Every finding on record at Stokes County Nursing Home

Based on record review and staff interview, the facility failed to ensure the facility assessment included a contingency plan that was informed by the facility assessment to address the availability of staff and other resources for events that did not require activation of the facility's emergency plan but had the potential to affect resident care. This had the potential to affect 38 of 38 facility residents. The findings included:The review of the facility assessment dated 2025 did not identify a written contingency plan that was informed by the facility assessment to address the availability of nursing staff and other resources for events that did not require activation of the facility's emergency plan but had the potential to affect resident care. An interview occurred with the Assistant Administrator on 11/20/2025 at 2:30 pm. She stated she was unaware that a contingency plan for staffing/resources for events that did not require activation of the facility's emergency plan needed to be addressed in the facility assessment. She was uncertain why this was not completed.An interview with the Director of Nursing (DON) on 11/20/2025 at 9:15 am, revealed there was no plan in writing that specified what to do when the facility had an event that had the potential to affect resident care. The DON did not know why there was not a written plan in place for staffing/resources during an event that could interrupt resident care needs. An interview with the Administrator on 11/20/2025 at 3:40 pm revealed the Facility Assessment was reviewed and revised annually, however the written contingency plan informed by the facility assessment was not included in the facility assessment. She stated that turnover had been complex related to increased management changes that started in 2025, but the facility still had a responsibility to complete the requirements of the facility assessment.

Based on record review, and staff, Physician and Consultant Pharmacist interviews, the facility failed to provide ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for potential adverse reactions to antipsychotic medications for 3 of 5 residents reviewed for unnecessary medications (Residents #30, #2, and #3). The findings included: a. Resident #30 was readmitted on [DATE] with diagnoses including dementia with behaviors and generalized anxiety disorder. Physician order dated 6/13/24 included Olanzapine (antipsychotic) oral tablet 2.5 milligrams (MG). Give one (1) tablet by mouth at bedtime related to unspecified dementia, unspecified severity with other behavioral disturbances. Resident #30's active care plan dated 6/2/25 indicated a risk for complications related to the use of psychotropic and antipsychotic medications. Interventions included AIMS testing per protocol. Resident #30's medical record documented one AIMS assessment on file dated 3/10/25. There were no other AIMS found in the medical record. b. Resident #2 was admitted on [DATE] with diagnoses including unspecified dementia unspecified severity without behavior, psychotic disturbance, mood disturbance, and anxiety.Physician order dated 5/15/25 included Olanzapine (antipsychotic) oral tablet 5 milligrams (MG). Give one (1) tablet by mouth one time a day related to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #2's active care plan dated 5/15/25 revealed goals and interventions for Resident #2's medication, Olanzapine. The interventions included monitoring/documenting for side effects and effectiveness. There were no interventions for an AIMS to be completed. The quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired. The MDS also revealed Resident #2 received antipsychotic medications. Review of Resident #2's medical record revealed there were no AIMS assessments completed. c. Resident #3 was readmitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance; anxiety disorder; anxiety with delusional thoughts and behaviors harmful to self and others with psychotic features and lying; major depressive disorder, recurrent, unspecified multiple episodes of paranoia and restlessness; cerebral infarction. Resident #3's active care plan after re-admission to the facility dated 6/10/25 did not have focus, goals and interventions for antipsychotic medication. Physician order dated 6/30/25 included Quetiapine Fumarate (antipsychotic) oral tablet 50 milligrams (MG). Give one (1) tablet by mouth in the morning related to anxiety disorder; major depressive disorder, recurrent; and give 2 tablets by mouth at bedtime related to anxiety disorder, unspecified; major depressive disorder, recurrent. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and was coded for having verbal behaviors towards others 1-3 days during the look back period. The MDS also documented Resident #3 received antipsychotic and antidepressant medications routinely. The last Gradual Dose Reduction (GDR) documented was 5/19/25. Review of Resident #3's medical record revealed there were no AIMS assessments completed. An interview with the Director of Nursing (DON) on 11/19/25 at 2:30 PM revealed she was unaware the AIMS assessments were not being completed. She stated prior to her employment, the previous DON did not follow through with obtaining AIMS and she stated the unit went without a DON for a while and no one else followed up so the AIMS have not been completed as needed. The DON was unaware how often and when the AIMS assessments needed to be completed. She also stated in the past, the nurses were responsible for completing the AIMS assessments. The DON indicated there was not a process in place to alert staff when the AIMS assessments were due. She stated the AIMS assessments should have been completed as required. An interview was held with the Pharmacy Consultant on 11/19/25 at 3:45 PM. The Pharmacy Consultant stated she did not think the AIMS assessments still needed to be completed for residents prescribed antipsychotic medications. She indicated the AIMS was completed in one of the sections of the MDS. The Pharmacy Consultant stated she had not seen an AIMS assessment form in any of the residents' records. An interview with the Medical Director on 11/20/25 at 9:55 AM indicated he was unaware when and how often the AIMS assessment needed to be completed. He stated he would set up a meeting with the DON regarding completing the AIMS assessments. An interview conducted with the facility Physician on 11/20/25 at 10:22 AM revealed he did not complete the AIMS assessment for residents on antipsychotics. He discussed that since the facility had begun using the electronic medical record, he was unaware if staff were completing them. He stated since he assessed residents monthly, and if not monthly, then every other month, he could potentially add it to his list to do. The facility Physician stated he would meet with the DON to determine who would complete the AIMS going forward. An interview was held with the Administrator on 11/20/25 11:46 AM. The Administrator was made aware the AIMS assessments were missing or were past due. She stated the nursing staff historically were responsible for completing the AIMS assessments. Prior to transitioning to the electronic medical record, the AIMS assessment was included in a paper MDS packet. The AIMS assessment was supposed to be built into the electronic medical record software, but it was not. The Administrator stated other contributing factors to the missing and past due AIMS assessments were the MDS coordinator left in April 2025, the transition from paper chart to electronic medical record (EMR) at the end of May/beginning of June, and the previous DON left on 5/01/25.

Based on record review, and resident and staff interviews, the facility failed to revise the comprehensive care plan to include antipsychotic medication use for 1 of 5 residents reviewed for care plans (Resident #3).The findings included:Resident #3 was readmitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, anxiety disorder, anxiety with psychotic features and, recurrent unspecified major depressive disorder.A review of Resident #3's active comprehensive care plan dated 6/10/25 did not reveal a care plan had been initiated for antipsychotic medication use.Resident #3's physician's orders revealed an order dated 6/29/25 to give one tablet of Quetiapine Fumarate (an antipsychotic medication) 50 milligrams (MG) by mouth in the morning and give two tablets by mouth at bedtime related to unspecified anxiety disorder and unspecified recurrent major depressive disorder.Review of Resident #3's Medication Administration Record (MAR) from June 2025 through November 2025 revealed Resident #3 received Quetiapine Fumarate as ordered. The MAR also indicated Resident #3 was observed three times per day for side effects and behaviors.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and was coded for having verbal behaviors towards others 1-3 days during the look back period. The MDS also documented Resident #3 received antipsychotic medications routinely.The quarterly MDS dated [DATE] indicated Resident #3 was cognitively intact with no behaviors coded and received antipsychotic medication on a routine basis.An interview with the Director of Nursing (DON) on 11/20/2025 at 3:20 PM revealed she was not aware the care plan for Resident #3 did not include a plan for the antipsychotic medication, but there should be one. She stated the MDS coordinator or Administrator created and updated the care plans.Interview with the MDS Coordinator on 11/20/25 at 4:12 PM revealed that she was in training and was not responsible for creating care plans. She stated the Administrator was responsible for initiating and updating resident care plans.The Administrator was interviewed on 11/20/25 at 4:14 PM. The Administrator was made aware the care plans for Resident #3 did not include a care plan for antipsychotic medication. She stated the previous MDS Coordinator created resident care plans. The Administrator explained she had assisted with creating and updating care plans while the new MDS Coordinator was training. She stated the care plan was missing because Resident #3 was discharged to the hospital and later readmitted (6/2/25). Resident #3 was not prescribed an antipsychotic upon readmission. Resident #3 began to exhibit behaviors, and the antipsychotic medication was restarted on 6/29/25. The Administrator stated the care plan was not updated after the antipsychotic medication was resumed.

Based on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage that indicated the use of oxygen for 3 of 4 residents reviewed for respiratory care (Residents #2, #5, and #37).The findings included: a. Resident #2 was admitted to the facility on [DATE] with the diagnosis of Streptococcus pyogenes (Contagious bacterial infection that causes swelling and sudden painful sore throat). Resident #2's physician orders dated 6/19/25 revealed an order for oxygen to be administered continuously via nasal cannula at 2 liters per minute (lpm) to keep oxygen level above 90% (normal range for oxygen level is 95-100%) as needed. Resident #2's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was coded for receiving oxygen. Observations on 11/18/25 at 12:11 PM, 11/19/25 at 9:06 AM, 11/19/25 2:37 PM and 11/20/25 at 9:17 AM revealed Resident #2 was lying in bed in his room wearing a nasal cannula with oxygen administered at 2 lpm. There was no cautionary or safety signage posted at Resident #2's room to indicate oxygen was in use during the observations. b. Resident #5 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). On 11/17/25, the physician ordered oxygen to be administered to Resident #5 at 2 liters per minute via nasal cannula.Observations conducted on 11/18/25 at 12:12 PM, 11/19/25 at 2:52 PM, and 11/20/25 at 9:17 AM revealed there was no cautionary signage at Resident #5's room indicating oxygen was in use. Resident #5 was in her room using oxygen delivered via nasal cannula during the observation times. c. Resident #37 was admitted to the facility on [DATE] with the diagnosis of COPD. Resident #37's physician orders dated 6/19/25 revealed an order for oxygen to be administered continuously via nasal cannula at 2 lpm to keep oxygen level above 90% as needed. A review of the annual MDS dated [DATE] indicated Resident #2 was coded for receiving oxygen. Observations on 11/18/25 at 12:11 PM, 11/19/25 at 9:06 AM, 11/19/25 2:37 PM and 11/20/25 at 9:17 AM revealed Resident #37 was lying in bed in her room wearing a nasal cannula with oxygen administered at 2 lpm. There was no cautionary or safety signage posted at Resident #37's room to indicate oxygen was in use during the observations. An interview with Nurse Aide (NA) #5 was conducted on 11/19/25 at 2:34 PM. She stated she does not recall ever seeing cautionary signs at the residents' doors for oxygen in use. The NA stated she was made aware of which residents were on oxygen during her shift report. She was unaware of why there were no signs. An interview was conducted with Nurse #6 on 11/19/25 at 2:52 PM. The Nurse stated she had not seen any oxygen in use signs posted in the facility. On 11/20/25 at 9:21 AM an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not need precaution signs for oxygen in use since they were a smoke free facility. An interview with the Administrator was conducted on 11/20/25 at 3:26 PM. The Administrator stated no smoking signs were posted throughout the campus. She stated with being a smoke free facility, there was no need for cautionary oxygen in use signs on the residents' doors.

Based on record review and interviews with staff, Pharmacy Consultant, Facility Physician, and the Medical Director, the Pharmacy Consultant failed to identify and report irregularities when conducting monthly drug regimen reviews for 2 of 5 residents reviewed for unnecessary medications (Resident #3, and Resident #30).The findings included:a. Resident #3 was readmitted to the facility on [DATE] with diagnoses including unspecified dementia with unspecified severity and other behavioral disturbance, anxiety disorder, anxiety with delusional thoughts and behaviors harmful to self and others with psychotic features and lying, recurrent unspecified major depressive disorder, multiple episodes of paranoia and restlessness, and cerebral infarction.Review of Resident #3's medical record revealed Resident #3 did not have an Abnormal Involuntary Movement Scale (AIMS) assessment on file. The AIMS is an assessment that determines the severity of uncontrollable and involuntary movements in people prescribed antipsychotic medications.Resident #3's physician's orders revealed an order dated 6/29/25 to give one tablet of Quetiapine Fumarate (an antipsychotic medication) 50 milligrams (MG) by mouth in the morning related to unspecified anxiety disorder and unspecified recurrent major depressive disorder; and give two tablets by mouth at bedtime related to unspecified anxiety disorder and unspecified recurrent major depressive disorder.Review of the facility Pharmacy Consultant monthly drug regimen reviews for Resident #3 dated 7/20/25, 8/15/25, 8/18/25, 9/21/25, and 10/21/25, revealed no documentation of the need for the facility to complete AIMS assessments.b. Resident #30 was readmitted on [DATE] with diagnoses including dementia with behaviors and generalized anxiety disorder.Review of the physician order initiated on 6/13/24 documented an order to give one Olanzapine (antipsychotic) 2.5 milligrams (MG) tablet by mouth at bedtime related to unspecified dementia, unspecified severity with other behavioral disturbances.Resident #30's medical record documented one AIMS assessment on file dated 3/10/25 since the last recertification survey completed on 9/19/24.Review of the facility Pharmacy Consultant monthly drug regimen reviews for Resident #5 dated 8/19/25, 9/23/25, and 10/29/25 revealed no documentation of the need for the facility to complete AIMS assessments.During an interview on 11/19/25 at 3:45 PM, the Pharmacy Consultant stated she did not think the AIMS assessments still needed to be completed for residents prescribed antipsychotic medications. The Pharmacy Consultant communicated she rarely looked at the AIMS assessment unless one of the staff members informed her that a resident could be having side effects. The Pharmacy Consultant expressed she had not seen an AIMS assessment form in any of the residents' records.An interview with the Director of Nursing (DON) on 11/19/25 at 2:30 PM revealed she was unaware if the Pharmacy Consultant reviewed the residents' medical records for AIMS assessments during her monthly medication review. The DON indicated the Administrator reviewed the Pharmacy Consultant's report every month.On 11/20/25 at 9:55 AM an interview occurred with the Medical Director. He stated he was not aware if the Pharmacy Consultant performed complete medical record reviews that would include reviewing for the completion of AIMS assessments.An interview occurred with the Facility Physician on 11/20/25 at 10:22 AM. The Facility Physician was made aware that the Consultant Pharmacist was not reviewing resident medical records for AIMS assessments. He stated he was unaware the Pharmacy Consultant was not performing complete medical record reviews. The Facility Physician stated he would expect the Pharmacy Consultant to review the entire medical record during each monthly medical record review.An interview was held with the Administrator on 11/20/25 at 11:46 AM. The Administrator discussed being unaware that the Pharmacy Consultant was not reviewing the residents' medical records for an AIMS assessment. She stated she expected the Pharmacy Consultant would identify and report irregularities including the need for AIMS assessments during the monthly drug regimen reviews. The Administrator stated she did review the monthly Pharmacy Consultant reports but did not realize the Pharmacy Consultant was not reviewing for the AIMS assessments.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure a resident call light system was accessible for 1 of 3 residents (Resident # 28) observed for call light system.The findings included: Resident # 28 was admitted to the facility on [DATE] with multiple diagnoses that included absence of left leg above the knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 28 was assessed as cognitively intact. Resident #28 was independent for transfers, bed mobility, and toileting.An observation of Resident # 28's bathroom was conducted on 11/18/2025 at 12:05 pm. The call light in the bathroom did not have an attached pull cord.Resident # 28 was interviewed on 11/18/2025 at 12:42 pm. The resident stated he was independent with Activities of Daily Living (ADL) which included getting out of bed, transferring, and using the toilet. Resident # 28 confirmed there was no pull cord for the call light in the bathroom and stated he could not remember the last time the call light had a pull cord. He also stated if he was lying on the floor, he would be unable to use the call light for assistance. Another observation of Resident #28's bathroom occurred on 11/19/2025 at 1:35 pm. The call light in the bathroom did not have an attached pull cord.An observation of Resident # 28's bathroom was conducted on 11/20/2025 at 8:45 am. The call light in the bathroom did not have an attached pull cord.During an interview on 11/19/2025 at 2:30 PM with Nursing Assistant (NA) #6, the NA stated Resident # 28 was able to complete all ADL independently but needed assistance with showers. An interview occurred on 11/19/2025 at 4:15pm with NA #1. She stated Resident # 28 did not ask for assistance with grooming, toileting and transferring because he was able to complete the tasks on his own. An interview occurred on 11/20/2025 8:45AM with Occupational Therapist (OT) #1. She stated Resident # 28 was independent in daily care items such as, transferring from wheelchair to bed / toilet. An interview with the Facility Maintenance Director on 11/20/2025 at 8:50 am revealed the facility had a preventative maintenance program but they had been unable to complete the preventative maintenance. He stated he was unaware of the lack of the call light pull cord in Resident # 28's bathroom. The Facility Maintenance Director stated if staff did not call him or placed the repair needed in the engineering book at the nurse's station he would not know of the concern. Observation of the engineering book on 11/20/2025 at 9:10 am revealed that from 10/1/2025 through 11/20/2025 no service request was placed in the book for a replacement of the pull cord on the call light in Resident # 28's bathroom.An interview with the facility Environmental Service Manager on 11/20/2025 at 10:10 am revealed she utilized weekly checklist to review all rooms. She stated the checklist did not address the call lights and pull cords. She observed Resident # 28's bathroom on her weekly rounds on 11/19/2025 but did not notice the pull cord was missing from the call light. The Environmental Service Manager stated if she had noticed the pull cord was missing, she would have called maintenance to fix it.An interview with the Director of Nursing (DON) on 11/20/2025 at 9:15 am revealed that she was unaware the call light did not have a pull cord and that if a resident was on the floor they would have to yell out as the call light would be unavailable. The DON stated if she was aware of the missing pull cord she would have contacted maintenance to have it replaced. During an interview with the Administrator on 11/20/2025 at 9:40 am, the Administrator stated staff communicated with the maintenance department by writing in the engineering book at the nurse's station or if the area needed an immediate response staff would call maintenance directly. She stated staff would have been expected to call maintenance with a missing pull cord for the call light system.

Based on record review, and staff interviews, the facility failed to post accurate daily nurse staffing information for 30 of 30 days reviewed (10/20/25, 10/21/25, 10/22/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, 11/1/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, 11/17/25, and 11/18/25). The findings included: A review of the daily nurse staffing sheets dated 10/20/25 to 11/18/25 revealed:- The Registered Nurse (RN)/Licensed Practical Nurse (LPN) designation was not indicated for the assigned nurses. -The census was not listed and left blank for the morning (7:00 AM- 3:00 PM) and evening shifts (3:00 PM- 11:00 PM) for 10/21/25, 10/26/25, 10/27/25, 10/30/25, 11/5/25, 11/13/25, 11/16/25, and 11/18/25. -The census was also not listed and left blank for the evening shifts (3:00 PM- 11:00 PM) for 10/20/25, 10/23/25, 10/24/25, 10/25/25, 10/28/25, 10/29/25, 11/3/25, 11/4/25, 11/6/25, 11/10/25, 11/11/25, 11/12/25, 11/14/25, 11/15/25, and 11/17/25. An interview conducted with Nurse #1 on 11/21/25 at 9:11 AM revealed she was trained on how to complete the daily staffing report during her orientation with an LPN preceptor. Her employment started in April 2025. She was aware that all areas on the form needed to be completed. However, she only documented the census for the 11:00 PM to 7:00 AM shift because the number could change with the other shifts. Nurse #1 stated she was not aware the designation of RN and LPN needed to be listed beside each nurse's name. An Interview held with the Director of Nursing (DON) on 11/21/25 at 11:41 AM revealed she was unsure how training was completed for the nurses completing the daily staffing report. She stated it was always completed before she arrived at work in the mornings. The DON also stated she was not aware that the census needed to be fully completed. She thought it was per day, not per shift. However, this facility's report was always completed by the night shift nurse. She was not sure if the designation between RN/LPN was a state thing or a facility process. An interview with the Administrator on 11/21/25 at 11:04 AM indicated the nurses received training on completing the daily staffing report during orientation with their preceptor. The Administrator stated all areas of the report should be completed including the census. She also stated each nurse should have their designation listed next to their name determining whether they were an RN or LPN. The Administrator stated education would be provided to staff on how to correctly complete the daily staffing report and was not sure why the daily staffing report was being completed incorrectly.

Based on staff interview and record review, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) as required for quarter three of fiscal year (FY) 2023 (April 1- June 30, 2023). This failure occurred for 1 of 4 quarters reviewed. The findings included: A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ Staffing Data for quarter three of FY 2023. According to CASPER the data was not submitted. On 8/12/24 at 11:03 AM an interview with the Administrator indicated she was responsible for submitting PBJ data to CMS and was aware the PBJ staffing submission was late for quarter three FY 2023. The Administrator further revealed the data was submitted one day late due to staff changes.

Based on record review and staff interviews, the facility failed to have a documented water management program for Legionella. Failure to have a water management program had the potential to affect 34 of 34 residents in the facility. The findings included: Review of the facility's Emergency Preparedness Plan last reviewed by the facility on 2/17/2024 and Infection Control policies revealed no evidence of a water management program for Legionella. Interview with the Infection Preventionist (IP) on 8/12/24 at 1:13 PM revealed the IP was unsure about any written water management program for Legionella. Interview with the Administrator on 8/12/24 at 1:24 PM revealed it was the IP that oversaw water management. Further interview revealed the Maintenance Director did not have any knowledge in water management. She further revealed there was not a specific Legionella water management program to follow. The Administrator indicated it should have been her overseeing the IP and water management programs. The Administrator explained there should have been a written Legionella water management program to follow.

Based on observations and staff interviews, the facility failed to dispose of expired nutritional supplements and failed to dispose of expired individually packaged cartons of juice from 1 of 1 nourishment room. The findings included: Observations of the nourishment room on [DATE] at 11:42 AM and on [DATE] at 10:40 AM revealed the following: a. Nine (2.5 ounce) bottles of a protein supplement on the dry storage rack with a use by date of [DATE]. b. Six (2.5 ounce) bottles of a protein supplement in the refrigerator with a use by date of [DATE]. c. Ten (4 ounce) containers of prune juice in the freezer with a best by date of [DATE]. Dietary Aide #1 was interviewed on [DATE] at 10:43 AM, while she stocked the nourishment room. She explained the dietary department checked for expiration dates prior to stocking food and drink items in the nourishment room but had not checked dates for expiration after food and drink items were placed in the nourishment room. During an interview with the Unit Secretary on [DATE] at 10:46 AM, she stated dietary staff came to the unit daily and stocked the nourishment room and refrigerator. She thought dietary staff checked dates for expiration when they re-stocked the nourishment room. On [DATE] at 10:50 AM an interview was conducted with the Administrator. She had recently removed the protein supplements from the nourishment room since they had expired and didn't know why they were back in the dry storage area and refrigerator. She said the dietary department stocked the nourishment room. She added the night shift nursing staff checked the temperature in the refrigerator each night, and after reviewing information with nursing staff, verified that no one had consistently checked for expired foods in the nourishment room.

Based on staff interviews and medical record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the Assessment Reference Date (ARD) of the previous MDS assessment for 4 of 10 residents (Residents #9, #37, #14 and #2) reviewed for timely completion of MDS assessments. Findings included: 1. Resident #9 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident #9 revealed the last assessment completed was a quarterly assessment completed on 10/12/22. No other MDS assessments had been completed since 10/12/22. 2. Resident #37 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident #37 revealed the last assessment completed was a quarterly assessment completed on 10/17/22. No other MDS assessments had been completed since 10/17/22. 3. Resident #14 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident #14 revealed the last assessment completed was a quarterly assessment completed on 10/13/22. No other MDS assessments had been completed since 10/13/22. 4. Resident #2 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS) assessments for Resident #37 revealed the last assessment completed was a quarterly assessment completed on 10/30/22. No other MDS assessments had been completed since 10/30/22. During an interview with the Administrator on 3/9/23, she stated that the previous MDS nurse left in November 2022 and she was aware that there were several assessments that were overdue. She stated that they had just hired a new MDS nurse and it was her expectation that they would complete all the assessments that were overdue first and then making sure they complete the required MDS assessments in a timely manner going forward.

Based on resident and staff interview and medical record review, the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 1 of 1 resident (Resident #31) reviewed for participation in care plans. The findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses that included, in part, hypertension and diabetes. A care plan conference attendance sheet dated 9/25/22 was reviewed and revealed the Minimum Data Set (MDS) nurse and Activities Director signed as having met and reviewed Resident #31's care plan. There was no documented evidence that the resident was invited to attend or participate in the care plan conference. The annual Minimum Data Set assessment dated [DATE] revealed Resident #31 had intact cognition. During an interview with Resident #31 on 3/06/23 at 11:15 AM, he stated he had not been invited to participate in care plan meetings. He said he would like to be included in the care plan process and added, I want to know what is going on with his care. On 3/07/23 at 1:25 PM and 3/8/23 at 10:27 AM, interviews were conducted with the Administrator. She explained that typically, care plan meetings were held on Wednesdays and residents and families were invited to attend. She shared the facility had been without a MDS nurse since December 2022 and there hadn't been an invitation to residents and families to attend care plan meetings. She added a new MDS nurse had been hired and began work on 2/27/23 and the facility would be re-instituting inviting residents and families to care plan meetings.

Based on record review, staff interviews and resident interviews the facility failed to accommodate the needs of 1 of 1 residents (resident #33) by not providing the resident a shower gurney or chair to fit the resident resulting in the resident receiving only bed baths for the last few months. Findings included: Resident #33 was admitted to the facility on [DATE] with multiple diagnoses to include history of stroke, osteoarthritis, atrial fibrillation, and coronary artery disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident was cognitively intact. Resident #33 was coded as total dependence with 2 staff members assisting for transfers. The latest weight documented for Resident #33 was 326 pounds on 2/14/23. During an interview with Resident #33 on 3/7/23, he stated that he had only been getting bed baths for several months and that he preferred to have a shower. He stated that the facility didn't have the equipment needed to get him out of bed, onto the shower gurney, and down to the shower room. He added that they tried to get him on the gurney again the other day but it came up on two wheels and the girls were afraid he would fall so they put him back to bed. During an interview with Nurse Aide #1 on 3/8/23, she stated that she and another aide did attempt to get Resident #33 out of bed and onto the shower gurney a couple days ago. She stated that, she was not sure what the weight limit was for the gurney. She stated the gurney came up on two wheels but did not turn over when they placed him on there. She added that she and the other aide decided to put him back in bed for safety reasons which they did without any further incident. She added that Resident #33 had been receiving bed baths for at least 2 months. She was unsure of the exact time period. During an interview with Nurse #1 on 3/8/23, she stated that Resident #33 had gained about 100 pounds over the last year due to poor diet and sedentary lifestyle. She stated he usually only got out of bed for outside doctor appointments and the staff would use a lift. Nurse #1 stated that she was made aware Resident #33 was only receiving bed baths when Nurse Aide #1 advised her of the near accident the prior day. She stated that the resident had gained a lot of weight over the last year and agreed that it was probably unsafe to try to transport him on the shower gurney. She added that they did have a shower chair but she was unsure if that would be suitable for him or not. During an interview with the Administrator on 3/9/23, she stated she was unaware that Resident #33 was only receiving bed baths and that he had stated that the facility did not have the equipment that allowed him to use the shower. She stated the weight limit for the shower gurney was 166 kilograms/326 pounds. She stated that they had a shower chair that may have worked for him and added that she planned on involving physical therapy to assess for safety. She stated that every resident had the right to receive a shower based on their preferences.

Based on staff interview and medical record review, the facility failed to complete an annual Minimum Data Set (MDS) comprehensive assessment within 366 days of the previous comprehensive assessment for 1 of 2 residents (Resident #18) reviewed for timely completion of annual MDS assessments. The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses that included, in part, diabetes, congestive heart failure and dementia. The admission MDS assessment with an assessment reference date of 1/5/22 was reviewed and revealed the assessment was signed as completed on 1/9/22. The most recent MDS assessment in the medical record was a quarterly review, completed on 10/3/22. Further review of the medical record demonstrated an annual MDS assessment had not been completed. An interview was completed with the Administrator on 3/8/23 at 2:48 PM. She stated the most recent MDS assessment completed on Resident #18 was a quarterly dated 10/3/22. She explained the resident's next assessment should have been an annual assessment dated [DATE] and it just got missed. The Administrator noticed the assessment had not been completed when she was asked to provide the most recent MDS assessment. She shared the facility had been without a full time MDS nurse since December 2022 and MDS assessments fell behind schedule. The Administrator said she helped with MDS assessments, and there was a part time employee and another nurse who completed MDS assessments as well.

Based on staff interviews and review of the daily nursing staff postings, the facility's daily posting failed to include the number of registered nurses (RNs) or licensed practical nurses (LPNs) for 30 of 30 days; failed to include the census for 18 of 30 days; and failed to include nurses and certified nursing assistants (CNAs) actual hours worked for 4 of 30 days. Additionally, the facility failed to complete the daily posting for 10 of 30 days. Findings included: 1. The daily nursing staff postings were reviewed for February 5-March 6, 2023. The postings indicated the name of the nurse who worked each shift but did not include a designation of RN or LPN. On 3/8/23 at 2:38 PM an interview was completed with the Administrator. She explained the third shift nurse completed the daily posting for the entire day, which included all three shifts. She said the posting did not include an option that designated whether the nurse scheduled to work was a RN or LPN. 2. The daily nursing staff postings were reviewed for February 5-March 6, 2023. The postings did not include the facility census on the following dates: 2/5/23-2/6/23, 2/9/23-2/10/23, 2/12/23, 2/14/23, 2/18/23, 2/23/23-2/24/23, 2/28/23-3/1/23, and 3/5/23 (7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts); 2/7/23-2/8/23, 2/13/23, 2/15/23, 3/3/23 and 3/6/23 (3:00 PM-11:00 PM shift). On 3/8/23 at 2:38 PM an interview was completed with the Administrator. She explained the third shift nurse completed the daily posting for the entire day, which included all three shifts. She said the facility needed to designate a charge nurse who completed/updated the daily posting on the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts so that it accurately reflected changes in the census and any staffing changes such as call outs or replacements. 3. The daily nursing staff postings were reviewed for February 5-March 6, 2023. The postings did not include actual hours worked for nurses and CNAs on the following dates: 2/7/23-2/8/23 and 3/3/23 (3:00-11:00 PM shift), and 2/12/23 (7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts). On 3/8/23 at 2:38 PM an interview was completed with the Administrator. She explained the third shift nurse completed the daily posting for the entire day, which included all three shifts. She said the facility needed to designate a charge nurse who completed/updated the daily posting on the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts so that it accurately reflected changes in the census and any staffing changes such as call outs or replacements. 4. The daily nursing staff postings were reviewed for February 5-March 6, 2023. No posting was completed for the following dates: 2/16/23-2/17/23, 2/19/23, 2/21/23-2/22/23, 2/25/23-2/27/23, 3/2/23 and 3/4/23. On 3/8/23 at 2:38 PM an interview was completed with the Administrator. She explained the third shift nurse completed the daily posting for the entire day, which included all three shifts. She said the facility needed to designate a charge nurse who completed/updated the daily posting on the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts so that it accurately reflected changes in the census and any staffing changes such as call outs or replacements.

Based on observations and staff interviews, the facility failed to, (a) provide a clean bedside commode that was causing a urine odor for 1 of 20 resident rooms (Room 217), (b) failed to repair holes exposing drywall in resident rooms for 2 of 20 resident rooms (Rooms 210 and 217) and, (c) failed to maintain walls at exit doors in good repair for 1 of 2 halls (North hall). The findings included: a. An observation on 7/8/21 at 9:36 AM revealed a bedside commode in Room 217 that was soiled with urine on the top of the lid, under the lid and the bucket. The commode lid had yellowish brown stains on it. The entire base of the bedside commode was covered with erosion. A strong urine odor was observed in the room. An observation on 7/9/21 at 11:53 AM revealed the urine odor remained in Room 217 and the bedside commode remained stained. On 7/9/21 at 12:03 PM, an interview was conducted with Housekeeper #1. She stated it was the nursing assistant ' s responsibility to clean the bedside commodes. She added the bedside commode in Room 217 was very old and some of the stains would not come off. Using a wet paper towel, Housekeeper #1 observed the surveyor remove some of the urine stains from the bedside commode. On 7/9/21 at 12:04 PM an interview was conducted with Nurse #1. She stated nursing assistants were responsible for cleaning the bedside commodes. She stated if they needed a new one, they went downstairs to get one, but they were hard to come by. On 7/9/21 at 1:11 PM, an interview was conducted with NA #1. She stated the empties the bedside commode for the resident in Room 217 and wipes it clean but, sometimes is unable to get it completely clean. b. An observation on 7/8/21 at 8:59 AM revealed two large holes exposing drywall behind the A bed in Room 210. An observation on 7/8/21 at 9:36 AM revealed two holes exposing drywall behind the A bed in Room 217. On 7/9/21 at 2:30 PM, Housekeeper #2 was interviewed. She stated the holes in the wall behind the bed in Room 210 were there for a little while and she recalled letting her supervisor know. She stated she wrote things down when she found things that needed to be repaired in the resident rooms. On 7/9/21 at 1:18 PM, an interview was conducted with the Maintenance Director. He stated he has submitted 4 different options to the Quality Assessment and Performance Improvement Committee regarding renovating rooms and correcting things like holes in the walls. He further stated it has been discussed frequently but budget concerns prevent action. The maintenance director observed the holes in Room 210 and stated he was unaware of the holes in the room. He added he and his assistant conduct daily room rounds. c. An observation on 7/9/21 at 2:27 PM revealed the wall near the North hall exit door had areas of exposed drywall where the baseboard was pulled away from the wall. There was areas of cracked drywall up the right and left sides of the wall beside the door.

Based on observations, record review and staff interview, the facility failed to follow care plan interventions for a resident at risk for pressure ulcers for 1 of 12 sampled residents (Resident #18). The findings included: Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set assessment dated [DATE] revealed Resident #18 had severely impaired cognition. Resident #18 required total assistance of 2 people with bed mobility and transfers and was incontinent of bowel and bladder. He had a risk for pressure ulcers but had no current pressure ulcers and utilized a pressure relieving device to his bed. The Care Area Assessment indicated pressure ulcers would be care planned. The care plan, updated on 5/27/21, revealed a problem for pressure ulcer risk. An intervention included heel protectors while in bed. An assessment used to determine pressure ulcer risk dated 5/26/21 revealed Resident #18 was at high risk for developing pressure ulcers. A review of Resident #18 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] An observation on 7/8/21 at 9:36 AM revealed Resident #18 lying in bed with his heels directly on the mattress. There were not heel protectors on Resident #18. An observation on 7/9/21 at 11:53 AM revealed Resident #18 lying in bed with his heels directly on the mattress. There were not heel protectors on Resident #18. On 7/9/21 at 1:57 PM, an interview was conducted with NA #1. NA #1 was asked by the surveyor where Resident #18 ' s heel protectors were. NA #1 was observed looking around Resident #18 ' s room and inside his drawers and closet. NA #1 was unable to locate Resident #18 ' s heel protectors. She stated she did not know where they were, and they may have gone to the laundry and not returned to Resident #18 ' s room.

Based on record review and staff interviews, the facility failed to maintain an accurate medical record in the area of medications for 1 of 5 residents (Resident #32) reviewed for unnecessary medications. The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #32 ' s physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A monthly physician ' s progress note dated 5/26/21 revealed Resident #32 ' s current medications were listed as follows: [MEDICATION(S)] 10 milligrams at bedtime, [MEDICATION(S)] 50 milligrams daily, [MEDICATION(S)] SR 150 milligrams every 12 hours, tylenol 500 milligrams every 6 hours as needed, [MEDICATION(S)] 5 milligrams at bedtime, aspirin [MEDICATION(S)] coated 81 milligrams daily, [MEDICATION(S)] 100 milligrams daily, [MEDICATION(S)] 300 milligrams twice a day, [MEDICATION(S)] 1 gram three times a day before meals, vitamin b-12 1,000 milligrams daily, [MEDICATION(S)] 0.25 milligrams daily as needed, [MEDICATION(S)] 500 milligrams at noon and supper, [MEDICATION(S)] 100 milligrams daily, [MEDICATION(S)] 80 milligrams half tablet every other day, [MEDICATION(S)] 70 milligrams weekly, [MEDICATION(S)] 5 milligrams daily, [MEDICATION(S)] 50 milligrams as needed, vitamin d 3 1.25 milligrams weekly, [MEDICATION(S)] 5 milligrams at bedtime as needed, [MEDICATION(S)] 75 milligrams daily, [MEDICATION(S)] 14milligrams/24 hour patch every 24 hours, [MEDICATION(S)] sulfate 108 micrograms aerosol powder 2 puffs as needed, [MEDICATION(S)] 8 milligrams twice a day as needed. An acute physician ' s progress note dated 6/16/21 revealed no changes in the listed medications Resident #32 currently received. On 7/9/21 at 10:44 AM, Nurse #2, who made rounds with the physician, was interviewed. She stated when the physician made monthly resident visits, they went through the chart and updated the resident ' s medications and made other necessary changes. She did not know why Resident #32 ' s medications were not updated.

Based on record review and staff interview the facility failed to protect a resident's right to be free from physical abuse when a nurse aide hit residents during the provision of care for 2 (Resident #1 and Resident #3) of 5 sampled residents reviewed for abuse. As a result of Nurse Aide #2's physical abuse Resident #1 experienced a deep purple bruise on her hand with additional bruises on her hands and arms and Resident #3 experienced a deep purple bruise on her left ring finger with multiple bruises on her arms. Findings included: 1. Resident #1 had cumulative diagnoses, some of which included dementia, adult failure to thrive, and [MEDICAL CONDITION]. A quarterly minimum data set assessment dated [DATE] coded Resident #1 as having severely impaired cognition with no behaviors or rejection of care. The assessment coded the resident as dependent on two people for bed mobility, dressing, hygiene, bathing, toilet use, in addition to being incontinent of both bowel and bladder. An interview was conducted with the former Director of Nursing (DON) on 3/13/20 at 12:17 PM. The DON explained that on the morning of 9/30/19 she was contacted by an employee of the facility at approximately 8:30 AM revealing nurse aide (NA #1), who had worked 11:00 PM to 7:00 AM on 9/29/19 to 9/30/19, had witnessed abusive behavior by a nurse aide (NA #2). The former DON stated she instructed the employee to have NA #1 write down what happened and to return to the facility to give a statement. The former DON indicated she informed the Administrator of the abuse allegations that were made. The former DON indicated NA #1 returned to the facility with her statement on 9/30/19 at approximately noon and was subsequently interviewed in the presence of the DON, Administrator, and the minimum data set assessment (MDS) coordinator. The statement written by NA #1, was signed and dated 9/30/19, stated in part, While I was changing (Resident #6), (NA #2) was changing (Resident #1). (NA #2) pulled the curtain between the two residents, but I could still see her in the mirror. Although (Resident #1) was combative per usual, I noticed when (Resident #1) would swing and hit (NA #2) that she would swing and hit back. I saw her mostly towards her arms and hands which seemed as if she was trying to get (Resident #1) to stop, but in a hateful way. When I finished with (Resident #6), I went to dump the dirty linen/brief into the cart. I came back into the room to her (NA #2) saying, I just realized I didn't put these pillows back under her feet, but honestly I don't give a (expletive) right now and she walked out. Documentation of the 9/30/19 interview by the former DON, Administrator, and the MDS coordinator conducted at 12:50 PM with NA #1 revealed, When we went into (Resident #1's) room, (NA #2) told me to change (Resident # 6). I could see in the mirror that (Resident #1) was trying to fight her and (Resident #1) don't like to be touched. I heard (Resident #1) say get off me and stop hitting me. I could see her hitting back at (Resident #1). The pillows are usually under (Resident #1's) feet and she had not put them there. (NA #2) commented, I don't give a (expletive) now and walked away. (NA # 1) thought (Resident #1) looked scared. NA #1 was interviewed on 3/13/20 at 2:18 PM. NA #1 indicated that she was in initial facility training on 9/29/19 to 9/30/19 and the 11:00 PM to 7:00 AM shift which was the first time she had trained on that shift. NA #1 confirmed the accuracy of her written statements and that she saw NA #2 hit Resident #1 on the arms and hands on 9/30/19. Documentation of an interview on 9/30/19 at 7:10 PM revealed NA #2 was questioned as to the etiology of unknown bruises on Resident #1 and if anything, out of the ordinary occurred on her shift on 9/29/19 to 9/30/19. The documentation of the response by NA #2 stated in part, (Resident #1 name) is not really hitting me, nothing out of the ordinary and The residents who had bruising are (Resident #1) and (Resident #3). (Resident #1) has a large bruise on her right hand. (NA #2) responded that (Resident #1) and (Resident #3) always have bruises. I can't think of a time when they don't have a bruise. For (Resident #1) If I had bruised her it would be red. I don't grab her by the hands, I use her shoulders and waist to turn her. I don't think she would keep (geriatric) sleeves on to help her bruising. The documentation in the interview with NA #2 on 9/30/19 indicated NA #2 was suspended after the interview pending a full investigation. NA #2 was interviewed on 3/14/20 at 2:06 PM. NA #2 revealed that on the 11:00 PM to 7:00 AM shift on 9/29/19 to 9/30/19, she was training a new nurse aide (NA #1). NA #2 explained that it took two to three hours to do incontinent care rounds and she was very tired on that day. NA #2 further explained that she did see the bruises on Resident #1 on her shift, but she was sure someone else had seen them and reported them. NA #2 recalled that she had bothered the nurse (Nurse #3) on the unit about many other concerns on that shift and she did not want to bother him again. NA #2 indicated she did her first incontinent rounds when she arrived at 11:30 PM. NA #2 indicated she did not initially notice the bruising on Resident #1 on the first incontinent care rounds but did notice the bruising on the second incontinent care rounds she made in the early morning hours. NA #2 confirmed the bruising was two to three black purple tinted bruises on the right hand of Resident #1. NA #2 confirmed she did not report the bruising on Resident #1 to Nurse #2 on 9/30/19. NA #2 stated that Resident #1 would hit at her sometimes but that she took the time to try to explain to Resident #1 what she was doing while providing care. Nurse #3, who was working on the 11:00 PM to 7:00 AM shift on 9/29/19 to 9/30/19, was interviewed on 3/14/20 at 6:25 AM. Nurse #3 stated that he had seen NA #2 be a little rough with the residents in the past, but he had never seen NA #2 hit any of the residents. Nurse #3 revealed he did not see the bruising on Resident #1 on the morning of 9/30/19 but saw them after the fact. Nurse #3 revealed he thought NA #2 was more verbally abusive than physically abusive to the residents. When asked why he did not say anything to a supervisor, Nurse #3 replied that he thought they already knew. An interview was conducted with the interim DON/MDS coordinator on 3/13/20 at 12:45 PM. The interim DON/MDS coordinator revealed that after the administrative interview with NA #1 on 9/30/19 at 12:50 PM, a skin assessment was completed for Resident #1. The interim DON/MDS coordinator indicated the skin assessment revealed bruising on the right upper arm, right hand, and the left forearm of Resident #1. The interim DON/MDS coordinator further stated that the nursing staff members who worked on the 7:00 AM to 3:00 PM shift and the 3:00 PM to 11:00 PM shift on 9/29/19 were interviewed regarding any bruising on Resident #1 on those shifts. The interim DON/MDS Coordinator stated no one who worked on these shifts stated they observed any bruising on Resident #1. A problem focused charting - altered skin integrity report by Nurse #4 dated 9/30/19 at 3:30 PM documented Resident #1 had bruising 6 centimeters in length by 4 centimeters in width on the right hand. There were no other further details on the report. Nurse #4 was interviewed on 3/19/20 at 11:35 AM regarding her observations on 9/30/19 of the skin assessment for Resident #1. Nurse #4 revealed she was asked by the DON to complete documentation on the bruising the DON had observed on Resident #1. Nurse #4 stated she was a little overwhelmed because the local authorities were taking pictures of Resident #1 and she knew an investigation was being initiated. Nurse #4 admitted she did not fill out the paperwork on the problem focused charting - altered skin integrity sheet for Resident #1 dated 9/30/19 as completely as she could have. Nurse #4 elaborated and described scattered bruises on the hand, right upper arm, and left forearm of Resident #1. Nurse #4 stated that her major focus was on a large deep purple bruise on the resident's right hand. Nurse #1, who worked on the 7:00 AM to 7:00 PM shift on 9/29/19 on the unit which Resident #1 resided, was interviewed on 3/13/20 at 2:34 PM. Nurse #1 stated there was no new bruising on Resident #1 on 9/29/19. Nurse #1 revealed that Resident #1 sometimes had small bruises on her hands and forearms, but she did not have any new or any major bruising to her arms on her shift on 9/29/19. Nurse #2, who worked 3:00 PM to 11:00 PM on 9/29/19, was interviewed on 3/13/20 at 2:00 PM. Nurse #2 indicated she was not notified of any bruising nor did she notice any bruising on Resident #3 during her shift on 9/29/19. Nurse aide (NA #3), who worked on the 3:00 PM to 11:00 PM shift on 9/29/19 on the hall which Resident #1 resided, was interviewed on 3/13/20 at 2:08 PM. NA #3 was adamant that there was no bruising on Resident #1 during his shift on 9/29/19. Nurse aide (NA #4), who worked on the 3:00 PM to 11:00 PM shift on 9/29/19 on the hall which Resident #1 resided, was interviewed on 3/13/20 at 3:29 PM. NA #4 indicated she worked with NA #3 on the hall for which Resident #1 resided on 9/29/19. NA #4 confirmed that she did not notice any bruising to Resident #1 on her shift on 9/29/19. The Administrator was interviewed on 3/13/20 at 11:39 AM. The Administrator indicated that after the allegations were made, the bruising on Resident #1 observed, and staff interviews were made, the evidence pointed to abuse that could not be discounted. The Administrator stated that the resident was prone to bruising but the extensive bruising discovered on 9/30/19 on her right upper arm, left forearm, and the bruising on the right hand could not be explained away as accidental or self-inflicted. The Administrator revealed that NA #2 was suspended during the initial investigation but was terminated on 10/7/20 after providing a statement regarding the events on 9/30/19. The Administrator was interviewed again on 3/14/20 at 12:47 PM. The Administrator revealed and reviewed the steps taken after the allegation of abuse of Resident #1 was made at the facility. The Administrator revealed local law enforcement was contacted along with the state division of health service regulation on 9/30/19. The residents in the long-term care unit were interviewed by the facility social worker by 10/1/19. The social worker questioned all the residents regarding their perceived safety, disrespect from staff, and if staff had hurt them. Any concerns expressed by the residents were followed up by the Director of Nursing. A retrospective analysis of the 2019 reported bruises and injuries of unknown origin was completed on 10/3/19 by the risk manager to determine if any patterns of potential abuse could be identified. Skin assessments of the residents were completed by 10/4/19. The facility immediately interviewed and took statements from all the nursing staff members who had worked on 9/29/19 and 9/30/19 in the long-term care unit. The facility additionally interviewed and took statements from additional nursing co-workers of NA #2. All the interviewed staff members were received immediate retraining on the abuse policies and procedures for the facility focusing on the reporting aspect of the training. The Administrator revealed all the nursing staff working in the long-term care unit were retrained in the abuse policies and procedures as of 10/4/19. The entire staff, to include volunteers, was retrained on the abuse policies and procedures in November and December 2019. The Administrator explained that prior to the retraining of the entire staff, the abuse policies and procedure training was redone and updated to emphasize the importance of the information. The Administrator explained and provided documentation of discussion in the patient safety organization committee held on 10/17/19 regarding bruising of unknown origin. Quality assurance performance improvement committee meetings were held on 10/14/19 and 11/19/19 during which discussion and review of continued abuse training for the staff as well as the details of extra elements of safety for the long-term care residents. The Administrator confirmed the investigation and the retraining of the staff on abuse policies and procedures was completed as of 10/4/19. 2. Resident #3, admitted on [DATE], had cumulative [DIAGNOSES REDACTED]. Documentation on the quarterly minimum data set assessment dated [DATE] coded the resident as severely cognitively impaired with physical behavioral symptoms one to three days of the assessment period. Documentation on the same assessment specified the resident required total care assistance of two staff members with bed mobility, transfers, dressing, toilet use, personal hygiene, bathing in addition to being incontinent of both bowel and bladder. The care plan for Resident #3, reviewed on 9/26/19, revealed a problem area for behavioral symptoms of combativeness toward staff at times with yelling, cursing, throwing food, and pinching staff. Documentation of the interventions revealed multiple interventions some of which included: Always approach resident calmly and unhurriedly and speak in a calm voice and If appropriate, stop giving care when resident is hostile and try again later. An interview was conducted with the former Director of Nursing (DON) on 3/13/20 at 12:17 PM. The DON explained that on the morning of 9/30/19 she was contacted by an employee of the facility at approximately 8:30 AM revealing nurse aide (NA #1), who had worked 11:00 PM to 7:00 AM on 9/29/19 to 9/30/19, had witnessed abusive behavior by a nurse aide (NA #2). The former DON stated she instructed the employee to have NA #1 write down what happened and to return to the facility to give a statement. The former DON indicated she informed the Administrator of the abuse allegations that were made. The former DON indicated NA #1 returned to the facility with her statement on 9/30/19 at approximately noon and was subsequently interviewed in the presence of the DON, Administrator, and the minimum data set assessment (MDS) coordinator. The statement written by NA #1, signed and dated 9/30/19, stated in part, When I finished with (Resident #7) and (Resident #8), I go into help finish and put (Resident #3) on the Hoyer (lift), so she (Resident #3) would be up for the day. Once we got her (Resident #3) into the chair, she (NA #2) asked me if she had a comb which I went out and combed her hair. While she (NA #2) changed (Resident #3) in the hall, I was making up (Resident #3's) bed and I could see from the corner of my eye that (Resident #3) was trying to hit (NA #2), but it seemed as if (NA #2) was hitting (Resident #3) back stating, You better not start with me today, quit hitting me, I'm not in the mood. Documentation of the 9/30/19 interview by the former DON, Administrator, and the MDS coordinator conducted at 12:50 PM with NA #1 revealed, The other hall is when she (NA #2) started hitting them. (Resident #3) - Put shirt on and (NA #2) said bring the comb to do her hair. (Resident #3) was angry and swings arms to swat away at staff and (NA #2) swung back at her and commented, You better not start with me today. NA #1 was interviewed on 3/13/20 at 2:18 PM. NA #1 indicated that she was in initial training on 9/29/19 to 9/30/19 and the 11:00 PM to 7:00 AM shift was the first time she had trained on that shift. NA #1 confirmed the accuracy of her written statements and that she saw NA #2 swing at Resident #3 hitting her arms and hands on 9/30/19. Documentation of an interview on 9/30/19 at 7:10 PM revealed NA #2 was questioned as to the etiology of unknown bruises on Resident #2 and if anything, out of the ordinary occurred on her shift on 9/29/19 to 9/30/19. The documentation of the response by NA #2 stated in part: (Resident #3) swats but I don't hit back or anything; The residents who had bruising are (Resident #1) and (Resident #3). (Resident #1) has a large bruise on her right hand. (NA #2) responded that (Resident #1) and (Resident #3) always have bruises. I can't think of a time when they don't have a bruise; and (Resident #3) always swats at us when we are getting her ready in the morning. The documentation in the interview with NA #2 on 9/30/19 indicated NA #2 was suspended after the interview pending a full investigation. NA #2 was interviewed on 3/14/20 at 2:06 PM. NA #2 revealed that on the 11:00 PM to 7:00 AM shift on 9/29/19 to 9/30/19, she was training a new nurse aide (NA #1). NA #2 explained that it took two to three hours to do incontinent care rounds and she was very tired on that day. NA #2 insisted Resident #3 always had bruises on her hands because the resident fights with the staff every day. NA #2 stated Resident #3 was well documented in the nursing notes as hitting the nurse aides. NA #2 insinuated that she was being unfairly judged for bruising on Resident #3 that was always there. NA #2 insisted that she did report the bruising when she saw it. Nurse #3, who was working on the 11:00 PM to 7:00 AM shift on 9/29/19 to 9/30/19, was interviewed on 3/14/20 at 6:25 AM. Nurse #3 stated that he had seen NA #2 be a little rough with the residents in the past, but he had never seen NA #2 hit any of the residents. Nurse #3 revealed he thought NA #2 was more verbally abusive than physically abusive to the residents. When asked why he did not say anything to a supervisor, Nurse #3 replied that he thought they already knew. Nurse #3 confirmed Resident #3 was combative at times and needed to be left alone to calm down. Nurse #3 stated he was not aware of the bruising on Resident #3 on 9/30/19. An interview was conducted with the interim DON/MDS coordinator on 3/13/20 at 12:45 PM. The interim DON/MDS coordinator revealed that after the administrative interview with NA #1 on 9/30/19 at 12:50 PM, a skin assessment was completed for Resident #3, revealing bruising on the arms and hands of Resident #3. The DON/MDS coordinator further stated that the nursing staff members who worked on the 7:00 AM to 3:00 PM shift and the 3:00 to 11:00 PM shift on 9/29/19 were interviewed regarding any bruising on Resident #3 on those shifts. The former DON lamented that it was determined it was the cognitively impaired residents, the most vulnerable, who were injured by NA #2. Documentation on a problem focused charting - altered skin integrity report dated 9/30/19 at 3:30 PM revealed, scattered bruising on bilateral arms and hands on Resident #3. There were no other further details on the skin assessment. Nurse #4 was interviewed on 3/19/20 at 11:35 AM regarding her observations on 9/30/19 of the skin assessment for Resident #3. Nurse #4 revealed she was asked by the DON to complete documentation on the bruising the DON had observed on Resident #3. Nurse #4 stated she was a little overwhelmed because the local authorities were taking pictures of Resident #3 and she knew an investigation was being initiated. Nurse #4 revealed she did not know why she did not chart further documentation on the bruising. Nurse #4 described scattered bruising on the upper forearms of Resident #3 that she saw on 9/30/19. Nurse #4 stated she saw three bruises on the right arm and three bruises on the left arm. Nurse #4 stated she saw a deep purple bruise on the ring finger of left hand of Resident #3. Nurse #1, who worked on the 7:00 AM to 7:00 PM shift on 9/29/19 on the unit which Resident #1 resided, was interviewed on 3/13/20 at 2:34 PM. Nurse #1 stated Resident #3 did not have the bruising on her arms and hands on her shift on 9/29/19 and she did not see the bruising on Resident #3 until she returned to work on 10/2/19. Nurse #1 did confirm that Resident #3 would hit at the nurse aides who were attempting to provide care. Nurse #2, who worked 3:00 PM to 11:00 PM on 9/29/19, was interviewed on 3/13/20 at 2:00 PM. Nurse #2 indicated she was not notified of any bruising nor did she notice any bruising on Resident #3 during her shift on 9/29/19. Nurse aide (NA #3), who worked on the 3:00 PM to 11:00 PM shift on 9/29/19 on the hall which Resident #3 resided, was interviewed on 3/13/20 at 2:08 PM. NA #3 confirmed there was no bruising on Resident #3 during his shift on 9/29/19. NA #3 revealed Resident #3 was calm on his shift on 9/29/19. Nurse aide (NA #4), who worked on the 3:00 PM to 11:00 PM shift on 9/29/19 on the hall which Resident #3 resided, was interviewed on 3/13/20 at 3:29 PM. NA #4 indicated she worked with NA #3 on the hall for which Resident #3 resided on 9/29/19. NA #4 confirmed that she did not notice any bruising to Resident #3 on her shift on 9/29/19. The Administrator was interviewed on 3/13/20 at 11:39 AM. The Administrator indicated that after the allegations were made, the bruising on Resident #3 observed, and staff interviews were made, the evidence pointed to abuse that could not be discounted. The Administrator indicated that the bruising between the fingers of Resident #3 could not be explained away as accidental. The Administrator revealed that NA #2 was suspended during the initial investigation but was terminated on 10/7/20 after providing a statement regarding the events on 9/30/19. The Administrator was interviewed again on 3/14/20 at 12:47 PM. The Administrator revealed and reviewed the steps taken after the allegation of abuse of Resident #3 was made at the facility. The Administrator revealed local law enforcement was contacted along with the state division of health service regulation on 9/30/19. The residents in the long-term care unit were interviewed by the facility social worker by 10/1/19. The social worker questioned all the residents regarding their perceived safety, disrespect from staff, and if staff had hurt them. Any concerns expressed by the residents were followed up by the Director of Nursing. A retrospective analysis of the 2019 reported bruises and injuries of unknown origin was completed on 10/3/19 by the risk manager to determine if any patterns of potential abuse could be identified. Skin assessments of the residents were completed by 10/4/19. The facility immediately interviewed and took statements from all the nursing staff members who had worked on 9/29/19 and 9/30/19 in the long-term care unit. The facility additionally interviewed and took statements from additional nursing co-workers of NA #2. All the interviewed staff members were received immediate retraining on the abuse policies and procedures for the facility focusing on the reporting aspect of the training. The Administrator revealed all the nursing staff working in the long-term care unit were retrained in the abuse policies and procedures as of 10/4/19. The entire staff, to include volunteers, was retrained on the abuse policies and procedures in November and December 2019. The Administrator explained that prior to the retraining of the entire staff, the abuse policies and procedure training was redone and updated to emphasize the importance of the information. The Administrator explained and provided documentation of discussion in the patient safety meeting held on 10/17/19 regarding bruising of unknown origin. Quality assurance performance improvement committee meetings were held on 10/14/19 and 11/19/19 during which discussion and review of continued abuse training for the staff as well as the details of extra elements of safety for the long-term care residents. The Administrator confirmed the investigation and the retraining of the staff on abuse policies and procedures was completed as of 10/4/19.

Based on staff interview and record review the facility failed to report to the state agency within the two-hour required time frame allegations of a staff member physically abusing two (Resident #1 and Resident #3) of five sampled residents reviewed for abuse. Findings included: 1. Resident #1 had cumulative diagnoses, some of which included dementia, adult failure to thrive, and [MEDICAL CONDITION]. Documentation on a quarterly minimum data set assessment dated [DATE] coded Resident #1 as having severely impaired cognition with no behaviors or rejection of care. Documentation on the same assessment coded the resident as dependent on two people for bed mobility, dressing, hygiene, bathing, toilet use, in addition to being incontinent of both bowel and bladder. An interview was conducted with the former Director of Nursing (DON) on 3/13/20 at 12:17 PM. The DON explained that on the morning of 9/30/19 she was contacted by an employee of the facility at approximately 8:30 AM revealing nurse aide (NA #1), who had worked 11:00 PM to 7:00 AM on 9/29/19 to 9/30/19, had witnessed abusive behavior by a nurse aide (NA #2). The former DON stated she instructed the employee to have NA #1 write down what happened and to return to the facility to give a statement. The former DON indicated she then went into a meeting with the Administrator during which she revealed the abuse allegations that were made. The former DON indicated NA #1 returned to the facility with her statement on 9/30/19 at approximately noon and was subsequently interviewed in the presence of the DON, Administrator, and the minimum data set assessment (MDS) coordinator. The former DON revealed that NA #2 was suspended pending the investigation on 9/30/19. Documentation on the statement written by NA #1, signed and dated 9/30/19, stated in part, While I was changing (Resident #6), (NA #2) was changing (Resident #1). (NA #2) pulled the curtain between the two residents, but I could still see her in the mirror. Although (Resident #1) was combative per usual, I noticed when (Resident #1) would swing and hit (NA #2) that she would swing and hit back. I saw her mostly towards her arms and hands which seemed as if she was trying to get (Resident #1) to stop, but in a hateful way. When I finished with (Resident #6), I went to dump the dirty linen/brief into the cart. I came back into the room to her (NA #2) saying, I just realized I didn't put these pillows back under her feet, but honestly I don't give a (expletive) right now and she walked out. Documentation of the 9/30/19 interview by the former DON, Administrator, and the MDS coordinator conducted at 12:50 PM with NA #1 revealed, When we went into (Resident #1's) room, (NA #2) told me to change (Resident #6). I could see in the mirror that (Resident #1) was trying to fight her and (Resident #1) don't like to be touched. I heard (Resident #1) say get off me and stop hitting me. I could see her hitting back at (Resident #1). The pillows are usually under (Resident #1's feet and she had not put them there. (NA #2) commented, I don't give a (expletive) now and walked away. (NA # 1) thought (Resident #1) looked scared. Documentation on a fax receipt for the initial report sent the Division of Health Service Regulation revealed the report regarding the physical abuse allegation for Resident #1 was sent on 9/30/19 at 8:24 PM with a busy signal as a result, resent on 9/30/19 at 8:50 PM with a busy signal result, and 10/01/19 at 8:04 AM with the result being okay. An interview was conducted with the Administrator on 3/14/20 at 12:47 PM. The Administrator explained that after the meeting with NA #1 she was in shock. The Administrator explained that her administrative nursing staff started contacting staff members to conduct interviews and skin assessments of the residents were conducted. The Administrator revealed that after the bruises were discovered on Resident #1, the local law enforcement was contacted. The Administrator stated, It didn't seem like we could come up for air until we uncovered everything. The Administrator said in retrospective it would have been a good idea to have someone from the administrative staff separate from the group and prepare an initial report for the state. The Administrator explained she had never called law enforcement for the long-term care portion of her facility and she had never had anything like this happen in her facility before causing her to forget the necessity of sending a 2-hour initial report to the state. 2. Resident #3 was admitted on [DATE] and had cumulative [DIAGNOSES REDACTED]. Documentation on the quarterly minimum data set assessment dated [DATE] coded the resident as severely cognitively impaired with behavioral symptoms one to three days of the assessment period. Documentation on the same assessment revealed the resident required total care assistance of two staff members with bed mobility, transfers, dressing, toilet use, personal hygiene, bathing in addition to being incontinent of both bowel and bladder. An interview was conducted with the former Director of Nursing (DON) on 3/13/20 at 12:17 PM. The DON explained that on the morning of 9/30/19 she was contacted by an employee of the facility at approximately 8:30 AM revealing nurse aide (NA #1), who had worked 11:00 PM to 7:00 AM on 9/29/19 to 9/30/19, had witnessed abusive behavior by a nurse aide (NA #2). The former DON stated she instructed the employee to have NA #1 write down what happened and to return to the facility to give a statement. The former DON indicated she then went into a meeting with the Administrator during which she revealed the abuse allegation that was made. The former DON indicated NA #1 returned to the facility with her statement on 9/30/19 around lunch time and was subsequently interviewed in the presence of the DON, Administrator, and the minimum data set assessment (MDS) coordinator. The former DON revealed that NA #2 was suspended pending the investigation on 9/30/19. Documentation on the statement written by NA #1, signed and dated 9/30/19, stated in part, When I finished with (Resident #7) and (Resident #8), I go into help finish and put (Resident #3) on the Hoyer (lift), so she (Resident #3) would be up for the day. Once we got her (Resident #3) into the chair, she (NA #2) asked me if she had a comb which I went out and combed her hair. While she (NA #2) changed (Resident #3) in the hall, I was making up (Resident #3's) bed and I could see from the corner of my eye that (Resident #3) was trying to hit (NA #2), but it seemed as if (NA #2) was hitting (Resident #3) back stating, You better not start with me today, quit hitting me, I'm not in the mood. Documentation of the 9/30/19 interview by the former DON, Administrator, and the MDS coordinator conducted at 12:50 PM with NA #1 revealed, The other hall is when she (NA #2) started hitting them. (Resident #3) - Put shirt on and (NA #2) said bring the comb to do her hair. (Resident #3) was angry and swings arms to swat away at staff and (NA #2) swung back at her and commented, You better not start with me today. Documentation on a fax receipt for the initial report sent the Division of Health Service Regulation revealed the report regarding the physical abuse allegation for Resident #3 was sent on 9/30/19 at 8:24 PM with a busy signal as a result, resent on 9/30/19 at 8:50 PM with a busy signal result, and 10/01/19 at 8:04 AM with the result being okay. An interview was conducted with the Administrator on 3/14/20 at 12:47 PM. The Administrator explained that after the meeting with NA #1 on 9/30/19 she was in shock. The Administrator explained that her administrative nursing staff started contacting staff members to conduct interviews and skin assessments of the residents were conducted. The Administrator revealed that after the bruises were discovered on Resident #3, the local law enforcement was contacted. The Administrator stated, It didn't seem like we could come up for air until we uncovered everything. The Administrator said in retrospective it would have been a good idea to have someone from the administrative staff separate from the group and prepare an initial report for the state. The Administrator explained she had never called law enforcement for the long-term care portion of her facility and she had never had anything like this happen in her facility before causing her to forget the necessity of sending a 2-hour initial report to the state.

Based on observations, staff interviews and record review, the facility failed to provide a medical justification for the use of a urinary catheter for 1 of 3 sampled residents (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed the resident had a stage two pressure ulcer and an indwelling catheter. Resident's Care Area Assessment (CAA) triggered for urinary incontinence and indwelling urinary catheter. Review of the care plan dated 12/11/13 for Resident #5 revealed that the facility identified incontinence / urinary catheter / pressure ulcer as a problem with a goal that Resident #5 will have no urinary tract infection for the next 90 days, her current pressure ulcers will be resolved in the next 90 days and no new pressure ulcer formation for the next 90 days. It is hand written on the care plan that the current pressure ulcer had been resolved, but there was no date documented as to when it had been resolved. Interventions included changing the urinary catheter and drainage bag monthly and as needed, daily bath assuring catheter, external and internal labia are cleansed well, monitor for any areas of redness, irritation, or worsening of current ulcers or formation of new ulcers and nursing assistants to report promptly to hall nurse. It is hand written on the care plan to continue with the same plan of care on 3/5/14, 5/28/14 and 8/21/14. Review of Resident #5's MDS dated [DATE] revealed the resident had a stage two pressure ulcer and an indwelling catheter. physician's orders [REDACTED]. physician's orders [REDACTED]. Review of Resident #5's pressure ulcer healing chart revealed that on 4/29/14 the width x length x depth of the pressure ulcer was 0 x 0 x 0. It was also documented that the pressure ulcer was closed/resurfaced, the wound is completely covered with epithelium (new skin). physician's orders [REDACTED]. Review of Resident #5's MDS dated [DATE] revealed the resident was assessed as having short and long term memory problems, was severely impaired for cognitive skills and daily decision making. Resident #5 had an indwelling urinary catheter, a urinary tract infection in the last 30 days and had no pressure ulcers. Review of Resident #5's physician's orders [REDACTED]. Lab results on 7/14/14 were positive for E-coli and Proteus mirabilis. physician's orders [REDACTED]. On 7/20/14 the Keflex was discontinued and Resident #5 was started on Bactrim DS twice a day for 5 days. Review of Resident #5's MDS dated [DATE] revealed the resident was assessed as having short and long term memory problems, was severely impaired for cognitive skills and daily decision making. Resident #5 had an indwelling urinary catheter, a urinary tract infection in the last 30 days and had no pressure ulcers. Observation on 9/3/14 at 10:00 AM revealed that Resident # 5 had an indwelling urinary catheter draining to a collection bag secured to the right side of the bed in a protective cover. physician's orders [REDACTED]. Interview on 9/4/14 at 1:21 PM with nurse # 1 revealed that Resident #5's urinary catheter was placed due to a sacral decubiti sometime in April. Nurse # 1 further stated that when the resident's pressure ulcer healed in April 2014, the urinary catheter was continued due to urinary incontinence. Interview on 9/4/14 at 2:00 PM with the Director of Nursing (DON) revealed her expectations would have been for Resident #5's urinary catheter to be removed upon healing of the pressure ulcer unless there was another justification for maintaining the indwelling catheter. The Director of Nursing also reported that the DON would attend the care plan meeting and bring issues to the meeting and carry out any changes that needed to be made.