the nurse that completed the incident/accident report was responsible to complete the report and determine the cause of injury and come up with an initial plan of correction. The DON stated both she and the nurse practitioner were notified of any major injuries. The DON stated the incident report would flag and be accessible to management staff to review. The DON stated within 24 hours of an incident the responsible nurse or nurse manager was responsible to do a follow-up review to determine if anything was missed in the investigation and if there were any suspicions of abuse. The DON stated when the fall/incident committee met they reviewed the incident reports to determine if there was any missing information in the review. The DON stated what was discussed in the fall/incident meeting was included in the notations. The DON stated a 24 hour and 5 day report would be completed and submitted to the North Carolina Health Care Personnel Registry (state agency) if they suspect equipment malfunction or abuse or neglect. On 03/09/16 at 3:34 PM in a follow-up interview the DON stated that initially on 11/13/15 when the bruise was found on the hip of Resident #142 they did not know about the 11/07/15 fall because the nurse had only partially completed an incident report. The DON stated though the bruising on 11/13/15 was fresh, she felt the bruise, swelling and [MEDICAL CONDITION] were all related to the 11/07/15 fall. The DON stated she did not have any additional information related to the bruise/swelling and fracture discovered on 11/13/15 on Resident #142. The DON stated she spoke with staff that worked with Resident #142 on 11/12/15 and nothing unusual was reported. The DON stated staff interviewed were not documented and written statements were not obtained. The DON stated because Resident #142 is completely bedfast, non weight bearing and totally dependent they did not suspect abuse and did not complete a 24 hour or 5 day report. The DON stated she felt when Resident #142 slid out of the chair on 11/07/15 it caused a hairline fracture and the fracture became displaced either when staff placed Resident #142 in bed on 11/12/15 or were providing between 11/12/15-11/13/15. On 03/09/16 at 4:24 PM Nurse #2 that worked with Resident #142 from 11/12/15 at 7:00 PM-11/13/15 at 7:00 AM stated she recalled the bruising that was reported in the AM on 11/13/15. Nurse #2 stated she filled out the incident report which included the circumstances. Nurse #2 stated she did not do an investigation when completing an incident report. Nurse #2 stated because of the seriousness of the injury she did report it to the oncoming nurse as well as the physician. Nurse #2 stated when the incident report was completed she assumed management staff did the investigation which included talking to staff. Nurse #2 stated she did not interview staff about the bruising, did not recall being interviewed about the injury by management staff and had not written a statement. Nurse #2 stated the post fall assessments completed 11/13/15 and 11/14/15 included a no to the question was abuse indicated in relation to this incident and was answered in the negative only because the cause of the injuries was not witnessed. On 03/09/16 at 4:49 PM Nurse Aide (NA) #5 that worked with Resident #142 on 11/12/15 from 7:00 PM-11/13/15 at 7:00 AM stated she recalled working with Resident #142 on 11/12/15-11/13/15. NA #5 stated she was present when the skin tear happened on 11/12/15, had assisted to reposition Resident #142 during the night and was present when the bruising and swelling was found in the AM on 11/13/15. NA #5 stated she immediately reported the bruising and swelling to the nurse and the nurse asked her if anything happened. NA #5 stated other than the nurse, no one had asked her about working with Resident #142 on 11/12/15-11/13/15 and she had not written a statement. On 03/09/16 at 3:00 PM NA #4 that worked with Resident #142 on 11/12/15 from 7:00 PM-11/13/15 at 7:00 AM stated she assisted another NA to put Resident #142 to bed that night and did not see any bruising on her hip or thigh. NA #4 stated after 11/13/15 she was asked by management staff if she was aware of any bruising. NA #4 stated she was not asked any other questions about the events of 11/12/15-11/13/15 and had not written a statement. On 03/09/16 at 4:00 PM NA #3 stated she gave Resident #142 a shower a couple days after the 11/07/15 fall and did not see any swelling or bruising on the resident's thighs or hips. On 03/10/16 at 10:00 AM the DON provided written statements about the bruising/swelling and [MEDICAL CONDITION] involving Resident #142 on 11/13/15. The DON stated she obtained the statements from staff on 03/09/16-03/10/16. One of the statements provided was from Nurse #4 that was present on 11/07/15 when Resident #142 fell out of her chair. This statement noted that Resident #142 had been assessed 11/07/15-11/12/15 and no injuries were noted. The DON stated although the 11/13/15 injury involving Resident #142 was unwitnessed she felt she did not have to complete the 24 hour or 5 day working report to the State Agency because she did not suspect abuse.