Every finding on record at White Oak Manor - Burlington

Based on record review and staff interviews, the facility failed to develop a baseline care plan that addressed the resident's immediate needs related to a diagnosis of post-traumatic stress disorder (PTSD) for 1 of 1 resident reviewed for mood and behavior (Resident #125). The findings included: A review of the discharge summary from Resident #125's previous facility revealed he was discharged on 9/12/25 with diagnoses that included PTSD. The discharge summary from the previous nursing facility did not document any information regarding residents' history of past trauma or triggers that may cause re-traumatization. Review of the FL2 (a North Carolina Medicaid form that documents a patient's medical condition and needs for long term care facilities) completed 9/12/25 revealed Resident #125 had a diagnosis of PTSD. Resident #125 was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of the baseline care plan dated 9/12/25 completed by the Minimum Data Set (MDS) Nurse revealed no goal or interventions for Resident #125's diagnosis of PTSD. Review of Resident #125 physician order dated 9/12/25 indicated administer the Sertraline (antidepressant) 25 milligram (mg) along with Sertraline 50mg tablet for a total of 75mg once daily for PTSD. An interview with MDS Nurse #1 on 9/24/25 at 10:48am revealed she had 48 hours to complete a baseline care plan. MDS Nurse #1 indicated Resident #125 had care plans initiated on 9/12/25 without a care plan for PTSD or behaviors associated with PTSD. PTSD and behaviors associated with PTSD would normally be included in the baseline care plan. Interview conducted with MDS Nurse #2 on 9/24/25 at 10:55am revealed she did not know why Resident #125 did not have a baseline care plan to address his diagnosis of PTSD. She stated it may not have been added at the time the baseline care plan was completed if the facility had not received information about Resident #125 PTSD diagnosis from the discharging facility. An interview conducted with the Director of Nursing (DON) on 9/25/25 at 12:31pm revealed she was not sure if Resident #125 had a diagnosis of PTSD. The DON indicated she expected to be notified prior to or on admission of a PTSD diagnosis, trauma triggers, behaviors, or potential behaviors. She expected PTSD, trauma triggers, and behaviors to be included in the baseline care plan. The DON stated she was not sure if Resident #125's baseline care plan reflected his PTSD diagnosis. An interview with MDS Nurse #2 on 9/25/25 at 12:35pm revealed information included in the baseline care plan would depend on the information the facility received at admission. MDS Nurse #2 revealed the facility might have been waiting to get information on the trauma and triggers associated with Resident #125's PTSD diagnosis.

Based on observation, record review, and staff and resident interviews, the facility failed to follow therapy recommendations to apply a soft hand splint for 1 of 4 sampled residents (Resident #3) reviewed for positioning and mobility.The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included a left-hand contracture. The Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #3 had a left-hand contracture. The OT discharge recommendations stated Resident #3 was to be followed by Restorative Nursing with a goal that included Resident #3 would apply and wear a left-hand splint 4-6 hours daily. Review of Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and had one upper extremity impairment. An interview and observation were conducted with Resident #3 on 9/22/25 at 3:36 PM. Resident #3's left hand was observed to have 4 fingers and thumb tight into a fist. A blue, soft resting hand splint was observed on the corner of his nightstand. Resident #3 stated the resting hand splint on the nightstand was his, but staff had not been putting in on his hand in a long time. Resident #3 was unable to identify the length of time that staff had not put the resting hand splint on his left hand.Observation on 9/24/25 at 10:00 AM revealed Resident #3's left hand to have 4 fingers and thumb held tightly into his fist. A blue soft hand splint was observed on a corner nightstand. Observation on 9/25/25 at 10:30 AM revealed Resident #3's left hand to have 4 fingers and thumb held tightly into his fist. A blue soft hand splint was observed on a corner nightstand. On 9/25/25 at 4:14 PM Resident 3's left hand was observed to have 4 fingers and thumb contracted into fist. Resident #3's left resting hand splint was observed on the corner of his nightstand. During an interview on 9/26/2025 at 9:46 AM, the Rehabilitation Director indicated when a resident transitioned from rehabilitation to restorative nursing services, a form was filled out by rehabilitation. The form would include restorative nursing services start date, interventions, frequency, precautions, and when a therapist should be alerted. The completed restorative nursing form would be placed in the Restorative Nurse's mailbox. She did not know how the previous Rehabilitation Director communicated discharge recommendations for Resident #3 to the nursing staff or the Restorative Nurse. Upon review of Resident #3's OT Discharge summary dated [DATE], the Rehabilitation Therapy Director revealed Resident #3 was discharged to Restorative Nursing Services for range of motion and splinting on 5/13/25. An interview was conducted on 9/26/2025 at 9:28 AM with the Restorative Nurse. She stated discharge instructions were given to the Restorative Nurse when a resident transitioned from therapy to restorative services. The discharge instructions were provided on the restorative nursing form which outlined program goals. To her knowledge, the Restorative Nurse had not received a Restorative Services request for Resident #3 on 5/13/25 and he was not on the restorative list. On 9/26/25 at 10:30 AM a phone interview was conducted with the Occupational Therapist who treated Resident #3 and wrote the discharge recommendations dated 5/13/25. She stated the discharge summary goals and interventions would have been documented on a restorative nursing form by the Occupational Therapy Assistant or the Rehabilitation Director. She did not know if a restorative nursing form had been filled out for Resident #3 upon his discharge from OT. She stated that to her knowledge, residents who needed restorative services were discussed during the daily morning stand-up meeting. On 9/26/2025 at 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated information regarding restorative nursing was relayed verbally during the morning stand up meeting. She was unaware of any form that would be given to restorative nursing regarding the need for restorative services or the application of splints. The DON stated the physician would have to sign the order for Restorative Nursing and she was unsure why Resident #3's therapy recommended splint had not been implemented. On 9/26/2025 at 1:20 PM an interview was conducted with the Administrator. He stated therapy would make recommendations for restorative services. He stated that the Restorative Nurse would use her nursing judgement on how to carry out therapy recommendations. The Administrator stated the therapy director had recently been replaced which could have been the reason Resident #3 had not received services for applying the therapy recommended left resting hand splint. It was his expectation that residents therapy recommendations be followed until a resident would be reassessed by therapy.

Based on record review and staff interviews, the facility failed to maintain daily nurse staffing sheets for 5 of 62 days reviewed for daily posted nurse staffing information (7/25/25, 7/29/25, 8/3/25, 8/11/25 and 8/15/25).The findings included:Review of the daily nurse staffing sheets posted for 7/1/25- 7/31/25 revealed no information was available for the days of 7/25/25 and 7/29/25.Review of the daily nurse staffing sheets posted for 8/1/25-8/31/25 revealed no information was available for the days of 8/3/25, 8/11/25, and 8/15/25. An interview was conducted with the Nursing Staff Scheduler on 9/26/25 at 3:30 PM. The Nursing Staff Scheduler stated she worked Monday through Friday, and she prepared staff postings for weekends which were given to the weekend supervisor each Friday. The Nursing Staff Scheduler stated she did not know where the weekend supervisor put weekend staffing sheets as they were not returned to her. She stated no weekend posted daily staffing sheets were returned to her since she had worked as the Nursing Staff Scheduler. She did not provide an explanation for the missing nurse staffing information sheets for weekdays.During an interview with the Director of Nursing (DON) on 9/26/25 at 4:00 PM, the DON stated the Nursing Staff Scheduler was responsible for completing and maintaining the daily posted staffing sheets. The weekend supervisor completed daily posted staffing sheets on the weekend and shared changes with the Nursing Staff Scheduler. She did not know why there were missing nurse staffing information sheets. The weekend supervisor was unavailable for interview during the time of the survey.During an interview on 9/26/25 at 4:30 PM, the Administrator stated the Nursing Staff Scheduler was responsible for the daily posted staffing sheets. His expectation was for daily staffing sheets to be accurate and posted daily.

Based on record review, and interviews with staff, Physician, and Nurse Practitioner, the facility failed to ensure the physician was notified when Resident # 3 was initially identified by Nurse Aide # 5 to have discomfort with positioning, swelling, and bruises on his arm and chest with no known cause and while the resident was not receiving an anticoagulant. The physician was not notified until the following shift. When Resident # 3's physician was notified and a complete assessment was conducted, multiple bruises were found on both arms and the resident's chest which was a broader area than had been reported by Nurse Aide # 5 when she identified bruising. The bruising was irregular in shape and included both red and purple bruising. Two days following the initial identification of the bruises, the resident was transferred to the hospital ED (Emergency Department) where A CT (computerized tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma (a collection of blood, usually clotted, outside of a blood vessel) underlying pacer control box measuring 9.5 X 5.2 cm. 2) Superficial soft tissue contusion of the left flank and hip. Unexplained bruises could be a sign of abuse or neglect and require an investigation. According to an interview with Resident # 3's physician, the provider should have been notified on the shift the bruises, discomfort, and swelling were identified because of the extent of the unexplained bruises. Additionally, for another resident (Resident #9), the facility failed to notify the physician on multiple occurrences when Resident # 9's documented elevated FSBS (finger stick blood sugar) readings exceeded 400 and both the Nurse Practitioner and Physician reported they should have been notified so that orders could be given. (Normal blood sugar values for nondiabetic individuals typically do not exceed 125). On the evening of 1/24/25 after Resident # 9's last documented finger stick blood sugar (FSBS) reading registered 524 the resident fell after becoming dizzy. The resident was transferred to the hospital where he was diagnosed with a small subdural hematoma (type of bleeding near your brain that can happen after a head injury). For a third resident (Resident # 11), the facility also failed to ensure the physician was notified following falls while the resident was receiving anticoagulant medication which placed him at greater risk of bleeding. This was for three of five sampled residents reviewed for physician notification. Immediate Jeopardy began on 12/18/24 for Resident # 3 when Nurse Aide # 5 identified during her shift that Resident # 3 had unexplained bruises, swelling, and discomfort and there was no physician notification. Immediate Jeopardy began for Resident # 9 on 1/8/25 when his FSBS registered 409 and there was no physician notification. Immediate Jeopardy was removed on 3/28/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E to ensure education is completed and monitoring systems put in place are effective. Example # 3 was cited at a scope and severity level of D. The findings included: 1. Resident # 3 was admitted to the facility on [DATE]. The resident's diagnoses in part included dementia, congestive heart failure, Parkinson's, atrial fibrillation, anxiety, and dysphagia. Resident # 3's annual Minimum Data Set (MDS) assessment, dated 10/14/24, coded the resident as severely cognitively impaired and as needing total staff assistance for bathing, dressing, and hygiene needs. Resident # 3 was coded as needing partial to moderate assistance to roll from side to side in bed and as needing substantial to maximum assistance to transfer. Review of Resident # 3's medication regimen for December 2024 revealed Resident # 3 was not on an anticoagulant. Review of staffing sheets revealed on the night shift which began at 11:00 PM on 12/17/24 and ended at 7:00 AM on 12/18/24, Employee # 1 was assigned to care for Resident # 3 as a nurse. Review of Employee # 1's statement revealed it was dated on 12/19/24 and read, I was collecting [Resident # 3's] routine 02 when I notice he had some bruising to his right shoulder as well as some to his left. No fall or bruising was reported from the previous shift to me in report so my next thought was to bring it to our unit coordinators attn. that he had bruising on him. Before I could bring it to [Unit Coordinator's] attention it was brought to my attention once more by the next shift and when the unit coordinator got here I immediately let her know my findings so it could be documented properly. Employee # 1 was interviewed on 3/25/25 at 2:57 PM. This interview revealed Employee # 1 was not a nurse, she did not know how the bruises had occurred, and she had not notified the physician about Resident # 3's bruises. According to staffing sheets, NA # 5 was assigned to care for Resident # 3 on the night shift which began at 11:00 PM on 12/17/24. NA # 5's written statement within the facility's investigative file read, When I was doing my 3:00 AM rounds, upon entering [Resident # 3's] room I noticed he had removed his gown and blanket which he usually does. However I notice some bruising on his arm and chest along with some swelling. Upon me waking him up he seemed startled (more than usual) but he eventually calmed down after I talked with him. I notice while turning him to his left he jerked himself back and became uncomfortable so I turned him back on his back and since he had not soiled himself, I put the gown and blanket back over him. When I came back around 5 AM I did change him but made sure not to roll him on his left arm since that is where his bruise that I noticed was located. Moving forward I will make sure to have another aid to do a walk through with me and/or assist with changes. No matter how minor or major it be if I notice ANYTHING it will be reported to the NURSE and I will leave written reports to the DON. NA # 5 was interviewed on 3/21/25 at 11:25 AM and reported the following information about her 12/17/24 shift which began at 11:00 PM. When she arrived at work, she got report and had been told that Resident # 3 had been washed up by the 2nd shift. He was asleep in bed on first rounds and again at 1:00 AM and she did not disturb him. Around 3:00 AM she noticed Resident # 3 had bruising. There was a golf ball sized bruise on his arm which appeared light reddish and turning purple. There was bruising on his chest which was larger than what was on his arm, but his gown partially covered the bruise, and she did not pull the gown down to look at the extent of the bruising. She assumed the bruising had happened earlier during another shift and staff were already aware it was there. Nothing had happened on her shift. She did not tell Employee # 1, who she thought was a nurse. A review of nursing notes revealed the first entry documenting the resident's bruising and that the physician was notified was on 12/18/24 at 7:32 AM by Nurse # 1. The entry was entered into the record as a late entry on the date of 12/19/24 at 8:08 AM. The entry read, Resident able to make needs writer made aware during report that resident had bruising to left side of chest, armpits, and arms. VS 128/77 (blood pressure), 97 % on RA (room air), 18 (respirations), 97.9 (temperature), 63 (pulse.) No s/s (signs and symptoms) of SOB (shortness of breath), wheezing or labored breathing. Facial grimacing noted when resident move his left arm. Resident refused to be repositioned . Nurse # 1 further noted Resident # 3 had an order for Tylenol 325 mg (milligrams) 2 tabs every 6 hours. Nurse # 1 also noted the physician was notified and orders were obtained for a stat x-ray on the chest, right arm and left arm. The Director of Nursing (DON), Unit Coordinator, and Social Worker were also notified. Review of physician progress notes revealed the resident's physician, who served as the facility medical director, assessed Resident # 3 on 12/18/24. The physician noted, He (Resident # 3) was noted this morning to have bruising on his upper body. Patient has cognitive impairment and is not able to tell us what happened. Last BIMS (brief interview for mental status) 2/15. He seems to only have pain when moving the left shoulder. No documented falls. He was given Tylenol for pain. The physician further documented measurements of the bruising as follows: Note Bruises were irregular shaped and were measured at largest diameter. Right anterior chest upper near midline, about 5.5 X 3.5 cm (centimeters) reddish with some faint purplish area inferior to it. Right shoulder near AC joint circular reddish abrasion. Right shoulder lateral clavicle about 7 x 6 cm irregular shaped reddish bruise with faint deeper purple underneath it extending further down about 5 X 8 cm at largest diameter. Right arm-3 circular bruises about 1 cm each-2 inner bicep mid to distal and 1 lateral inferior. Left chest wall- Pacemaker scar with 6 small irregular shaped purplish red bruises. Pacemaker appears more lateral and turned/sticking out. Left side -about 7 X 3 cm reddish bruise with faint edges in shoulder near clavicle. Large reddish purple about 10 X 4 cm inferior to tattoo on lateral upper arm. Left arm-irregular shaped bruise going down bicep with varying colors-reddish to darker purple inferior, 12 X 4 cm around to lateral aspect of arm. 8 X 3 cm circular bruise purplish inferior and medial to elbow. Large left chest wall bruise light purplish edges wraps around chest lateral to nipple, darker purple on posterior chest. No ecchymosis (discoloration of the skin, typically caused by bruising) neck, facial area, or body below waist. Within the progress note, the physician noted a chest x-ray and complete blood count would be obtained. The physician further noted that she was unsure when the pacemaker had been placed or last tested . She further noted the pacemaker appeared to be turned/sticking out more. Resident # 3's Physician, who serves as the facility's medical director, was interviewed on 3/21/25 at 3:13 PM and reported the following information. When she evaluated Resident # 3 on 12/18/24 the bruising was all on his upper body which included areas on his arms and chest wall which wrapped around some on his trunk. According to the Physician the provider should have been called during the night when the bruising was found due to the extent of the bruising. She learned of the bruising when she arrived at the facility during the dayshift of 12/18/24. 2. Record review revealed Resident # 9 was admitted to the facility on [DATE] and had diagnoses which in part included diabetes and Alzheimer's dementia. Review of Resident # 9's admission Minimum Data Set assessment, dated 11/13/24, coded Resident #9 as severely cognitively impaired and as receiving Insulin. Review of physician orders revealed Resident # 9 was ordered to receive Eliquis 5 mg (milligrams) every 12 hours for atrial flutter. This order began on 11/8/24. (Eliquis is an anticoagulant and increases the chances of bleeding). Resident # 9's care plan included the information that Resident # 9 was a diabetic. This was added to the care plan on 11/8/24 and remained part of the resident's active care plan. Staff were directed on the care plan to monitor blood sugar levels as ordered and both observe and report any signs and symptoms of hyperglycemia or hypoglycemia. Review of physician orders and Resident # 9's January 2025 MAR (medication administration record) revealed the following information. Resident # 9 had an order for FSBS (fingerstick blood sugars) twice per day. This order had originated on 11/8/24 and was in effect until discontinuation on 1/27/25. There were no physician orders regarding what parameters the physician should be notified when the FSBSs were obtained. According to the January 2025 MAR, the FSBS were scheduled for 6:30 AM and 4:30 PM. There were no orders for parameters to call the provider regarding results and there was no order for sliding scale insulin coverage based on FSBS results. Review of physician orders revealed between the dates of 1/1/25 and 1/24/25, the only type of insulin Resident # 3 was prescribed was a long acting insulin given at night and there was one order change in Resident # 9's diabetic medication dosages. Specific medications and the dosage order change were as follows: Jardiance 25 mg (milligram tablet once per day. This order was in effect from 12/7/24 until its discontinuation on 1/27/25. Metformin 500 mg tablet twice per day. This order was in effect from 12/13/24 until discontinuation on 1/27/25. Ozempic pen injector; 0.5 mg; subcutaneous once per week on Monday. This order was in effect from 11/11/24 until discontinuation on 1/27/25. Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Administer 15 units subcutaneous at bedtime. This order was in effect from 12/31/2024 until the discontinuation on 01/06/2025. (Lantus is a long- acting insulin which can last up to 24 hours but does not have a rapid onset of action). Insulin glargine-yfgn insulin pen; 100 unit/mL (3 mL); Administer 15 units subcutaneous at bedtime. This order was in effect from 1/6/25 until discontinuation on 1/18/25. (Insulin glargine-yfgn is a biosimilar interchangeable insulin product to insulin glargine which the resident was already receiving. There were no dosage changes). The date of 1/18/25 was the only date where an increase in insulin dosage order was noted in the chart from 1/1/25 to 1/24/25. The order was for insulin glargine-yfgn insulin pen; 100 unit/mL (3 mL); Administer 18 units subcutaneous at bedtime. This order was in effect until discontinuation on 1/27/25. According to the record, the physician entered a progress note on 1/18/25 and noted his hemoglobin HgbA1c on 12/24/24 had been 9.2 and she would increase the resident's long-acting insulin from 15 to 18 units. (Hemoglobin A1c is a blood test that measures the average blood sugar result in the last two to three months. A result of 6.5% and above reflects diabetes.) Review of Resident # 9's MAR revealed multiple times Resident # 9's FSBS exceeded 400 from 1/1/25 to 1/24/25 without any documentation the physician was notified in the record. Specifics are as follows On 1/8/25 at 6:30 AM Employee # 1 documented 409 on the MAR. On 1/10/25 at 6:30 AM Nurse # 6 documented 433 on the MAR. On 1/10/25 at 4:30 PM Nurse # 7 documented 423 on the MAR. On 1/18/25 at 4:30 PM Nurse # 8 documented 413 on the MAR. On 1/22/5 at 6:30 AM Medication Aide (MA) # 1 documented 453 on the MAR. On 1/22/25 at 4:30 PM MA # 2 documented 456 on the MAR. On 1/23/25 at 6:30 AM Nurse # 9 documented 419 on the MAR. On 1/23/25 at 4:30 PM MA # 3 documented 403 on the MAR. On 1/24/25 at 6:30 AM MA # 4 documented high on the MAR. On 1/24/25 at 4:30 PM Nurse # 5 documented 524 on the MAR. Nurse # 6 was interviewed on 3/25/25 at 1:45 PM and reported she did not recall details of the date of 1/10/25 but she would normally call the physician and make a note she had done so for elevated blood sugars. Nurse # 7 was interviewed on 3/26/25 at 9:48 AM and reported she wasn't aware she was to call for blood sugars over 400 but would have done so if the blood sugars went over 500. An attempt was made to talk to Nurse # 8 on 3/25/25 at 1:21 PM and the nurse could not be reached by phone. MA # 1 was interviewed on 3/25/25 at 6:30 AM and reported she would have reported to a nurse the FSBS on 1/22/25 but did not recall who the nurse was. MA # 1 reported she always did so, and that Resident # 9 would often eat sugary items brought in by the family. MA # 2 was interviewed on 3/25/25 at 12:38 PM and reported she could not recall specific details of 1/22/25 but she would have told a nurse about an elevated blood sugar over 400, rechecked it in an hour and put it on the 24-hour nursing report. Nurse # 9 was interviewed on 3/25/25 at 12:10 PM and reported she had not worked on the night shift on 1/23/25 at 6:30 AM to have obtained a FSBS of 419 and did not know why her initials were signed off on the MAR as obtaining the result. The nurse reported she was a day shift nurse. An attempt was made to interview MA # 3 on 3/25/25 at 11:29 AM and she could not be reached. MA # 4 was interviewed on 3/25/25 at 10:28 PM and reported the following information. She recalled Resident #9's blood sugar registering high on the morning of 1/24/25. At the time she was to be reporting to Employee # 1, who she thought was a nurse at the time. She told Employee # 1 about the high blood sugar and Employee # 1 stated she would check the record for sliding scale orders and call the physician. She saw Employee # 1 make a phone call and talk to someone, but she did not know to whom she was talking to. Afterwards Employee # 1 asked to look in her (MA # 4's) medication cart, obtain an insulin pen, and go into Resident # 9's room. She did not know what insulin pen Employee # 1 had obtained or what she had done when she went into the room. When she had checked the FSBS, Resident # 9 had appeared okay. Employee # 1 was interviewed on 3/25/25 at 3:30 PM and reported the following information. She had applied and been accepted to work at the facility as a nurse. She had provided a false license to the facility and had no nursing education nor a license to perform job duties of a nurse. She had taken care of diabetic family members and had some partial training as a medication assistant in another state. On the morning of 1/24/25 when Resident # 9's blood sugar registered high she had called the doctor and gotten an order for some insulin. She had given the insulin. When interviewed about the issue that Resident # 9 did not have any short acting insulin ordered and filled for her to access for him, Employee # 1 replied they kept some on the cart or in back up for times such as this. Nurse # 5 was interviewed on 3/25/25 at 1:26 PM and reported the following information. She was new at the time on 1/24/25 when Resident # 9's FSBS registered 524. She was walking to the desk when she saw MA # 1. She asked MA # 1 if Resident # 9's FSBS usually ran high, and MA # 1 told her that Resident # 9 would get sugary things on his hands and recommended to clean his finger better and recheck it. There was not much time between Nurse # 5 talking to MA # 1 before she then went back to recheck the FSBS. She then obtained a result in the 300s but did not recall what it was. She thought she had documented the FSBS but had not done so. Nurse # 5 was interviewed regarding whether she had cleaned Resident # 9's finger well the first time and responded that she thought she had done so. She had not communicated with the physician following either FSBS check. Nurse #5 further stated during her shift Resident # 9 appeared to be okay. Interview with Unit Coordinator # 1 on 3/25/25 at 12:46 PM revealed the facility kept a communication book that the provider could reference when they arrived at the facility. She had looked through the physician communication book and found no record of communication left for the provider between the dates of 1/1/25 to 1/24/25 about Resident # 9's elevated blood sugar readings. Further review of nursing notes revealed the only note on 1/24/25 was dated 1/24/25 at 7:16 PM and was written by Nurse # 10. Nurse # 10 documented at this time that Resident # 9 was in the shower with staff present and became dizzy and fell . Resident # 9 sustained a laceration to his head with minimal bleeding. Nurse # 10 further documented that given the resident was on an anticoagulant the resident was transferred by EMS services to the hospital. Interview with Nurse # 10 on 3/25/25 at 10:44 AM revealed she had not been caring for Resident # 9 at the time of the fall, but was closet to the shower room when the resident fell . Review of EMS records dated 1/24/25 revealed the EMS paramedics arrived at 7:23 PM on 1/24/25 and Resident # 9 did not complain of blurred vision or dizziness at the time of their arrival. Review of the hospital records for the date of 1/24/25 to 1/30/25 revealed the following information. Resident # 9 was diagnosed with a small subdural hematoma. His blood sugar was 305 at 8:40 PM on 1/24/25 when drawn by the lab. The hospital physician noted Resident # 9's last HgbA1C was 10.2. The hospital physician noted the resident should receive both long acting and short acting insulin upon discharge back to the facility. Also, the hospital discharge summary included information that the resident had been hypotensive when he arrived to the hospital and his Toprol (used for heart failure) was held. Also, while hospitalized , neurosurgery was consulted and recommended holding the resident's anticoagulant medication. Prior to discharge, a repeat CT scan was performed to ensure the resident's subdural hematoma had not worsened. Discharge orders included that the resident should be placed on sliding scale insulin coverage and in addition to the prescribed sliding scale insulin, when the FSBS was greater than 400, the primary physician should be contacted. On 1/30/25 Resident # 9 returned to the facility with the new insulin orders and designated parameters to call the physician. Interview with Resident # 9's NP (Nurse Practitioner) on 3/24/25 at 5:15 PM and again on 3/26/25 at 11:21 AM revealed the following information. She was at the facility three days per week. She also took call during the day. She had not been notified of blood sugar results greater than 400 from 1/1/25 to 1/24/25. If she had been, then she would have left orders for the resident. During the night if the resident's blood sugar registered over 400, the facility staff could call an on-call provider. She had reviewed the on-call provider log and found no documentation of calls that came into the on- call provider between the dates of 1/1/25 and 1/24/25 related to Resident # 9's blood sugars being above 400. The NP also validated that the change made on 1/6/25 in Resident # 9's long-acting insulin was a substitution and was probably due to insurance covering one form of insulin. The order change had not been due to notification of elevated blood sugar readings. The facility's Medical Director, who also was Resident # 9's physician, was interviewed on 3/21/25 at 3:13 PM and again on 3/27/25 at 1:42 PM. The physician reported the following information. The staff should call the provider about blood sugars which were greater than 400 unless there are specific instructions in the orders and a different parameter is set for a specific resident based on their individual history. If she had been notified of a blood sugar greater than 400 then she would have given an order to address it. She did not typically answer her phone before 7:00 AM unless she was on call and did not know to whom Employee # 1 had talked to on 1/24/25. The Physician was further interviewed about whether residue on an individual's finger could affect a FSBS result and reported that it sounded strange that by just cleaning someone's finger that such a large difference in a result would occur as reported by Nurse # 5 unless something was wrong with the glucometer itself. The Physician reported even if the FSBS was in the 300s that also needed to be addressed. On 3/25/25 at 8:55 PM the Administrator was notified of Immediate Jeopardy. The Administrator presented the following Credible Allegation of Immediate Jeopardy Removal Plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident #3 was noted with significant Chest and upper arm bruising initially by a Certified Nursing Assistant (CNA) on 12/18/2024. The CNA failed to notify any nurse of the bruising. Her failure to report the bruising to the nurse delayed assessment and treatment of Resident # 9 by the provider. In the month of January 2025 resident # 9 experienced multiple instances of seriously elevated blood sugars (greater than 400). During this time period resident # 9 did not have orders for sliding scale insulin or parameters for notifying physician of blood sugar elevations. During January several nurses including employee #1 and nurse #5 failed to notify the provider or nurses on subsequent shifts of these seriously high blood sugars resulting in the delayed assessment, treatment, and monitoring. And as a result of the failure resident # 9 experienced hyperglycemia. On 3/26/25 The DON conducted an audit of all nursing progress notes from 3/19/25-3/25/25 to ensure that the provider had been notified of any residents with a significant change in condition. The audit revealed that there were no changes in condition that were not communicated to the provider. A complete audit from 3/19/2025-3/25/2025 of the Vital Signs (Blood Glucose Values) for elevated blood glucose levels over 400 with proper physician notification was completed by the DON on 3/25/2025. Identified elevations without proper physician notification were communicated by the DON to the provider on 3/25/2025. No further orders were given by the provider for identified residents. 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. On 3/26/25 The Director of Nursing (DON) conducted education with all licensed nurses and Medication Aides on blood glucose parameters and the necessity of notifying the provider of any reading above 400. All nurses and Medication Aides were contacted either face to face or via phone communication on 3/26/25. Education was provided to prevent any further failures of nurses to notify providers and to prevent uncontrolled hyperglycemia in facility residents. On 3/27/25 the Staff Development Coordinator was educated by the DON that all Newly hired nurses, medication aides and agency nurses will receive this training in orientation by the Staff Development Coordinator. On 3/26/2025 the Quality information manager (QIM) audited and entered the verbiage to each blood sugar order on the MAR: blood sugar greater than 400 call provider. On 3/25/25 the Director of nursing educated licensed nurse to add blood sugar greater than 400 call provider to newly admitted resident with finger stick blood sugar orders for proper notification to the provider. On 3/27/25 the QIM was educated by the Director of Nursing to include in the current QIM admission order review process to ensure blood sugar greater than 400 call provider has been added by the nurse to those residents with finger stick blood sugar orders for proper notification to the provider. On 3/26 & 3/27/2025 the DON and Staff Development Coordinator (SDC) completed education with all nurses, CNAs, activities (life enrichment), social services and therapy staff on recognition and reporting of significant changes, and proper chain of communication to the provider for reporting bruising or other resident changes in condition. Education was completed either by face to face or phone communication. The SDC will also educate all newly hired nurses, CNAs, Activities (Life enrichment) staff, therapy and social services staff on the recognition and reporting of significant changes, and proper chain of communication to the provider for reporting bruising or other resident changes in condition as part of the facility orientation process. Date of Immediate Jeopardy removal will be 3/28/25. On 3/31/25 the facility's Credible Allegation of Immediate Jeopardy Removal Plan was validated by the following actions: The facility presented an audit of all resident's records in which the Director of Nursing had reviewed progress notes and vital signs to identify changes in condition. Recent progress notes were printed by the DON. The DON had made written notations regarding the physician was aware on any progress note which indicated a resident was experiencing an acute medical condition. The facility presented evidence of blood sugar checks to ensure the physician was being informed of elevated levels. Review of a random diabetic resident's record revealed the information had been added to the resident's record that the physician should be contacted for blood sugars greater than 400. Interview with nurses revealed they were aware they were to immediately call for blood sugars greater than 400 unless otherwise specified in the physician's orders. The facility presented evidence of education as outlined in their removal plan. The facility's date of immediate jeopardy removal was validated to be 3/28/25. 3. Resident # 11 was admitted to the facility on [DATE]. Resident # 11's diagnoses in part included dementia and a history of pulmonary embolus. Resident # 11's admission MDS (Minimum Data Set) assessment, dated 12/16/24 coded Resident # 11 as severely cognitively impaired. The resident was also coded as needing substantial to maximum assistance with his hygiene needs, requiring total staff assistance to turn in bed, not ambulatory during the assessment period, and as having no falls. Review of orders revealed Resident # 11 was prescribed Eliquis 5 mg (milligrams) from 12/17/24 to 1/30/25. (Eliquis is an anticoagulant which places a resident at greater risk for bleeding). On 12/28/24 12:30 AM Employee # 1 documented, Resident slipped of the left side of the bed sitting on the floor, laid down on his left side, head propped up against the nightstand. No obvious injury or bruising. Head trauma protocol given and vitals record at the time of the fall. Temp-97.9, Pulse-71, Resp. 20 B/P (blood pressure) 115/64. Employee # 1 was interviewed on 3/25/25 at 3:30 PM and reported the following information. She was not a licensed nurse and had never completed any formal training program in health care. She had taken care of bedridden family members, and she thought she knew what to do. Resident # 11 did not seem hurt to her on 12/28/24 and 1/9/25 and she had not called the physician. There was no record the physician was called regarding the resident's fall he sustained while on Eliquis. Review of nursing notes following 12/28/24 did not reveal any documented injury from the 12/28/24 fall. NA # 8 had cared for Resident # 11 on the night shift which had begun on 12/27/24 at 11:00 PM. NA # 8 was interviewed on 3/25/25 at 6:45 AM and reported she did not recall taking care of Resident # 11 that night and did not know how he had fallen. Interview with the Director of Nursing on 3/21/25 at 9:00 AM revealed Employee # 1 had worked at the facility from November 2024 until her termination in February 2025 under false pretenses as a nurse. She had not been a licensed nurse while caring for Resident # 11. On 1/9/25 at 7:27 AM Employee # 1 documented, [Resident # 11] was laying on the floor in the room beside his bed and neuro assessment to make sure he did not sustain any blows to the head. T-94.6 P 64 R 20 B/P 126/83. He was alert and oriented. (A temperature reading of 94.6 would indicate a hypothermic reading which is a lower than normal body temperature). Review of the nursing notes revealed no notification to the physician was documented. Interview with Resident # 11's Physician on 3/21/25 at 3:13 PM revealed the provider should be contacted when a cognitively impaired resident, who was on Eliquis, falls and it is not known if the resident hit their head. In those cases, the resident would be sent out to the hospital to be checked.

Based on record review and staff interviews, the facility failed to implement their abuse policy for employees who worked in the capacity of a licensed nurse by not screening and verifying Employee #1's credentials prior to hiring her as a licensed nurse and allowing her to perform licensed nurse duties for which she had no documented education or nursing license. Employee #1 provided the facility nurse license information for an individual she found online with a name that was similar to her own and she worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. During this timeframe, Employee #1 had resident assignments and performed licensed nurse responsibilities that she was not qualified to provide. On the shift that started on 11:00 PM on 12/17/24 Employee #1 was assigned to Resident #3, who was not on an anticoagulant (blood thinner) when she identified bruising to the resident's shoulders with no known cause. Employee #1 was responsible for assessing the resident and notifying the physician of significant changes. Employee #1 did not notify the physician and there was no evidence of an assessment or interventions implemented for Resident #3 until he was assessed the following shift by the physician. The bruises continued to spread and on 12/20/24 Resident #3 was seen in the Emergency Department (ED) where a Computed Tomography (CT) scan revealed a large (9.5 centimeters [cm] by 5.2 cm) left subpectoral (situated under the chest muscles) hematoma (a collection of blood, usually clotted, outside of a blood vessel) and a superficial soft tissue contusion (bruising) of the left flank and hip. On 1/24/25 Medication Aide (MA) #4 reported to Employee #1, who she believed to be a nurse, that Resident #9's finger stick blood sugar (FSBS) registered outside of the meter's highest measurable range indicating a dangerously high blood sugar reading (normal blood sugar levels are between 70 and 100). There was no evidence Resident #9 was provided with treatment to address the high blood sugar level, and the physician was not notified. On 12/8/24 and 1/9/25 Employee #1 was assigned to Resident #11, who had severe cognitive impairment and was on an anticoagulant, in the role of a licensed nurse when he experienced falls. The assigned nurse was responsible for completing a comprehensive assessment and utilizing nursing judgment regarding whether to call the physician. Employee #1 was not qualified to complete a comprehensive assessment of Resident #11 nor was she qualified to use nursing judgement to make decisions. Additionally, Nurse Aide (NA) #5 did not implement the abuse policy related to reporting injuries of unknown source when she identified that Resident #3 had discomfort with positioning, swelling, and bruises on his arm and chest with no known cause. These deficient practices affected Resident #3, Resident #9, and Resident #11 in addition to placing all residents Employee #1 was assigned to care for in the capacity of licensed nurse for the high likelihood of a serious adverse outcome or harm. This occurred for 1 of 3 employes whose personnel records were reviewed for credentials (Employee #1) and 1 of 3 nurse aides reviewed for reporting an injury of unknown source or allegation of abuse (Nurse Aide # 5). Immediate jeopardy began on 11/5/24 when the facility failed to screen and verify credentials for Employee #1, who fraudulently presented herself to the facility as a licensed nurse, prior to hiring her and allowing her to perform licensed nurse duties. Immediate Jeopardy was removed on 3/28/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E to ensure education is completed and monitoring systems put in place are effective. Example 2 is being cited at a scope and severity level severity of E. The findings included: Review of the facility's Plan for the Prevention of Elder Abuse, which was undated and provided to the surveyor as the facility's current policy, included the following information. A thorough preemployment screening would be conducted in efforts to prevent negligence or abuse. This included a pre-employment interview, reference checks, and licensure verification. 1. Review of Employee # 1's personnel file records provided to the state surveyor revealed the following information. Employee # 1's application for employment was signed as submitted on 10/21/24 for a position as a licensed practical nurse/registered nurse on third shift from 11:00 PM to 7:00 AM. The only employment history included on the application noted Employee # 1 had attended an out-of-state high school. No further education experience was listed. There was one record of employment history listed. This was from the dates of 2/1/2016 until 5/1/2017 for an employer located in the USA. Employee # 1 listed chat support agent as her job duty for this employer. There was one person listed as a reference whose relationship to Employee # 1 was noted to be her employer. This individual, who was listed as Employee # 1's work reference, was noted to share the same last name as Employee # 1. Under Reference Entry # 2 on the application form, Employee # 1 had submitted, I do not have a # 2 Reference Entry. Under the question, Please indicate education or skills training which you believe qualifies you for the position you are applying, Employee # 1's typed response was, CNA (Certified Nurse Aide) and 5 years of home health. At the bottom of the application there were some scribbled notes which read, In home care currently dementia 2 yrs-Nurse for 4 1/2 years 3rd shifts M-F FT. There was no documentation of who had made the notes on the application. There was no documentation in the personnel file showing Employee # 1's one reference was checked and there was no resume. Also located in the personnel file, there was an employment notice record for Employee # 1 which did not note for which employment position she was being hired. It did note the hours would be from 11 PM to 7:00 AM as a full-time employee. It was signed by a corporate Human Resources Consultant on the date of 11/5/24. There was no evidence of nursing license verification prior to 11/5/24 in the personnel records provided to the surveyor. Within the personnel file were different records provided by the Staff Development Coordinator and signed by Employee # 1 on dates which included 11/7/24 and 11/8/24 indicating she had reported to work for training on those days. The first license verification in Employee # 1's personnel file was a copy of an email from Employee # 1 to the DON (Director of Nursing). The email, dated 11/19/24, only contained a picture of a QuickConfirm License Verification Report from QNursys. (QNursys is an online national nurse licensure and disciplinary database.) The picture within the email noted that the individual on the license was licensed in the compact state of Georgia with a multistate license as a practical nurse. Within the personnel file were copies of Employee # 1's social security card and driver's license. The name on the nursing license in the 11/19/24 email varied from the name on Employee # 1's copies of her social security card and her driver's license. They varied in the following ways. The first name of Employee # 1 had an extra a letter in it than the first name on the nursing license. The middle name was totally different. The last name was the same. According to Employee # 1's driver's license, she was born in 1996. The original nursing license issue date was 4/5/2006 on the license provided in the email to the DON, which indicated that Employee # 1 would have been nine years old when she was licensed. The Administrator and DON (Director of Nursing) were interviewed together on 3/21/25 at 9:00 AM and a follow up interview was conducted with the DON again on 3/21/25 at 9:45 AM revealing the following information. During the interviews the Administrator reported Employee # 1 would have been interviewed by the DON and the former Human Resources Manager (HRM #1). HRM # 1 would have been responsible for checking the nursing license of Employee # 1. The DON reported the following information during the interviews. Employee # 1's original hire date was 11/5/24. The DON did not recall any details of the interview or what was discussed. The DON recalled that it was called to her attention after hire, that Employee # 1's license was single state in Georgia only and therefore there was no reciprocity on the license for her to practice in North Carolina. She had contacted Employee # 1 and explained she needed to verify her license was for multi-state. After doing so, Employee # 1 sent the email (which was in the personnel file) with the license information to her (the DON) noting the license was multistate. At the time the license was submitted by email on 11/19/24 there had been no red flags that Employee # 1 was not really a nurse. Therefore, the DON looked at the license that Employee # 1 emailed her, noted that it did document she had a multistate license from Georgia, and it was placed in the personnel file without further questions. Employee # 1 continued to work through 2/6/25 as a licensed nurse on third shift until her termination. At some point prior to 2/6/25 it had been brought to the DON's attention that Employee # 1's documentation skills were not professional. Therefore, she looked at Employee # 1's notes and started to question things. On 2/6/25 she (the DON) pulled Employee # 1's license again herself. At that time the license came up in Georgia as a single state again and she (the DON) noted during that check that the nursing license issue date was in 2006, which would have meant that Employee # 1 would have been nine years old when licensed. She (the DON) then noted Employee # 1's first name varied very slightly and that the middle name was not the same. Employee # 1 was confronted by her and terminated. When confronted, Employee # 1 maintained she did have a nursing license and would get it to the DON, which she never did. The State Board of Nursing was contacted on 2/6/25 and a report was filed with them. After the State Board of Nursing's investigation, they were also unable to verify any nursing license for Employee # 1 and directed the facility to call the police which they did. A review of a police report revealed the Administrator called the police on 3/18/25 to notify them of Employee # 1 impersonating a nurse. The responding officer noted in the 3/18/25 police report that there was evidence of fraudulent documentation provided by Employee # 1 to the facility and the case would be forwarded for review and possible charges related to identity fraud. HRM # 1 was interviewed on 3/21/25 at 10:45 AM and reported the following information. She left employment at the facility in the middle of October 2024. She had nothing to do with Employee # 1 being hired and knew nothing about her. The corporate Human Resources Consultant was interviewed on 3/24/25 at 11:32 AM and reported the following information. He had signed the Employment notification form on 11/5/24 in order to help get Employee # 1 in the payroll system and her start date was considered 11/5/24. He was assisting the facility in the interim when the facility was without a human resource manager. HRM # 1 had already done all the hiring paperwork before leaving on 10/25/24. It would have been HRM #1's or the DON's responsibility to have checked to see if Employee # 1 had a nursing license. This task would have fallen to whoever did her interview. He had never personally met Employee # 1. When he was helping in November 2024, during the interim when there was no human resources manager, he had noted that Employee # 1 had initially provided a nursing license that said single state licensure for Georgia only. When he noted the single state licensure, he mentioned to the DON that Employee # 1 would need to be pulled off the floor until they could verify her nursing license. He did not know what had happened to this initial nursing license she had submitted and why it was not on file in the personnel record given to the surveyor. According to human resource records, which the Corporate Human Resources Consultant referenced during the interview with the surveyor, Employee # 1 did not work from 11/14/24 through 11/18/24 because of this. Employee # 1 sent a copy of a license on 11/19/24 and he also looked at her nursing license online. At the time, he (the Corporate Human Resources Consultant) looked up her nursing license, he did not note anything suspicious. He never suspected that she was not really the person she was presenting to be. His thought was that if she had the capability to get the nursing license changed from single state to multi state, then she must be the person on the nursing license. The corporate Human Resource Consultant was interviewed regarding the lack of education and nursing experience on Employee # 1's application and reported the following information. It was not uncommon for employees to initially apply through a third-party website to their organization and then the application fed into their corporate system. At times the application might not be complete, but the applicant would then provide some sort of resume to fill in the gaps. Employee # 1 was interviewed on 3/25/25 at 3:30 PM and reported the following information. She knew it was a shot in the dark when she applied for a nurse job at the facility. She had been homeless, living in a car, and had a child to support. She never thought that the facility would reach out to her after she submitted the application, but they did. She went to an interview. She did not know anybody by the name of HR# 1. She was interviewed by a male person and someone else, who was not the DON. Although she had never finished any type of formal health care training, she attended a medical assistant school in another state, and she did know about health care to some degree. She also had taken care of family members who were bedridden or diabetics and reported herself to be a fast learner. She told the facility during the interview she had health care experience. They never asked her for a license. She was surprised when the facility called her and offered her a job. They called and texted her to come to training which had already started. There was supposed to be four days of training, and she attended the last two days only. Then they put her with a nurse on night shift for about two or three days and she went to work. She had been working for about two weeks before they even asked her about a nursing license. She looked up her name on a website and found someone with a similar name to hers that had a nursing license and she decided to give that to the facility. She did not think the facility would accept it and reported she was baffled myself when they did, but they never questioned it and let her come back to work. Her intent was never to hurt anyone, and it was her perception that she did as well as the other nurses who had a nursing license. She was trying to go back to school to actually get a nursing license while she was working at the facility. Interview with the Administrator on 3/21/25 at 5:50 PM revealed HRM # 1 had been responsible for hiring Employee # 1 and no longer worked at the facility. HRM # 1 had been terminated out of the system on 10/25/24. Applicants for positions at the facility can provide an application for employment through a third-party system on the internet. That is how Employee # 1's application came through to them. He did not know everything HRM # 1 had done in hiring Employee # 1 but did know she had sent some on boarding documents through to get her hired. The Administrator stated Employee # 1's nursing license should have been verified before hire. He could find no reference checks in the personnel file. The records of three residents, who were cared for by Employee # 1 while she worked as a Nurse, were reviewed. Although not all inclusive of all the nursing task performed and judgements made by Employee # 1 while she was impersonating a licensed nurse and employed at the facility, these three records revealed some of the following examples of nursing duties performed or required of Employee # 1 to be done safely. Employee # 1 had been the responsible assigned Nurse for Resident # 3 on the night shift which began on 12/17/24 at 11:00 PM. Review of a facility investigative report revealed during this shift, Resident # 3 was identified by Resident # 3's Nurse Aide to have unexplained bruises to his chest and arm which were accompanied by swelling and discomfort with positioning. Employee # 1 would have been responsible for the assessment and notification of the physician during the night shift, and per her statement in the facility's investigative file she was aware of the bruises during the night shift. Employee # 1 noted in her statement she had seen the bruises on the resident's shoulders. Interview with the physician on 3/21/25 at 3:13 PM revealed she or another provider had not been notified by Employee # 1, and this should have been done. During the interview with the physician, the physician reported the bruising was all on the resident's upper body which included areas on his arms and chest wall which wrapped around some on his torso. He was also having some left shoulder pain. The physician further reported that Resident # 3 was a cognitively impaired resident and could not report what had happened. Further review of Resident # 3's nursing notes and 12/20/24 hospital ED (Emergency Department) records revealed Resident # 3's bruising continued to spread, and a CT (computerized tomography) scan performed on 12/20/24 at the hospital showed the resident had a large left subpectoral hematoma underlying his pacer control box measuring 9.5 X 5.2 cm. (centimeters) and superficial soft tissue contusion (bruising) of the left flank and hip. Per record review Employee # 1 was responsible for performing FSBS (Finger Stick Blood Sugar Checks) for Resident # 9 and making judgements about when to call the physician for blood sugar readings. There was documentation in Resident # 9's record that Employee # 1 administered Insulin to Resident # 9 according to Resident # 9's MAR (Medication Administrator Record). On 1/8/25 when Employee # 1 documented on the MAR Resident # 9's FSBS was 409, there was no documentation the physician was notified and orders received although the resident had no sliding scale insulin coverage ordered at the time. Furthermore, per a 3/25/25 interview at 10:28 AM with Medication Aide (MA) #4, MA # 4 reported the following information. She (MA # 4) had taken Resident # 9's FSBS on 1/24/25 when it was due to be checked at 6:30 AM. The result was high and did not register on the glucometer. She reported the result to Employee # 1, who at the time MA # 4 believed to be a nurse. She (MA # 4) observed Employee # 1 call someone. She did not know who Employee # 1 called and did not know what she said to them. Later Employee # 1 received a notice that someone was on the phone line for her. She (MA # 4) again saw Employee # 1 talk to someone but did not hear the conversation. After the conversation, Employee # 1 went through the insulin pens on the medication cart, removed one, and walked into Resident #9's room. MA # 4 did not know what type of insulin pen was removed or to whom it belonged. A review of the chart revealed no documentation or orders for any insulin administration to address Resident # 9's 1/24/25 6:30 AM FSBS reading of high. Resident # 4's next blood sugar check was next performed when it was scheduled to be completed at 4:30 PM, and the result was documented as 524. During an interview with Resident # 9's NP (Nurse Practitioner) on 3/25/25 at 9:00 AM, the NP validated she had not been called on the morning of 1/24/25. The NP further reported she had checked the on-call log for that date, and there was no record of a call being placed to the on-call provider on the morning of 1/24/25 regarding Resident #9. The NP did not know to whom Employee # 1 had spoken before Employee # 1 went into Resident # 9's room with an insulin pen. The interview with Resident # 9's physician revealed she only had given her personal number to the Unit Managers and therefore she did not know how the employee could have reached her. She did not usually answer her phone before 7:00 AM when she was not on call for the medical practice, and she did not know to whom Employee # 1 had spoken on 1/24/25 before going into Resident # 9's room with an insulin pen. According to Resident # 11's record, the resident's 12/16/24 Minimum Data Set assessment coded the resident as severely cognitively impaired, and a review of physician orders revealed he received an anticoagulant. According to nursing notes, Employee # 1 documented Resident # 1 was on the floor on the dates of 12/28/24 and 1/9/25. Within her nursing note of 1/9/25, Employee # 1 documented she did a neurological assessment to make sure the resident did not sustain any blows to the head. Employee # 1 was responsible for making a nursing judgment regarding whether to call the physician that night and there was no documentation she did so although a review of Resident # 11's orders revealed he was receiving Eliquis (an anticoagulant) when the falls were sustained. On 3/24/25 at 8:55 PM the Administrator was notified of Immediate Jeopardy and provided the following Credible Allegation of Immediate Jeopardy Removal Plan Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to implement their abuse and neglect policy to screen, conduct reference checks, and thoroughly evaluate Employee # 1 when she was hired in November 2024. As a result, Employee #1 was hired as a nurse, despite not being licensed as a nurse and provided care to multiple residents during her employment period at the facility which lasted from her hire date in November 2024 until her termination on 2/6/2025. During this time, unlicensed Employee # 1 performed multiple job duties which require education and training to perform correctly to ensure residents are safe and not neglected. This includes but is not limited to blood sugar checks, neurological checks following falls, insulin administration and other medication administration, and oxygen saturation level assessments. Furthermore, the facility failed to implement their abuse/neglect/ and injury of unknown origin policy when Nursing aide # 5 failed to report unexplained injuries- bruises she found on Resident #3 during night shift of 12/17/25 11pm to 12/18/25 7am to the charge nurse on the shift. On 2/6/25 The Human Resource (HR) manager conducted a complete audit of all nursing licenses and CNA certifications to ensure no discrepancies in name spelling or state of residence. There were no discrepancies noted in the audit. 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. On 2/6/25 the Human Resources (HR) manager was performing an audit of nursing licenses and noted a slight discrepancy in the spelling of Employee #1's name on her identification (ID) and the name on the presented Georgia LPN license. It was also noted that employee #1 had a [NAME] North Carolina address on her ID and was practicing with a GA LPN license. Employee #1 was questioned by the HR manager and the DON related to the discrepancies and was immediately removed from resident care duties and terminated. On 2/6/25 the Director of Nursing submitted a complaint to the North Carolina Board of Nursing (NCBON) related to unlicensed employee #1 and the suspicion that she had falsified her credentials as an LPN. On 3/18/25 the NCBON contacted the Director of Nursing and informed her that they had completed their investigation and unlicensed employee #1 had falsified her LPN credentials and advised the DON to contact law enforcement. On 3/18/25 The DON contacted the [NAME] NC Police and filed a report with the findings from the facility internal investigation and the NCBON investigation. Since 2/6/25 the HR manager has continued to evaluate licenses and certifications for any potential nurse or CNA seeking employment to ensure there are no discrepancies with the spelling of names or state of residence. The HR manager also ensures that any potential nurse seeking employment has a valid license and is in good standing with the Board of Nursing (BON). The HR manager also checks the North Carolina Nurse Aide Registry for any potential CNA seeking employment to ensure that they have an active certification and are in good standing. This will prevent any unlicensed or uncertified staff from working in the facility. On 2/6/2024 the HR manager received verbal and written re-education on the hiring policy and all of the above-mentioned steps from the Corporate Human Resources Manager. Any newly hired HR managers will receive this education from the Corporate Human Resources Manager as part of their orientation process. On 3/27/25 the decision was made by the Corporate HR Manager to review and revise the current hiring policy for this center to state that the HR Manager will obtain two professional references prior to employment. The HR Manager will also ensure that all employees undergo background checks prior to employment. On 2/20/25 the DON identified in her investigation of Resident #3's injury of unknown origin that NA #5 had noted bruising and discomfort but had failed to report it to any nurse. The DON then implemented education with all nurses and CNAs on unit 300 about reporting bruising or injuries of unknown origin. The education was face to face and was completed on 2/27/25. On 3/26/25 through 3/27/25 The DON, SDC, and Administrator completed education with all staff on immediately reporting any injury of unknown origin to the DON or administrator. Education was presented face to face or via telephone. There are no Agency nurses currently contracted. Newly hired agency staff will be educated during orientation by the Staff Development Coordinator to immediately report an injury of unknown origin to the DON or administrator. Date of Immediate Jeopardy removal will be 3/28/25. On 3/31/25 the facility's Credible Allegation of Immediate Jeopardy Removal Plan was validated by the following actions: The facility presented evidence of license verification audits per their plan. The facility presented evidence they had reviewed and revised their hiring process per their plan of action to ensure employees were screened to prevent abuse and neglect. The facility presented evidence of inservice records per their removal plan. Interviews were conducted and validated that staff had been trained regarding abuse, neglect, and injuries of unknown origin and were aware they were immediately report instances when identified. The facility's date of immediate jeopardy removal was validated to be 3/28/25. 2. Review of the facility's Plan for the Prevention of Elder Abuse, which was undated and provided to the surveyor as the facility's current policy, included information that it was the responsibility of employees to promptly report any instances of injuries of unknown origin. Review of the facility's investigative file for reportable incidents of injuries for which there was no known cause revealed the following information. On 12/18/24 the facility submitted an initial report, which was completed by Unit Coordinator # 1, to the state agency noting that at 7:20 AM on 12/18/24 Resident # 3 had been identified with a baseball size bruise on the front right shoulder, large hematoma to his left side under arm, swelling and bruising on his left upper chest and below clavicle. The report also noted the resident was unable to lift his left arm without pain and there was swelling. According to staffing sheets, NA # 5 was assigned to care for Resident # 3 on the night shift which began at 11:00 PM on 12/17/24. NA # 5's written statement within the facility's investigative file read, When I was doing my 3:00 AM rounds, upon entering [Resident # 3's] room I noticed he had removed his gown and blanket which he usually does. However I notice some bruising on his arm and chest along with some swelling. Upon me waking him up he seemed startled (more than usual) but he eventually calmed down after I talked with him. I notice while turning him to his left he jerked himself back and became uncomfortable so I turned him back on his back and since he had not soiled himself, I put the gown and blanket back over him. When I came back around 5 AM I did change him but made sure not to roll him on his left arm since that is where his bruise that I noticed was located. Moving forward I will make sure to have another aid to do a walk through with me and/or assist with changes. No matter how minor or major it be if I notice ANYTHING it will be reported to the NURSE and I will leave written reports to the DON. NA # 5 was interviewed on 3/21/25 at 11:25 AM and reported the following information about her 12/17/24 shift which began at 11:00 PM. When she arrived at work, she got report and had been told that Resident # 3 had been washed up by the 2nd shift. He was asleep in bed on first rounds and again at 1:00 AM and she did not disturb him. Around 3:00 AM she noticed Resident # 3 had bruising. There was a golf sized bruise on his arm which appeared light reddish and turning purple. There was bruising on his chest which was larger than what was on his arm, but his gown partially covered the bruise, and she did not pull the gown down to look at the extent of the bruising. She assumed the bruising had happened earlier during another shift and staff were already aware and therefore she did not report it. Nothing had happened on her shift. She did not tell Employee # 1, who she thought was a nurse. She did not immediately report the bruises to anyone. Employee # 1 further reported that after her shift had ended, she later received a phone call from the Director of Nursing and the DON (Director of Nursing) informed her that she was supposed to report bruises immediately to the nurse on duty and not to wait to report.

Based on record review, and interviews with staff, physician, and Nurse Practitioner, the facility failed to ensure Resident # 3 was initially assessed by a nurse after Nurse Aide # 5 identified the resident to have discomfort with positioning, swelling, and bruises on his arm and chest with no known cause and while the resident was not receiving an anticoagulant. When Resident # 3's was assessed the following shift by the physician multiple bruises were found on both arms and the resident's chest which was a broader area than had been reported by Nurse Aide # 5. The bruising was irregular in shape and included both red and purple bruising. The bruises continued to spread and two days following the initial identification of the bruises, Resident # 3 was seen in the ED (Emergency Department) where a CT (Computed Tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma (a collection of blood, usually clotted, outside of a blood vessel) underlying pacer control box measuring 9.5 X 5.2 cm. 2) Superficial soft tissue contusion of the left flank and hip. Additionally, the facility failed to ensure staff communicated amongst themselves effectively regarding Resident # 9's documented elevated finger stick blood sugar readings and also failed to ensure he was monitored for hyperglycemia in order that he receive treatment. On three consecutive days Resident # 9's documented finger stick blood sugar (FSBS) exceeded 400 or registered high on the glucometer after intermittent readings had already exceeded 400 during the month of January 2025. On the evening of 1/24/25 after Resident # 9's last documented finger stick blood sugar (FSBS) reading registered 524 the resident fell in the shower room after becoming dizzy. The resident was transferred to the hospital where he was diagnosed with a small subdural hematoma (type of bleeding near your brain that can happen after a head injury). The facility also failed to ensure Resident # 11 received an assessment by a nurse following falls while on an anticoagulant medication. This was for three of five sampled residents reviewed for professional standards of practice. Immediate Jeopardy began on 12/18/24 for Resident # 3 when Nurse Aide # 5 identified during her shift that Resident # 3 had unexplained bruises, swelling, and discomfort and there was no assessment by a nurse. Immediate Jeopardy began for Resident # 9 on 1/8/25 when his FSBS registered 409 and the facility failed to effectively treat his dangerously high blood sugars. Immediate Jeopardy was removed on 3/28/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E to ensure education is completed and monitoring systems put in place are effective. Example # 3 was cited at a scope and severity level of D. The findings included: 1. Resident # 3 was admitted to the facility on [DATE]. The resident's diagnoses in part included dementia, congestive heart failure, Parkinson's, atrial fibrillation, anxiety, and dysphagia. Review of physician orders revealed Resident # 3 was not ordered to receive an anticoagulant. Resident # 3's annual Minimum Data Set (MDS) assessment, dated 10/14/24, coded the resident as severely cognitively impaired and as needing total staff assistance for bathing, dressing, and hygiene needs. Resident # 3 was coded as needing partial to moderate assistance to roll from side to side in bed and as needing substantial to maximum assistance to transfer. The resident was coded as using a manual wheelchair to roll 50 feet after set-up assistance. The resident was not coded as having falls during the assessment period. Review of Resident # 3's care plan revealed the following information. On 10/19/23 staff added the resident was at risk for falls. This remained part of the resident's active care plan. On 10/27/23 staff added the resident picked at his skin causing skin tears and bruises at times. This remained as part of the resident's active care plan. On 2/10/24 staff added that Resident # 3 could be combative with care. This remained as part of the resident's active care plan. Review of the facility's investigative file for reportable incidents of injuries for which there was no known cause revealed the following information. On 12/18/24 the facility submitted an initial report, which was completed by Unit Coordinator # 1, to the state agency noting that at 7:20 AM on 12/18/24 Resident # 3 had been identified with a baseball size bruise on the front right shoulder, large hematoma to his left side under arm, swelling and bruising on his left upper chest and below clavicle. The report also noted the resident was unable to lift his left arm without pain and there was swelling. Review of staffing sheets revealed on the night shift which began at 11:00 PM on 12/17/24 and ended at 7:00 AM on 12/18/24, Employee # 1 was assigned to care for Resident # 3 as a nurse. Review of Employee # 1's personnel file revealed Employee # 1 was hired as a nurse but was not licensed as a nurse and her application prior to hire indicated no nursing education. During an interview with the DON (Director of Nursing) on 3/21/25 at 9:00 AM, the DON confirmed that Employee # 1 had submitted someone else's nursing license number upon hire in November 2024 and was terminated in February 2025 when this had been validated. At the time she had been caring for Resident # 3 on the night shift of 12/17/24, the facility had not noted she was impersonating a nurse and was not licensed and trained to perform assessments and nursing duties. Review of Employee # 1's statement read, I was collecting [Resident # 3's] routine 02 (oxygen) when I notice he had some bruising to his right shoulder as well as some to his left. No fall or bruising was reported from the previous shift to me in report, so my next thought was to bring it to our unit coordinators attn. that he had bruising on him. Before I could bring it to [Unit Coordinator's] attention it was brought to my attention once more by the next shift and when the unit coordinator got here, I immediately let her know my findings so it could be documented properly. Employee # 1 was interviewed on 3/25/25 at 2:57 PM and acknowledged she had given someone else's nursing license number who shared a similar name to the facility in order to work as a nurse. According to Employee # 1 she completed no type of Nurse Education or Nurse Aide training. She reported she had some medical assistant training from another state but had not completed that either. She was interviewed regarding Resident #3's bruises and reported she had called the DON at 12 something when she saw them on the 11:00 PM to 7:00 AM shift which began on 12/17/24 when she did the oxygen level and saw the bruises. Employee # 1 reported she did not know who obtained Resident # 3's weight which she had recorded. Employee # 1 did not know how the bruises occurred and reported she would never do anything to hurt a resident. A review of Resident # 3's vital sign log revealed Employee # 1 documented Resident # 3's oxygen level was checked at 12/18/24 at 12:56 AM. The reading was 94%. There was no notation it was taken again on Employee # 1's shift. According to staffing sheets, NA # 5 was assigned to care for Resident # 3 on the night shift which began at 11:00 PM on 12/17/24. NA # 5's written statement within the facility's investigative file read, When I was doing my 3:00 AM rounds, upon entering [Resident # 3's] room I noticed he had removed his gown and blanket which he usually does. However, I noticed some bruising on his arm and chest along with some swelling. Upon me waking him up he seemed startled (more than usual) but he eventually calmed down after I talked with him. I noticed while turning him to his left he jerked himself back and became uncomfortable so I turned him back on his back and since he had not soiled himself, I put the gown and blanket back over him. When I came back around 5 AM I did change him but made sure not to roll him on his left arm since that is where his bruise that I noticed was located. Moving forward I will make sure to have another aid to do a walk through with me and/or assist with changes. No matter how minor or major it be if I notice ANYTHING it will be reported to the NURSE and I will leave written reports to the DON. NA # 5 was interviewed on 3/21/25 at 11:25 AM and reported the following information about her 12/17/24 shift which began at 11:00 PM. When she arrived at work, she got report and had been told that Resident # 3 had been washed up by the 2nd shift (3:00 PM to 11:00 PM). He was asleep in bed on first rounds and again at 1:00 AM and she did not disturb him. Around 3:00 AM she noticed Resident # 3 had bruising. There was a golf ball sized bruise on his arm which appeared light reddish and turning purple. There was bruising on his chest which was larger than what was on his arm, but his gown partially covered the bruise, and she did not pull the gown down to look at the extent of the bruising. She assumed the bruising had happened earlier during another shift and therefore the nurses were already aware of it. Nothing had happened on her shift. She did not tell Employee # 1, who she thought was a nurse. She thought Employee # 1 had been in Resident # 3's room before her (NA # 5) at some time during the night shift but she did not see Employee # 1 go into Resident # 3's room and did not know what all she had done for the resident that night. A review of nursing notes revealed the first entry documenting an assessment of Resident #3 was on 12/18/24 at 7:32 AM by Nurse # 1. The entry was entered into the record as a late entry on the date of 12/19/24 at 8:08 AM. The entry read, Resident able to make needs writer made aware during report that resident had bruising to left side of chest, armpits, and arms. VS (vital signs) 128/77 (blood pressure), 97 % on RA (room air), 18 (respirations), 97.9 (temperature), 63 (pulse.) No s/s (signs and symptoms) of SOB (shortness of breath), wheezing or labored breathing. Facial grimacing noted when resident move his left arm. Resident refused to be repositioned . Nurse # 1 further noted Resident # 3 had an order for Tylenol 325 mg (milligrams) 2 tabs every 6 hours. Nurse # 1 also noted the physician was notified and orders were obtained for a stat x-ray on the chest, right arm and left arm. The DON, Unit Coordinator, and Social Worker were also notified. An attempt was made to interview Nurse # 1 on 3/21/25 at 12:01 PM and she could not be reached for an interview. The next nursing entry was dated 12/18/24 at 7:36 PM by Nurse # 2 and read, Was informed from previous shift nurse that resident had discoloration noted to chest area. Resident has discoloration noted to chest, sides of chest, armpits and arms. Measurements obtained and put in DON office Supervisor, MD (Medical Doctor), and DON aware. Nurse # 2 was interviewed on 3/21/25 at 10:28 AM and reported the following information. On the date of 12/18/24 she had reported to work at 11:00 AM because Nurse # 1 had to leave early that day. She had been told about Resident # 3's bruises in report at 11:00 AM and went to assess him and found bruises on his arms and chest. When he talked, he mumbled but if she asked him yes and no questions he would answer simple questions. When asked if he had fallen, Resident # 3 had replied, yes. When asked where he had fallen, Resident # 3 had pointed to the closet area of the room. The resident was not able to convey more about the incident. Review of physician progress notes revealed the resident's physician, who served as the facility medical director, assessed Resident # 3 on 12/18/24. The physician noted, He (Resident # 3) was noted this morning to have bruising on his upper body. Patient has cognitive impairment and is not able to tell us what happened. Last BIMS (brief interview for mental status) 2/15. He seems to only have pain when moving the left shoulder. No documented falls. He was given Tylenol for pain. The physician further documented measurements of the bruising as follows: Note Bruises were irregular shaped and were measured at largest diameter. Right anterior chest upper near midline, about 5.5 X 3.5 cm (centimeters) reddish with some faint purplish area inferior to it. Right shoulder near AC joint (joint at the top of the shoulder) circular reddish abrasion. Right shoulder lateral clavicle about 7 x 6 cm irregular shaped reddish bruise with faint deeper purple underneath it extending further down about 5 X 8 cm at largest diameter. Right arm-3 circular bruises about 1 cm each-2 inner bicep mid to distal and 1 lateral inferior. Left chest wall- Pacemaker scar with 6 small irregular shaped purplish red bruises. Pacemaker appears more lateral and turned/sticking out. Left side -about 7 X 3 cm reddish bruise with faint edges in shoulder near clavicle. Large reddish purple about 10 X 4 cm inferior to tattoo on lateral upper arm. Left arm-irregular shaped bruise going down bicep with varying colors-reddish to darker purple inferior, 12 X 4 cm around to lateral aspect of arm. 8 X 3 cm circular bruise purplish inferior and medial to elbow. Large left chest wall bruise light purplish edges wraps around chest lateral to nipple, darker purple on posterior chest. No ecchymosis (discoloration of the skin, typically caused by bruising) neck, facial area, or body below waist. Within the progress note, the physician noted a chest x-ray and complete blood count would be obtained. The physician further noted that she was unsure when the pacemaker had been placed or last tested . She further noted the pacemaker appeared to be turned/sticking out more. On 12/18/24 at 7:38 PM Nurse # 2 noted Resident # 3's chest x-ray was normal. Review of the 12/18/24 Chest x-ray result showed that the pacemaker was present but did not note any abnormalities with the pacemaker or with the resident's heart or lungs. The radiologist noted the report was negative. A review of Resident # 3's 12/18/24 CBC result revealed the resident's platelet count was normal. (Low platelets can increase the chance of bleeding.) On 12/19/24 Resident # 3 was seen by the NP (Nurse Practitioner) who noted the following information. Resident # 3's CBC (complete blood count) did not show thrombocytopenia (low platelets), and the chest x-ray had been normal. There had been a concern that the resident's pacemaker had been dislodged, and she had asked for a reread of the chest x-ray. Resident # 3 denied pain at the time. Interview with Resident # 3's Nurse Practitioner on 3/24/25 at 5:15 PM revealed she was not aware of how the bruising had occurred. The NP reported she attempted to see if the radiologist, who performed the chest x-ray at the facility, could determine if something occurred to the resident's pacemaker, but they were not able to determine. Review of nursing notes revealed on 12/20/24 at 2:21 PM Unit Coordinator #1 noted that Resident # 3's bruising was spreading from his bilateral shoulders down into his abdomen, left arm, and left side rib cage and he was being transferred to the hospital for further evaluation. Interview with Unit Coordinator # 1 on 3/21/25 at 11:10 AM revealed she first became aware of the bruising on the morning of 12/18/24. She had been stopped in the hallway but did not recall who told her about it. She initially recalled the bruising to be on the resident's shoulder and over time it spread downwards. Review of 12/20/24 ED (Emergency Department) notes revealed the following information was documented. Resident # 3 had extensive chest and abdominal wall ecchymosis. A CT (Computed Tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma (a collection of blood, usually clotted, outside of a blood vessel) underlying pacer control box measuring 9.5 X 5.2 cm. 2) Superficial soft tissue contusion of the left flank and hip 3) No other CT evidence of acute traumatic injury to the chest, abdomen, or pelvis. 4) emphysema, 5) coronary artery disease. Upon preparing for discharge, the ED physician did not note any further comments about the hip contusion. The ED physician did note CT scan obtained demonstrating hematoma around his pacemaker site but otherwise superficial contusion. There was no notation regarding how the hematoma could have formed around the pacemaker site. The resident was noted to be stable for discharge from the ED with a final diagnosis of chest wall hematoma, left and superficial bruising of back, left. There were no ED discharge orders. On 12/20/24 at 10:55 PM Nurse # 1 documented Resident # 3 returned from the hospital in no distress, no pain, and no new orders. Interview with the Director of Nursing at 5:30 PM on 3/21/25 revealed the facility had not recognized that Employee # 1 was not licensed and trained to do an assessment of Resident # 3 when she was caring for him during the time the injury was first observed on her shift. 2. Record review revealed Resident # 9 was admitted to the facility on [DATE] and had diagnoses which in part included diabetes, Alzheimer's dementia, atrial flutter, cardiomyopathy, and congestive heart failure. Review of physician orders revealed Resident # 9 was ordered to receive Eliquis 5 mg (milligrams) every 12 hours for atrial flutter. This order began on 11/8/24. (Eliquis is an anticoagulant and increases the chances of bleeding). Review of Resident # 9's admission Minimum Data Set assessment, dated 11/13/24, coded Resident #9 as severely cognitively impaired. The resident was also coded as needing partial to moderate assistance with his bathing needs, as ambulatory with supervision, and occasionally incontinent of urine. Resident # 9's care plan included the information that Resident # 9 was a diabetic. This was added to the care plan on 11/8/24 and remained part of the Resident # 9's active care plan. Staff were directed on the care plan to monitor blood sugar levels as ordered and both observe and report any signs and symptoms of hyperglycemia or hypoglycemia. Review of physician orders and Resident # 9's January 2025 MAR (medication administration record) revealed the following information. Resident # 9 had an order for FSBS (fingerstick blood sugars) twice per day. This order originated on 11/8/24 and was in effect until discontinuation on 1/27/25. According to the January 2025 MAR, the FSBS's were scheduled for 6:30 AM and 4:30 PM. There were no orders for parameters to call the provider regarding results and there was no order for sliding scale insulin coverage based on FSBS results. Review of physician orders revealed between the dates of 1/1/25 and 1/24/25, the only type of insulin Resident # 3 was prescribed was a long- acting insulin given at night and there was one order change in Resident # 9's diabetic medication dosages. Specific medications and the dosage order change were as follows: Jardiance 25 mg (milligram) tablet once per day. This order was in effect from 12/7/24 until its discontinuation on 1/27/25. Metformin 500 mg tablet twice per day. This order was in effect from 12/13/24 until discontinuation on 1/27/25. Ozempic pen injector; 0.5 mg; subcutaneous once per week on Monday. This order was in effect from 11/11/24 until discontinuation on 1/27/25. Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Administer 15 units subcutaneous at bedtime. This order was in effect from 12/31/2024 until the discontinuation on 01/06/2025. (Lantus is a long acting insulin which can last up to 24 hours but does not have a rapid onset of action). Insulin glargine-yfgn insulin pen; 100 unit/mL (3 mL); Administer 15 units subcutaneous at bedtime. This order was in effect from 1/6/25 until discontinuation on 1/18/25. (Insulin glargine-yfgn is a biosimilar interchangeable insulin product to insulin glargine which the resident was already receiving. There were no dosage changes). According to the record, the physician saw the resident on 1/18/25 and noted his hemoglobin HgbA1c (hemoglobin A1C) on 12/24/24 had been 9.2 and she would increase the resident's long- acting insulin from 15 to 18 units. (Hemoglobin A1c is a blood test that measures the average blood sugar result in the last two to three months. A result of 6.5% and above reflects diabetes.) The date of 1/18/25 was the only date where an increase in insulin dosage order was noted in the chart from 1/1/25 to 1/24/25. The order was for insulin glargine-yfgn insulin pen; 100 unit/mL (3 mL); Administer 18 units subcutaneous at bedtime. This order was in effect until discontinuation on 1/27/25. Review of Resident # 9's MAR revealed the following FSBS results documented. On 1/8/25 at 6:30 AM Employee # 1 (an unlicensed employee) documented 409 on the MAR. On 1/10/25 at 6:30 AM Nurse # 6 documented 433 on the MAR. On 1/10/25 at 4:30 PM Nurse # 7 documented 423 on the MAR. On 1/18/25 at 4:30 PM Nurse # 8 documented 413 on the MAR. On 1/22/25 at 6:30 AM Medication Aide (MA) # 1 documented 453 on the MAR. On 1/22/25 at 4:30 PM MA # 2 documented 456 on the MAR. On 1/23/25 at 6:30 AM Nurse # 9 documented 419 on the MAR. On 1/23/25 at 4:30 PM MA # 3 documented 403 on the MAR. On 1/24/25 at 6:30 AM MA # 4 documented high on the MAR. On 1/24/25 at 4:30 PM Nurse # 5 documented 524 on the MAR. There was no documented nursing progress note with an assessment of Resident # 9 when the resident's blood sugar registered high on 1/24/25 at 6:30 AM. There were no orders entered into the record. MA # 4 was interviewed on 3/25/25 at 10:28 PM and reported the following information. She recalled Resident #9's blood sugar registering high on the morning of 1/24/25. At the time she was to be reporting to Employee # 1, who she thought was a nurse at the time. She told Employee # 1 about the high blood sugar and Employee # 1 stated she would check the record for sliding scale orders and call the physician. She saw Employee # 1 make a phone call and talk to someone, but she did not know to whom she was talking to. Afterwards Employee # 1 asked to look in her (MA # 4's) medication cart, obtain an insulin pen, and go into Resident # 9's room. She did not know what insulin pen Employee # 1 had obtained or what she had done when she went into the room. When she had checked the FSBS, Resident # 9 had appeared okay. Employee # 1 was interviewed on 3/25/25 at 3:30 PM and reported the following information. She had applied and been accepted to work at the facility as a nurse. She had provided a false license to the facility and had no nursing education nor a license to perform job duties of a nurse. She had taken care of diabetic family members and had some partial training as a medication assistant in another state. On the morning of 1/24/25 when Resident # 9's blood sugar registered high she had called the doctor and gotten an order for some insulin. She had given the insulin. When interviewed about the issue that Resident # 3 did not have any short acting insulin ordered and filled for her to access for him, Employee # 1 replied they kept some on the cart or in back up for times such as this. An interview with Nurse # 9, who had worked on Resident #9's unit, revealed the facility did not keep back up insulin stored on medication carts for newly ordered insulin. Interview with Resident # 9's NP (Nurse Practitioner) on 3/24/25 at 5:15 PM and with the Physician on 3/27/25 at 1:42 PM revealed they did not know who Employee # 1 had called on the morning of 1/24/25 because there was no history of calls to them or the on-call provider. According to staffing sheets, Unit Coordinator #1 worked as a floor nurse on the day shift on 1/24/25 and cared for Resident # 9. Unit Coordinator # 1 was interviewed on 3/25/25 at 12:46 PM and reported the following information. She could not recall the details of 1/24/25. In general, if she had been informed in report that Resident # 9's blood sugar was high, then she would have asked what had been done about it and ensured that this was all documented. She would have rechecked it herself and monitored the resident. Review of the record revealed no nursing progress notes on dayshift showing the blood sugar was rechecked and the resident was monitored on the dayshift of 1/24/25. According to the Medication Administration record, the next time the resident's blood sugar was checked again following the reading on 6:30 AM was on 1/24/25 at 4:30 PM by Nurse # 5. The result was 524. There was no assessment of the resident at that time or a documented follow-up reading. Nurse # 5 was interviewed on 3/25/25 at 1:26 PM and reported the following information. She had never received information in report that Resident # 9's blood sugar had been too high to register on the glucometer earlier that morning. She had cared for him on the evening shift (3:00 P to 11:00 PM) on 1/24/25. She was new at the time on 1/24/25 when Resident # 9's FSBS registered 524. She was walking to the desk to call the physician when she saw MA # 1. She asked MA # 1 if Resident # 9's FSBS usually ran high, and MA # 1 told her that Resident # 9 would get sugary things on his hands and recommended to clean his finger better and recheck it. There was not much time between Nurse # 5 talking to MA # 1 before she then went back to recheck the FSBS. She then obtained a result in the 300s but did not recall what it was. Nurse #5 thought she had documented the repeat FSBS but had not done so. Nurse # 5 was interviewed regarding whether she had cleaned Resident # 9's finger well the first time and responded that she thought she had done so. Nurse #5 further stated during her shift Resident # 9 appeared to be okay. Further review of nursing notes revealed the only nursing progress note on 1/24/25 was dated 1/24/25 at 7:16 PM and was written by Nurse # 10. Nurse # 10 documented at this time that Resident # 9 was in the shower with staff present. The resident became dizzy and fell . Resident # 9 sustained a laceration to his head with minimal bleeding. Nurse # 10 further documented that given the resident was on an anticoagulant, the resident was transferred by EMS (Emergency Medical Services) to the hospital. Interview with Nurse # 10 on 3/25/25 at 10:44 AM revealed she had not been caring for Resident # 9 at the time he fell on [DATE] but was closest to the shower room when Resident #9 fell . He had a cut to his head, so he was not moved. A Nurse Aide held pressure to the cut to stop the bleeding and she called 911. Interview with Nurse Aide # 7 on 1/25/25 at 1:40 PM revealed the following information. She had cared for Resident # 9 on the evening shift of 1/24/25. It seemed to her that Resident #9 did not feel well. He barely ate his evening meal. He was usually continent of urine and would go to the bathroom on his own. That evening he was soaked from urine. Therefore, she offered to take him to the shower room for a shower. When Resident # 9 initially stood up, he seemed dizzy and struggled to remain steady on his feet. She was able to walk him with a rolling walker to the shower. Once in the shower she let him sit to remove his top clothing. Then she helped him to stand, and as she was pulling down his pants he suddenly went blank and just fell over. She immediately called the nurse, and they called 911. Review of EMS records revealed the EMS paramedics arrived at 7:23 PM on 1/24/25 and Resident # 9 was alert and did not complain of blurred vision or dizziness at the time of their arrival. The paramedics documented Resident # 9's blood pressure was 101/55, pulse 61, respirations, 20, and oxygen saturation 99%. The paramedics did not record a blood sugar check. Review of the hospital records for the date of 1/24/25 to 1/30/25 revealed the following information. Resident # 9 was diagnosed with a small subdural hematoma. His blood sugar was 305 at 8:40 PM on 1/24/25 when drawn by the lab. The hospital physician noted Resident # 9's last HgbA1C was 10.2. The hospital physician noted the resident should receive both long acting and short acting insulin upon discharge back to the facility. Also, the hospital discharge summary included information that the resident had been hypotensive when he arrived to the hospital and his Toprol (used for heart failure) was held. Also, while hospitalized , neurosurgery was consulted and recommended holding the resident's anticoagulant medication. Prior to discharge, a repeat CT scan was performed to ensure the resident's subdural hematoma had not worsened. Discharge orders included that the resident should be placed on sliding scale insulin coverage and in addition to the prescribed sliding scale insulin, when the FSBS was greater than 400, the primary physician should be contacted. On 1/30/25 Resident # 9 returned to the facility with the new insulin orders and designated parameters to call the physician. On 3/25/25 at 8:55 PM the Administrator was informed of Immediate Jeopardy and provided the following Credible Allegation of Immediate Jeopardy Removal Plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #3 was noted with significant chest and upper arm bruising on 12/18/24. NA #5 failed to notify any nurse of the bruising, discomfort with positioning, and swelling of the bruised area when she first saw the bruises. Her failure to report the bruising to the nurse delayed the assessment and treatment of Resident #3 by any nurse and the provider. In the month of January 2025 Resident # 9 experienced multiple instances of seriously elevated blood sugars (greater than 400). During this time period resident # 9 did not have orders for sliding scale insulin or parameters for notifying physician of blood sugar elevations. During January several nurses, including employee #1 and nurse #5 failed to notify the provider or nurses on subsequent shifts of these seriously high blood sugars resulting in the delayed assessment, treatment, and monitoring. And, as a result of the failure resident # 9 experienced hyperglycemia. On 1/24/25 at 6:30am a blood sugar check for resident # 9 was performed and the reading of high was recorded on the medication administration record. Per her statement at 6:30 a.m. MA # 5 witnessed unlicensed Employee # 1 go into the resident #9's room with an insulin pen although there were no orders for any insulin at that time and no record of the physician giving orders. On 1/24/25 the unit manager was working as the floor nurse for resident #9 during the day shift, and in her statement the unit manager could not recall the specifics of 1/24/25 but stated that if she had been told in report that the resident's blood sugar was high she would have made sure the resident was monitored and follow up done. The unit manager also indicated that if she had been aware of the seriously elevated blood sugar, she would have requested orders from the provider and entered a nursing progress note of her actions. No new orders or progress notes were entered for dayshift on 1/24/25. A statement from the evening shift nurse for 1/24/25 indicated that it was never communicated to her that the resident's blood sugar was high at the 6:30 a.m. blood sugar check. When she performed the 4:30 p.m. blood sugar check the first time she received a reading of 524. A short time later the nurse re-checked the blood sugar again and received a reading in the 300s. Later in the evening shift on 1/24/25 resident #9 reported dizziness and did sustain a fall in the shower. The hyperglycemia experienced by Resident #9 shows that the Employee #1 failed to assess the resident, notify provider, and communicate the elevated blood sugar to the oncoming shift with this resulting in the resident experiencing a fall that evening. On 3/26/25 body audits were completed by unit coordinators for all 3 units to identify [TRUNCATED]

Based on record review and staff and Physician interviews the facility failed to have a system in place to ensure staff who were hired as nurses were trained and competent to perform their job duties. Employee #1, who was not licensed as a nurse and had no documented nursing education, worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. Her job duties included, but were not limited to: insulin administration, blood sugar monitoring, medication administration, assessments of a resident who sustained falls while on an anticoagulant (blood thinner), and utilizing nursing judgement to make decisions. These job duties required knowledge and education to perform safely. There was no documented competency evaluation completed for Employee #1's job duties or nursing skills. On the nursing shift which began at 11:00 PM on 12/17/24 Employee #1 was assigned to Resident #3, who was not on an anticoagulant, when she identified bruising to the resident's shoulders with no known cause. Employee #1 was responsible for assessing the resident and utilizing nursing judgement for decisions on when to notify the physician. On 1/24/25 Employee #1 was informed by a Medication Aide (MA) that Resident #9's finger stick blood sugar (FSBS) registered outside of the meter's highest measurable range indicating a dangerously high blood sugar reading. Employee #1 was responsible for assessing the resident, providing insulin, and utilizing nursing judgement for decisions regarding when to notify the physician for blood sugar readings. On 12/8/24 and 1/9/25 Resident #11, who had severe cognitive impairment and was on an anticoagulant, experienced falls. Employee #1 was assigned to Resident #11 on both dates and was responsible for assessing the resident and utilizing nursing judgement for decisions regarding when to call the physician. Allowing Employee #1 to work in the capacity of a licensed nurse with no verification of her competencies affected Resident #3, Resident #9, and Resident #11 in addition to placing all residents Employee #1 was assigned to care for in the capacity of licensed nurse at a high likelihood of a serious adverse outcome or harm. Additionally, the facility failed to verify the competencies of Nurse #13 and Nurse #14. This was for three of three staff (Employee #1, Nurse #13, and Nurse #14) whose personnel files were reviewed for competency. Immediate jeopardy began on 11/5/24 when the facility allowed Employee #1, who fraudulently presented herself to the facility as a licensed nurse, to work in the capacity of a licensed nurse without verifying she was trained and competent to perform licensed nurse skills and duties. Immediate Jeopardy was removed on 3/28/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity E to ensure education is completed and monitoring systems put in place are effective. Example 1b. and 1c. were cited at a scope and severity of E. The findings included: 1a. Review of Employee # 1's personnel file records provided to the state surveyor revealed the following information. Employee # 1's application for employment was signed as submitted on 10/21/24 for a position as a licensed practical nurse/registered nurse on third shift from 11:00 PM to 7:00 AM. The only employment history included on the application noted Employee # 1 had attended an out-of-state high school. No further education experience was listed. Under the question, Please indicate education or skills training which you believe qualifies you for the position you are applying, Employee # 1's typed response was, CNA (certified Nurse Aide and 5 years of home health. The Administrator and DON (Director of Nursing) were interviewed together on 3/21/25 at 9:00 AM and a follow up interview was conducted with the DON again on 3/21/25 at 9:45 AM revealing the following information. Employee # 1 presented herself falsely as a licensed nurse when she applied for employment and provided the facility with another individual's nursing license. The name on the nursing license, which was provided to the facility, was similar to Employee # 1's name. She was hired on 11/5/24 and continued to work until her termination on 2/6/25. The records of three residents, who were cared for by Employee # 1 while she worked as a Nurse, were reviewed. Although not all inclusive of all the nursing task performed and judgements made by Employee # 1 while employed at the facility, these three records revealed some of the following examples of nursing duties performed or required of Employee # 1 to be done safely. Employee # 1 had been the responsible assigned Nurse for Resident # 3 on the night shift which began on 12/17/24 at 11:00 PM. Review of a facility investigative report revealed during this shift, revealed Resident # 3 was identified by Resident # 3's Nurse Aide to have unexplained bruises to his chest and arm which were accompanied by swelling and discomfort with positioning during this shift. Employee # 1 would have been responsible for the assessment and notification of the physician during the night shift, and per her statement in the investigative file she was aware of the bruises during the night shift. She noted in her statement she had seen bruises on his shoulders. The interview with the physician on 3/21/25 at 3:13 PM revealed she or another provider had not been notified by Employee # 1, and this should have been done. During the interview with the physician, the physician reported the bruising was all on the resident's upper body which included areas on his arms and chest wall which wrapped around some on his torso. He was also having some left shoulder pain. The physician further reported that Resident # 3 was a cognitively impaired resident and could not report what had happened. Further review of Resident # 3's nursing notes and 12/20/24 and hospital ED (Emergency Department) records revealed Resident # 3's bruising continued to spread, and a CT (computerized tomography) scan performed on 12/20/24 at the hospital showed the resident had a large left subpectoral hematoma underlying his pacer control box measuring 9.5 X 5.2 cm. (centimeters) and superficial soft tissue contusion (bruising) of the left flank and hip. Per record review Employee # 1 was responsible for performing FSBS (Finger Stick Blood Sugar Checks) for Resident # 9 and making judgements about when to call the physician for blood sugar readings. There was documentation in Resident # 9's record that Employee # 1 administered Insulin to Resident # 9 according to Resident # 9's MAR (Medication Administrator Record). On 1/8/25 when Employee # 1 documented on the MAR Resident # 9's FSBS was 409, there was no documentation the physician was notified and orders received although the resident had no sliding scale insulin coverage ordered at the time. Furthermore, per a 3/25/25 interview at 10:28 AM with Medication Aide (MA) #4, MA # 4 reported the following information. She (MA # 4) had taken Resident # 9's FSBS on 1/24/25 when it was due to be checked at 6:30 AM. The result was high and did not register on the glucometer. She reported the result to Employee # 1, who at the time MA # 4 believed to be a nurse. She (MA # 4) observed Employee # 1 call someone. She did not know who Employee # 1 called and did not know what she said to them. Later Employee # 1 received a notice that someone was on the phone line for her. She (MA # 4) again saw Employee # 1 talk to someone but did not hear the conversation. After the conversation, Employee # 1 went through the insulin pens on the medication cart, removed one, and walked into Resident #9's room. MA # 4 did not know what type of insulin pen was removed or to whom it belonged. A review of the chart revealed no documentation or orders for any insulin administration to address Resident # 9's 1/24/25 6:30 AM FSBS reading of high. Resident # 9's next blood sugar check was performed next when it was scheduled to be completed at 4:30 PM, and the result was documented as 524. During an interview with Resident # 9's NP (Nurse Practitioner) on 3/25/25 at 9:00 AM, the NP validated she had not been called on the morning of 1/24/25. The NP further reported she had checked the on-call log for that date, and there was no record of a call being placed to the on-call provider on the morning of 1/24/25 regarding Resident # 9. The NP did not know to whom Employee # 1 had spoken before Employee # 1 went into Resident # 9's room with an insulin pen. The interview with Resident # 9's physician revealed she only had given her personal number to the Unit Managers and therefore she did not know how the employee could have reached her. She did not usually answer her phone before 7:00 AM when she was not on call for the medical practice, and she did not know to whom Employee # 1 had spoken. According to Resident # 11's record, the resident's 12/16/24 Minimum Data Set assessment coded the resident as severely cognitively impaired, and a review of physician orders revealed he received an anticoagulant. According to nursing notes, Employee # 1 documented Resident # 1 was on the floor on the dates of 12/28/24 and 1/9/25. Within her nursing note of 1/9/25, Employee # 1 documented she did a neurological assessment to make sure the resident did not sustain any blows to the head. Employee # 1 was responsible for making a nursing judgment regarding whether to call the physician that night and there was no documentation she did so although a review of Resident # 11's orders revealed he was receiving Eliquis (an anticoagulant) when the falls were sustained. Review of Employee # 1's personnel file and training records revealed there was a Nursing Assistant-Skills Checklist in the file. The checklist had multiple job duties typically assigned to Nurse Aides and areas where the form was to be dated and signed showing satisfactory return demonstration. According to the form, Employee # 1 had this form completed in her file with the notation that the SDC (Staff Development Coordinator) had observed return demonstration on the Nurse Aide skills listed. There was no similar skills checklist to demonstrate Nurse competency for tasks and skills Employee # 1 was responsible for while working as a nurse. The file also contained: directions on how to perform the Heimlich Maneuver; an ADL Coding Quiz; a check-off sheet for use of a mechanical lift and safe handling of residents; the facility's electronic medical system Nurse Aide Checklist; a checklist orientation of nursing assistants (which included resident rights and abuse and neglect); handwashing checklist; a hand hygiene quiz; competency on PPE (personal protective equipment; a nursing home infection prevention test; a general orientation checklist; education regarding the role of a licensed nurse as it relates to what a medication aide and Nurse Aide II can do; a checklist for the facility's electronic medical record system; a copy of instructions on how to perform a FSBS; an unsigned job description for a NC licensed Practical Nurse/Charge Nurse; and a multiple choice test entitled, Nurse Orientation Program Evaluation Questions, which included some medication questions. The last page of the evaluation form was the only page that indicated the evaluation was completed by Employee # 1 by requiring a signature and date. Employee # 1's signature with the date of 11/8/24 was on this last page. The last two medication questions were marked through and not answered. There were a total of 40 questions on the evaluation form. One example on the evaluation form was the question, Before preparing a resident's medication, the nurse should A) take a deep breath or B) check to be sure the resident is in his/her room. Employee # 1 had circled both A and B. Another question read, Correct medication administration time for a scheduled dose is A) plus or minus 1 hour of the scheduled dose B) plus or minus 30 minutes of the scheduled dose C) plus or minus 2 hours of the scheduled dose or D) all but A. Employee # 1 had answered, D indicating she incorrectly thought that she could administer scheduled medications plus or minus 2 hours. The SDC was interviewed on 3/21/25 at 9:20 AM and on 3/21/25 at 4:00 PM and reported the following information. When nurses were hired, they went through a four-day classroom orientation. The first two days were general education with all new employees. The third and fourth day included Nurse Aides, Medication Aides, and Nurses together. She checked the nurses off on Nurse Aide duties which nurses would be overseeing. She then included the Nurse Aide checklist in the Nurse's personnel file. The nurses were also required to watch instructional videos and complete the evaluation form with questions. There were four tasks she observed nurses to perform during the four-day orientation. They were: a glucometer check, putting on and taking off of PPE (personal protective equipment), use of mechanical lifts, and handwashing. Nurses were also required to show they could use an insulin pen but there was no sign off on that during orientation. According to the SDC she had done these tasks with Employee # 1. Following their four-day orientation, then the nurse was partnered with another experienced nurse for at least three days. The Scheduler would know with whom Employee # 1 was partnered after Employee # 1 completed the four-day orientation. The SDC was interviewed regarding competencies and training on other nursing tasks which there was no indication of evaluation and validation in Employee # 1's file. The SDC reported nurses were also required to watch a library of further videos on their own and take quizzes. The SDC indicated the last two questions on Employee # 1's form, which were blank, had not been required of the group when the test was taken. The Nurse Staffing Coordinator was interviewed on 3/21/25 at 3:05 PM and reported the following information. Employee # 1 had been partnered with Nurse # 11, Nurse # 12, and Nurse # 7 following her classroom orientation. She typically partnered a new nurse with an experienced nurse for a week and the new nurse could let her know if they needed more time with an experienced nurse. Employee # 1 did not request any further time. The interview further revealed the facility used to have a competency form used to check and validate a new nurse's skills, but that was not done for Employee #1 and was not being utilized anymore for newly hired nurses. The Nursing Staffing Coordinator provided no reason a competency form was not being used. Nurse # 7, who was one of the nurses partnered with Employee # 1, was interviewed on 3/24/25 at 6:50 AM and reported the following information. She had only been partnered with Employee # 1 for orientation purposes one night. Employee # 1 had acted disinterested and followed her (Nurse #7) around as she cared for residents. Employee # 1 watched Nurse # 7 do tasks and duties, but she (Nurse #7) did not observe Employee # 1 perform tasks and duties. It was more of showing Employee # 1 routines. Following that night, she (Nurse # 7) did not work directly with Employee # 1 but she (Nurse # 7) was aware that Nurse # 9 would receive a nursing report from Employee # 1 in the morning at times and Nurse # 9 had some concerns. Nurse # 9, who would at times receive report from Employee # 1, was interviewed on 3/24/25 at 7:18 AM and reported the following information. She thought Employee # 1 was dumb and just had not received a good education. An example was regarding checking oxygen saturation levels. Employee # 1 reported in shift change report a particular resident's oxygen level had been around 86% or 87% and Employee # 1 was not able to say in report what was done about it. She (Nurse # 7) went to that resident's room and checked it herself and the oxygen level was okay when she checked it. She took Employee # 1 to this resident's room and showed her what to do, while thinking that she just had not been educated well about checking oxygen saturation levels and measures to take if it was low. Nurse # 7 reported she was not aware of this resident, who utilized oxygen, ever being harmed or experiencing difficulty due to Employee # 1 taking care of him. Nurse # 11, who was one of the nurses partnered with Employee # 1, was interviewed on 3/24/25 at 9:23 AM and reported the following information. Employee # 1 struck her as a new nurse. She (Nurse # 11) had mainly helped Employee # 1 with paperwork. The first few nights Employee # 1 followed her (Nurse # 11) and she showed Employee # 1 routines. Then she told Employee # 1 she would be there for back up and Employee #1 had her own assignment. Nurse # 11 was interviewed regarding what tasks and duties she observed Employee # 1 to perform. She reported that tube feedings were difficult for Employee #1. Employee # 1 didn't seem to know how to get started, and she (Nurse # 11) thought it was just because Employee # 1 was a new graduate. She (Nurse # 11) had therefore showed Employee # 1 how to administer a tube feeding and afterwards watched her do it. After she showed Employee # 1 what to do, she did it correctly. She (Nurse # 11) watched her administer some medications but never watched Employee # 1 do a complete medication pass. She did not recall ever watching her administer insulin to anyone. She never observed Employee # 1 performing dressing changes or a physical assessment of a resident which would entail listening to their heart and lungs or a neurological assessment. She (Nurse # 11) only worked at the facility as needed and had only worked with Employee # 1 for a few nights. She (Nurse # 11) thought it might have been six or seven times she had worked with her. She was not aware of any cases where a resident was hurt while under Employee # 1's care. She (Nurse #11) never signed off on anything she had observed Employee # 1 to do. There had been no competency checklist to complete for Employee # 1. Nurse # 12, who according to the Nurse Staffing Coordinator had worked as one of the three partnering nurses with Employee # 1, was interviewed on 3/25/25 at 9:37 AM and reported the following information. She did not recall how many days she had worked with Employee # 1. When she worked with Employee # 1, she let Employee # 1 first watch her and follow along. Employee # 1 asked questions which seemed appropriate to Nurse # 12, and it did not stand out that Employee # 1's abilities should be questioned. There were not a lot of night shift (11:00 PM to 7:00 AM) medications to be given and night shift was when she worked with Employee # 1. She also watched Employee # 1 perform some tasks but there was no competency check off list that was completed showing all the tasks that she had observed Employee # 1 to perform. She had watched Employee #1 check a blood sugar and give insulin. She had never watched her do a neurological assessment of a resident. She had instructed Employee # 1 that a neurological assessment would need to be done after a resident fell but never watched her do one and did not check to make sure she knew how to do one. She did not recall how many days she had worked with Employee # 1 before Employee # 1 started working independently. The only thing that stood out as problematic was that one time it was brought to Nurse # 12's attention that Employee # 1 was not documenting in a professional manner by using medical terms. The Wound Care Nurse was interviewed on 3/21/25 at 9:55 AM and reported the following information. She had noticed that Employee # 1's documentation did not appear professional. Examples she had noted were as follows: Employee # 1 documented that she had mixed some cream and applied the cream to a resident's lady parts. The Wound Nurse did not recall which resident this was. Also, Employee # 1 would refer to checking a resident for blows to the head. She had called it to the attention of the Director of Nursing and the DON immediately looked into this. NA # 4 was interviewed on 3/24/25 at 3:21 PM and reported the following information. She had worked with Employee # 1. There was nothing that seemed to stand out that Employee # 1 did not know what she was doing except for a couple times when a Medication Aide mentioned that Employee # 1 did not know how to catheterize a resident to get a urine specimen. NA # 4 did not recall the specific resident. She reported she was not aware of anything bad that happened to the resident that needed a urine specimen, and she did not know how the specimen was finally obtained. NA # 5 was interviewed on 3/21/25 at 11:25 AM and reported the following. There was a resident who had a catheter, but his brief would become wet during the night. He would ask her (NA # 5) to have the nurse check it. She would report it to Employee # 1 and even after she reported it, the resident's brief was still wet as if nothing had been done. She did not recall specific dates this had occurred. Employee # 1 was interviewed on 3/25/25 at 3:30 PM and reported the following information. She knew it was a shot in the dark when she applied for a nurse job at the facility. She never thought that the facility would reach out to her after she submitted the application, but they did. Although she had never finished any type of formal health care training, she had gone to medical assistant school in another state, and she did know about health care to some degree. She also had taken care of family members who were bedridden or diabetics and reported herself to be a fast learner. She told the facility during the interview she had health care experience. They never asked her for a license. She was surprised when the facility did call her and offer her a job. They called and texted her to come to training and the training had already started. There was supposed to be four days of orientation, and she started on the last two days of the scheduled orientation. Then they put her with a nurse on night shift for about two or three days and she went to work. She had been working for about two weeks before they even asked her about a license. She looked up her name on a website and found someone with a similar name to her that had a nursing license, and she decided to give that to the facility. She did not think the facility would accept it and she was baffled myself when they did, but they never questioned it and let her come back to work. Her intent was never to hurt anyone, and it was her perception that she did just as well as the other nurses who had a license. She was trying to go back to school to actually get a license while she was working at the facility. The Administrator was notified on 3/25/25 at 8:55 PM of Immediate Jeopardy. The Administrator presented the following Credible Allegation of Immediate Jeopardy Removal Plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Employee #1 was hired as a nurse on 11/5/2024 without qualifications. A timecard report in the Paycom payroll system indicated that employee #1 attended and completed 3 out of 4 days of her scheduled orientation. The center failed to ensure that employee #1 completed a formal nursing competency form to ensure she was competent to perform job duties. During this time, unlicensed Employee # 1 performed multiple job duties which require education and training to perform correctly to ensure residents are safe and not neglected. This includes but is not limited to blood sugar checks, neurological checks following falls, insulin administration and other medication administration, and oxygen saturation level. Unlicensed employee #1 through her actions of falsifying her nursing license had the high likelihood of failing to identify changes in resident conditions, and the high likelihood of providing inadequate care to any resident in the facility. Resident #9 did experience an untreated elevated blood sugar of 409 on 1/8/25 at 6:30 AM and a high blood sugar on 1/24/25 at 6:30 A.M. The unlicensed employee #1 failed to notify the provider of the hyperglycemic event and Resident #9 was not treated for hyperglycemia. Employee #1 was responsible as a nurse for Resident #3 on the night shift when NA #5 noted Resident #3 to have bruises, swelling and discomfort with positioning. There was no documentation of an assessment by employee #1 and there was no documentation that employee #1 had been evaluated to be competent in assessment skills in the personnel file. An audit was conducted on 3/26/25 by the Staff Development Coordinator (SDC) to identify all newly hired nurses since 2/6/2025 to ensure that all components of the current nurse orientation process were completed. No discrepancies were identified. Specify the action the entity will take to alter the process or system failure to prevent a serous adverse outcome form occurring or recurring, and when the action will be complete. Employee #1 was terminated on 2/6/2025. On 3/27/25 the Director of Nursing (DON) and SDC were educated by the Assistant Regional nurse consultant on a nursing competency form. On 3/27/25 the Assistant Regional nurse consultant notified the Staff Development Coordinator (SDC) of the following process: The SDC will initiate the nursing competency form in orientation for all newly hired nurses. The newly hired nurse will be partnered with an experienced nurse and the experienced nurse will observe the newly hired nurse complete the tasks on the competency form. Any unsatisfactory demonstrations will be communicated to the Staff Development nurse for further training with the newly hired nurse. The newly hired nurse will have 90 days to complete the nursing competency form. The SDC will review the newly hired nursing competency form after 90 days and any areas the newly hired nurse could not complete on the competency (i.e. nasogastric tubes, tracheostomies) will be performed on the nursing training mannequin for competency. On 3/27/25 the SDC was educated by the Assistant Regional nurse that nurses who are partnered with the newly hired nurse will be educated on the competency form by the Staff Development coordinator prior to being scheduled with the newly hired nurse and their responsibility to check the newly hired nurse off on the competency when they are scheduled to work with the newly hired nurse. On 3/27/25 the Assistant Regional Nurse educated the Staffing coordinator that she will be responsible for notifying the SDC which nurses the newly hired nurse will be working with. Immediate jeopardy removal will be 3/28/2025 On 3/31/25 the facility's Credible Allegation of Immediate Jeopardy Removal Plan was validated by the following actions: The facility presented a nursing competency form which they had devised to utilize for newly hired nursing staff. The multipage competency form covered multiple tasks that nurses were required to demonstrate as evidence of competency. The facility presented evidence the Staff Development Nurse had been educated about competency evaluations for nurses. A nurse, who had recently been hired within the past few weeks, was interviewed and reported the facility began using the new competency form with her and she had started having her skills checked off on 3/28/25 as being observed by another nurse. The facility's date of immediate jeopardy removal was validated to be 3/28/25. 1b. Review of Nurse # 14's personnel records and training records provided to the state surveyor revealed Nurse # 14 was hired on 2/25/25. Nurse # 14 was interviewed on 3/24/25 at 3:27 PM and reported she had already been an employee at an earlier time period and was familiar with the facility policies and procedures. Upon her rehire she watched videos and took test. She was then partnered with another nurse on the floor who did skills with her and showed her how to use the facility's electronic medical record system. A review of training records did not reveal a competency validation form for all the nursing skills for which Nurse # 14 would be responsible. The Nurse Staffing Coordinator was interviewed on 3/21/25 at 3:05 PM and reported the following information. She typically partnered a new nurse with an experienced nurse for a week and the new nurse could let her know if they needed more time with an experienced nurse. They used to have a competency form used to check and validate a new nurse's skills, but that was not being utilized anymore. The Nursing Staffing Coordinator did not provide a reason why the competency form was not being used anymore. 1c. Review of Nurse # 13's personnel records and training records provided to the state surveyor revealed Nurse # 13 was hired on 2/25/25. An attempt was made to interview Nurse # 13 on 3/24/25 at 1:33 PM and she could not be reached. A review of training records did not reveal a competency validation form for all the nursing skills for which Nurse # 14 would be responsible. The Nurse Staffing Coordinator was interviewed on 3/21/25 at 3:05 PM and reported the following information. She typically partnered a new nurse with an experienced nurse for a week and the new nurse could let her know if they needed more time with an experienced nurse. They used to have a competency form used to check and validate a new nurse's skills, but that was not being utilized anymore. The Nursing Staffing Coordinator did not provide a reason why the competency form was not being

Based on observation, record review, and interview with residents, staff, Physician, and Nurse Practitioner the facility failed to protect Resident #3's right to be free of an injury of unknown source; and abuse/neglect. Resident # 3, who was a cognitively impaired resident, was identified to have significant bruises on his arm and chest which wrapped around his torso on 12/18/24. The bruises were also accompanied by swelling and discomfort with positioning when initially found. Staff reported they had not observed any incident which had caused the bruises. The resident could not provide detailed information about how the bruises occurred, and the extent of the bruising without a known cause indicated a suspicion of neglect or abuse. Also, Resident # 3 was under the care of a non-licensed employee (Employee # 1), who was working at the facility under the false pretense she was a nurse when the bruises were found. The bruises continued to spread and on 12/20/24 Resident # 3 was evaluated at the local hospital ED (Emergency Department) where it was noted Resident # 3 had extensive chest and abdominal wall ecchymosis (discoloration of the skin, typically caused by bruising). A CT (computerized tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma (a collection of blood, usually clotted, outside of a blood vessel) underlying pacer control box measuring 9.5 X 5.2 cm. 2) Superficial soft tissue contusion of the left flank and hip. This was for one (Resident # 3) of three residents reviewed for abuse, neglect, and injuries of unknown origin. Immediate jeopardy began on 12/18/24 when Nurse Aide # 3 identified during her shift that Resident # 3 had unexplained bruises, swelling, and discomfort. Immediate Jeopardy was removed on 3/28/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D to ensure education is completed and monitoring systems put in place are effective. The findings included: Resident # 3 was admitted to the facility on [DATE]. The resident's diagnoses in part included dementia, congestive heart failure, Parkinson's, atrial fibrillation, anxiety, and dysphagia. Resident # 3's annual Minimum Data Set (MDS) assessment, dated 10/14/24, coded the resident as severely cognitively impaired and as needing total staff assistance for bathing, dressing, and hygiene needs. Resident # 3 was coded as needing partial to moderate assistance to roll from side to side in bed and as needing substantial to maximum assistance to transfer. The resident was coded as using a manual wheelchair to roll 50 feet after set-up assistance. The resident was not coded as having falls during the assessment period. Review of Resident # 3's care plan revealed the following information. On 10/19/23 staff added the resident was at risk for falls. This remained part of the resident's active care plan. On 10/27/23 staff added the resident picked at his skin causing skin tears and bruises at times. This also remained as part of the resident's active care plan. On 2/10/24 staff added that Resident # 3 could be combative with care. This remained as part of the resident's active care plan. Review of November 2024 nursing notes revealed Resident # 3 sustained one fall which was on the date of 11/2/24 at 6:15 PM. According to a nursing note, Resident # 3 had attempted to try to transfer himself from the chair to the bed before staff could assist him. His upper body had landed on the bed and then his body had slid to the floor. According to the nursing note at 6:15 PM on 11/2/24, the resident's range of motion was at his baseline. A later nursing note on 11/2/24 at 9:57 PM noted the resident had some discoloration but no swelling to his left knee, and orders were given for an x-ray. Review of x-ray results reported on 11/3/24 revealed Resident # 3 had sustained no fractures from the 11/2/24 fall. Review of Resident # 3's medical record revealed no falls in December 2024 were documented. Review of Resident # 3's medication regimen for December 2024 revealed Resident # 3 was not on an anticoagulant. Review of nursing progress notes revealed no entry for the date of 12/17/24, which was the date prior to Resident # 3's injury being identified. Review of staffing sheets revealed NA (Nurse Aide) # 1 had cared for Resident # 3 on the 12/17/24 dayshift (7:00 AM to 3:00 PM) prior to the bruising being identified on 12/18/24. A statement written by NA # 1 read, I [Nurse Aide # 1] had [Resident # 3] from 7 AM 3 PM. No bruising or swelling at the time me and coworker [name of coworker] use [mechanical] lift to get resident up on 12/17/2024 and resident was dressed by me on 12/17/2024 around 11 AM. NA # 1 was interviewed on 3/21/25 at 12:25 PM and reported the following information. She routinely cared for Resident # 3. On 12/17/24 there had been no problems with his care or transfer and there had been no bruising on his body. She and another staff member used a lift to transfer the resident, and he was still up when she left at the end of her shift. Review of the investigative file revealed a statement by NA # 2 noting that she (NA # 2) had assisted NA # 1 on 12/17/24 with Resident # 3's transfer to the chair and there had been no incident or bruising on the resident. Review of the facility's investigative file revealed Nurse # 1 had been assigned to care for Resident # 3 on 12/17/24 during both the day shift and the evening shift (3:00 PM to 11:00 PM). Nurse # 1's statement within the facility's investigative file read, On 12/17/24 I [Nurse # 1] worked 1st (7:00 AM to 3:00 PM) and 2nd shift (3:00 PM to 11:00 PM) as [Resident # 3's] nurse. I did not observe any bruising or swelling on resident body. No one reported any swelling or bruising. I [Nurse # 1] last seen [Resident # 3] approximately around 9:25 PM with no shirt on while giving him his night meds. No bruising or swelling noted. An attempt was made to interview Nurse # 1 on 3/21/25 at 12:01 PM and she could not be reached for an interview. Review of staffing sheets revealed NA # 3 had cared for Resident # 3 on the 12/17/24 evening shift. A review of the investigative file provided to the surveyor did not include a statement from NA # 3. NA # 3 was interviewed on 3/21/25 at 12:34 PM and reported the following information regarding the evening shift of 12/17/24. Resident # 3 had not fallen and there had been no incidents. He had no bruises. She (NA # 3) had placed Resident # 3 back in bed with the mechanical lift with the help of NA # 4. After she placed Resident # 3 back in bed on the evening shift, she had checked on him every two hours and he had been fine. She had submitted a statement during the facility's investigation and did not know what had happened to it. NA # 4 was interviewed on 3/24/25 at 3:21 PM and corroborated NA # 3's statement. NA # 4 reported she did assist NA # 3 with transferring Resident # 3 on the evening shift of 12/17/24. NA # 4 reported Resident # 3 was okay at the time, and she had not observed any injuries. Review of the facility's investigative file for reportable incidents of injuries for which there was no known cause revealed the following information. On 12/18/24 the facility submitted an initial report, which was completed by Unit Coordinator # 1, to the state agency noting that at 7:20 AM on 12/18/24 Resident # 3 had been identified with a baseball size bruise on the front right shoulder, large hematoma to his left side under arm, swelling and bruising on his left upper chest and below clavicle. The report also noted the resident was unable to lift his left arm without pain and there was swelling. Review of staffing sheets revealed on the night shift which began at 11:00 PM on 12/17/24 and ended at 7:00 AM on 12/18/24, Employee # 1 was assigned to care for Resident # 3 as a nurse. Review of Employee # 1's personnel file revealed Employee # 1 was hired as a nurse but was not licensed as a nurse and her application prior to hire indicated no nursing education. During an interview with the DON (Director of Nursing) on 3/21/25 at 9:00 AM, the DON confirmed that Employee # 1 had submitted someone else's nursing license upon hire in November 2024 and was terminated in February 2025 when this had been validated. At the time she had been caring for Resident # 3 on the night shift of 12/17/24, the facility had not noted she was impersonating a nurse and was not licensed. A review of Resident # 3's vital sign log revealed Employee # 1 documented Resident # 3's oxygen level was checked at 12/18/24 at 12:56 AM. (According to Employee # 1's statement this was when she noticed the bruises.) The reading was 94%. There was no notation it was taken again on Employee # 1's shift. Employee # 1 also documented Resident # 3's weight was 127 pounds at 6:38 AM on 12/18/24. Review of Employee # 1's statement read, I was collecting [Resident # 3's] routine 02 (oxygen) when I notice he had some bruising to his right shoulder as well as some to his left. No fall or bruising was reported from the previous shift to me in report, so my next thought was to bring it to our unit coordinators attn. (attention) that he had bruising on him. Before I could bring it to [Unit Coordinator's] attention it was brought to my attention once more by the next shift and when the unit coordinator got here, I immediately let her know my findings so it could be documented properly. According to staffing sheets, NA # 5 was assigned to care for Resident # 3 on the night shift which began at 11:00 PM on 12/17/24. NA # 5's written statement within the facility's investigative file read, When I was doing my 3:00 AM rounds, upon entering [Resident # 3's] room I noticed he had removed his gown and blanket which he usually does. However I notice some bruising on his arm and chest along with some swelling. Upon me waking him up he seemed startled (more than usual) but he eventually calmed down after I talked with him. I notice while turning him to his left he jerked himself back and became uncomfortable so I turned him back on his back and since he had not soiled himself, I put the gown and blanket back over him. When I came back around 5 AM I did change him but made sure not to roll him on his left arm since that is where his bruise that I noticed was located. Moving forward I will make sure to have another aide to do a walk through with me and/or assist with changes. No matter how minor or major it be if I notice ANYTHING it will be reported to the NURSE and I will leave written reports to the DON. NA # 5 was interviewed on 3/21/25 at 11:25 AM and reported the following information about her 12/17/24 shift which began at 11:00 PM. When she arrived at work, she got report and had been told that Resident # 3 had been washed up by the 2nd shift. He was asleep in bed on first rounds and again at 1:00 AM and she did not disturb him. Around 3:00 AM she noticed Resident # 3 had bruising. There was a golf ball sized bruise on his arm which appeared light reddish and was turning purple. There was bruising on his chest which was larger than what was on his arm, but his gown partially covered the bruise, and she did not pull the gown down to look at the extent of the bruising. She assumed the bruising had happened earlier during another shift and therefore the nurses were already aware of it. Nothing had happened on her shift. She did not tell Employee # 1, who she thought was a nurse. She thought Employee # 1 had been in Resident # 3's room before her (NA # 5) at some time during the night shift but she did not see Employee # 1 go into Resident # 3's room. During a follow up interview with NA # 5 on 3/24/25 at 1:02 PM, NA # 5 reported she had not obtained Resident # 5's weight that had been documented on 12/18/24 at 6:38 AM. Review of the facility's investigative file revealed a statement from NA # 6 which showed discrepancies in what Employee # 1 had written in her statement. According to Employee # 1's statement she had seen the bruises when she checked Resident # 3's oxygen level and this had been recorded in Resident # 3's record by Employee # 1 at 12/18/24 at 12:56 AM. NA # 6's statement read, On 12/18/24 I came to work passing the trays (breakfast trays). I got [Resident # 3's] tray. As soon I drop it off, I saw him with no shirt on. I saw bruises on his right shoulder, left upper quadrant. As soon I saw the bruises I talked to 3rd shift (11:00 PM to 7:00 AM) nurse [Employee # 1]. I saw her go to [Resident # 3's] room and showed her the bruises. She told me that this first time seeing this, that they had no falls last night. Employee # 1 was interviewed on 3/25/25 at 2:57 PM and acknowledged she had given someone else's nursing certificate number who shared a similar name to the facility in order to work as a nurse. According to Employee # 1 she completed no type of Nursing Education or Nurse Aide training. She reported she had some medical assistant training from another state but had not completed that either. She was interviewed regarding Resident #3's bruises and reported she had called the DON at 12 something when she saw them on the 11:00 PM to 7:00 AM shift which began on 12/17/24 when she did the oxygen level and saw the bruises. Employee # 1 reported she did not know who obtained Resident # 3's weight which she had recorded. Employee # 1 did not know how the bruises occurred and reported she would never do anything to hurt a resident. A review of nursing notes revealed the first entry documenting the resident's bruising was on 12/18/24 at 7:32 AM by Nurse # 1. The entry was entered into the record as a late entry on the date of 12/19/24 at 8:08 AM. The entry read, Resident able to make needs writer made aware during report that resident had bruising to left side of chest, armpits, and arms. VS 128/77 (blood pressure), 97 % on RA (room air), 18 (respirations), 97.9 (temperature), 63 (pulse.) No s/s (signs and symptoms) of SOB (shortness of breath), wheezing or labored breathing. Facial grimacing noted when resident move his left arm. Resident refused to be repositioned . Nurse # 1 further noted Resident # 3 had an order for Tylenol 325 mg (milligrams) 2 tabs every 6 hours. Nurse # 1 also noted the physician was notified and orders were obtained for a stat x-ray on the chest, right arm and left arm. The DON, Unit Coordinator, and Social Worker were also notified. An attempt was made to interview Nurse # 1 on 3/21/25 at 12:01 PM and she could not be reached for an interview. The next nursing entry was dated 12/18/24 at 7:36 PM by Nurse # 2 and read, Was informed from previous shift nurse that resident had discoloration noted to chest area. Resident has discoloration noted to chest, sides of chest, armpits and arms. Measurements obtained and put in DON office Supervisor, MD, and DON aware. Review of Nurse # 2's written statement which was located in the facility's investigative file read, Came into my shift and was made aware by [Nurse # 1] about [Resident # 3] having bruising. Went to go see [Resident # 3] and noted bruising to chest, arms, armpits, sides of chest. I asked [Resident # 3] what happened he just mumbled. I asked [Resident # 3] did he fall. He said yes the other night. I asked where did he fall. He then pointed to the closet area. I asked [Resident # 3] did anyone hurt him and he stated no. I then obtained measurements of bruising and placed them in DON office. Nurse # 2 was interviewed on 3/21/25 at 10:28 AM and reported the following information. On the date of 12/18/24 she had reported to work at 11:00 AM because Nurse # 1 had to leave early that day. She had been told about Resident # 3's bruises in report at 11:00 AM and went to assess him and found bruises on his arms and chest. When he talked, he mumbled but if she asked him yes and no questions he would answer simple questions. When asked if he had fallen, Resident # 3 had replied, yes. When asked where he had fallen, Resident # 3 had pointed to the closet area of the room. The resident was not able to convey more about the incident. The facility Social Worker was interviewed on 3/24/25 at 10:56 AM and reported the following information. She had interviewed Resident # 3 on 12/18/24 after the bruises were brought to her attention. Resident # 3 was not able to convey what happened. She also interviewed Resident # 3's roommate (Resident # 12), who also had cognitive impairment. Resident # 12 had reported someone pushed a machine into their room during the night and it was not used for his roommate. Resident # 12 did not report Resident # 3 had fallen. He was not able to say what the machine was that was pushed into the room. Review of physician progress notes revealed Resident # 3's physician, who served as the facility medical director, assessed Resident # 3 on 12/18/24 and in addition to documenting the bruises also documented the resident had an abrasion to his skin. The physician noted, He (Resident # 3) was noted this morning to have bruising on his upper body. Patient has cognitive impairment and is not able to tell us what happened. Last BIMS (brief interview for mental status) 2/15. He seems to only have pain when moving the left shoulder. No documented falls. He was given Tylenol for pain. The physician further documented measurements of the bruising as follows: Note Bruises were irregular shaped and were measured at largest diameter. Right anterior chest upper near midline, about 5.5 X 3.5 cm (centimeters) reddish with some faint purplish area inferior to it. Right shoulder near AC joint (where the collar bone meets the shoulder blade) circular reddish abrasion. Right shoulder lateral clavicle about 7 x 6 cm irregular shaped reddish bruise with faint deeper purple underneath it extending further down about 5 X 8 cm at largest diameter. Right arm-3 circular bruises about 1 cm each-2 inner bicep mid to distal and 1 lateral inferior. Left chest wall- Pacemaker scar with 6 small irregular shaped purplish red bruises. Pacemaker appears more lateral and turned/sticking out. Left side about 7 X 3 cm reddish bruise with faint edges in shoulder near clavicle. Large reddish purple about 10 X 4 cm inferior to tattoo on lateral upper arm. Left arm-irregular shaped bruise going down bicep with varying colors-reddish to darker purple inferior, 12 X 4 cm around to lateral aspect of arm. 8 X 3 cm circular bruise purplish inferior and medial to elbow. Large left chest wall bruise light purplish edges wraps around chest lateral to nipple, darker purple on posterior chest. No ecchymosis (discoloration of the skin, typically caused by bruising) neck, facial area, or body below waist. Within the progress note, the physician noted a chest x-ray and complete blood count would be obtained. The physician further noted that she was unsure when the pacemaker had been placed or last tested . She further noted the pacemaker appeared to be turned/sticking out more. On 12/18/24 at 7:38 PM Nurse # 2 noted Resident # 3's chest x-ray was normal. Review of the 12/18/24 Chest x-ray result showed that the pacemaker was present but did not note any abnormalities with the pacemaker or with the resident's heart or lungs. The radiologist noted the report was negative. A review of Resident # 3's 12/18/24 CBC result revealed the resident's platelet count was normal. (Low platelets can increase the chance of bleeding.) On 12/19/24 Resident # 3 was seen by the NP (Nurse Practitioner) who noted the following information. Resident # 3's CBC did not show thrombocytopenia (low platelets), and the chest x-ray had been normal. There had been a concern that the resident's pacemaker had been dislodged, and she had asked for a reread of the chest x-ray. Resident # 3 denied pain at the time. Review of nursing notes revealed on 12/20/24 at 2:21 PM Unit Coordinator # 1 noted that Resident # 3's bruising was spreading from his bilateral shoulders down into his abdomen, left arm, and left side rib cage and he was being transferred to the hospital for further evaluation. Review of 12/20/24 ED (Emergency Department) notes revealed the following information was documented. Resident # 3 had extensive chest and abdominal wall ecchymosis. A CT (computerized tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma (a collection of blood, usually clotted, outside of a blood vessel) underlying pacer control box measuring 9.5 X 5.2 cm. 2) Superficial soft tissue contusion of the left flank and hip 3) No other CT evidence of acute traumatic injury to the chest, abdomen, or pelvis. 4) emphysema, 5) coronary artery disease. Upon preparing for discharge, the ED physician did not note any further comments about the hip contusion. The ED physician did note CT scan obtained demonstrating hematoma around his pacemaker site but otherwise superficial contusion. There was no notation regarding how the hematoma could have formed around the pacemaker site. The resident was noted to be stable for discharge from the ED with a final diagnosis of chest wall hematoma, left and superficial bruising of back, left. There were no ED discharge orders. On 12/20/24 Nurse # 1 documented Resident # 3 returned from the hospital in no distress, no pain, and no new orders. Interview with Resident # 3's Nurse Practitioner on 3/24/25 at 5:15 PM revealed she was not aware of how the bruising had occurred. The NP reported she attempted to see if the radiologist, who performed the chest x-ray at the facility, could determine if something occurred to the resident's pacemaker, but they were not able to determine. It had not been brought to her attention that the hospital's CT showed a contusion on the resident's hip. Resident # 3's physician was interviewed on 3/21/25 at 3:13 PM and reported the following information. When she evaluated Resident # 3 on 12/18/24 the bruising was all on his upper body which included areas on his arms and chest wall which wrapped around some on his torso. She did not recall any bruising extending to his hip when she examined him on 12/18/24. He was also having some left shoulder pain. Prior to 12/18/24 there had been no history the resident had a pacemaker. The resident was thin and on the date of 12/18/24 the pacemaker was noticeable and appeared to be turned more to a lateral position and more towards the antecubital area. The resident had poor safety awareness and was not able to explain how the bruising occurred when she talked to him. If he had told the staff he had fallen, she was not sure the staff could go totally by what the resident had said because of his confusion. He was sent to the ED to be reviewed also, but the ED physician did not make mention of problems with the pacemaker itself. The ED physician also had not put anything in her notes about the contusion to the left hip which had shown up on the CT scan. It had not been brought to her attention that the CT in the ED showed a contusion to the left hip. She was unsure if the contusion to the left hip was related to the 12/18/24 incident or a separate event. They had made a referral for a cardiologist, but the son had canceled the appointment. The physician was further interviewed regarding whether the pacemaker could have moved causing the resident's injuries. The physician reported the following information. She (the physician) was not a cardiologist and was not aware of what type of stitches had been placed when the pacemaker had originally been placed. She would think that over time scar tissue would help hold the pacemaker in place. She could not say 100 % for sure but would think that something would have had to happen to cause a pacemaker to move if it had done so. She did not know how far it could be moved. She would have to refer to a cardiologist's opinion. Interview with the facility appointment scheduler on 3/21/25 at 2:55 PM revealed Resident # 3 had a cardiology appointment scheduled after the 12/18/24 incident but the son canceled the appointment. Due to the resident's payment sources, he was to be seen at a particular provider. They had talked to the son and arranged for the appointment to be rescheduled and it was rescheduled for 4/7/25. Resident # 3 was interviewed on 3/20/25 at 2:45 PM. During the interview Resident # 3 mumbled and his words could not be understood. Following the interview, Resident # 3 was observed to roll himself out of his room and into the hallway independently. He was not observed to use his feet to propel the wheelchair, only his arms. Several times he would run his wheelchair into the wall or objects as he propelled himself and would readjust the wheelchair himself to continue to move forward. Resident # 3's roommate (Resident # 12) was interviewed on 3/20/25 at 3:00 PM. A review of Resident # 12's record revealed his BIMS (Brief Interview for Mental Status) score on a 2/18/25 MDS assessment was a 6, indicating severe cognitive impairment. Resident # 12 reported he had never witnessed anyone mistreat him or his roommate. Resident # 12, who was aware it was March during the interview, stated Resident # 3 had two falls he had recalled. One seemed to him (Resident # 12) about a month ago and then another one prior to that. One had happened in the hallway near the doorway and the other had happened in the room. The staff had helped the resident off the floor both times. Resident # 12 reported at times Resident # 3 had problems moving his wheelchair in the room. Interview with Unit Coordinator # 1 on 3/21/25 at 11:10 AM revealed she first became aware of the bruising on the morning of 12/18/24. She had been stopped in the hallway but did not recall who told her about it. She knew that Employee # 1 had been aware of the bruising and had said she had just seen it. When she (Unit Manager # 1) was made aware on the morning of 12/18/24, she notified the DON, and the DON informed her they needed to complete a reportable injury of unknown origin to the state agency. During an interview on 3/20/25 at 3:20 PM with Nurse # 3, who oversaw safety reports in the facility, Nurse # 3 reported Resident # 3's last recorded fall was 11/2/24. Nurse # 3 also reported that Resident # 3's roommate (Resident # 12) was confused and was not a reliable source to report falls. On 3/24/25 at 11:12 AM during a follow up interview, Nurse # 3 reported Resident # 3's 11/2/24 fall was the only time the facility had on record that the resident had fallen since he had resided at the facility. Interview with the DON and Administrator on 3/21/25 at 5:30 PM revealed the following information. They had conducted their investigation following the identification of the bruising on 12/18/24. Employee # 1 had never called on her shift to report any injury. It was not reported until the dayshift on 12/18/24 and at that time they did an investigation and reported the incident to the state. None of the staff had reported they witnessed Resident # 3 to fall or have an accident for them to conclude a particular cause of the bruising. They thought something had happened to the pacemaker spontaneously, which had caused bleeding under the skin and had spread downwards. According to the DON, she had read of this occurring for other individuals. They had not been aware that the hospital CT showed there was a contusion of the hip also and had not included that in their investigation. The ED report had been sent to them and scanned into their computer without this being drawn to their attention. A Device Nurse at the cardiology clinic, where Resident # 3 had been historically seen, was interviewed on 3/24/25 at 11:55 AM and reported the following information. She had been a device nurse for [AGE] years and had never known a pacemaker to spontaneously move. The pacemakers are sutured in place and then scar tissue formed around them to hold them in place. Resident # 3 had not been seen by the cardiologist since 2021. Their records showed he had a pacemaker and not an implanted defibrillator. The hospital ED (emergency department) physician, who evaluated Resident # 3 on 12/20/24, was interviewed on 3/31/25 at 10:11 AM. Prior to the interview the ED physician had been sent a message that one of the questions which the surveyor would like to discuss was whether a pacemaker could spontaneously move. During the interview, the ED physician reported the following information. She had never heard of a pacemaker moving. After receiving the surveyor's question, she had reviewed studies and case reports and found one case in which an individual with an implanted defibrillator had an electrode lead to migrate causing some external bruising on the patient's left side. This had been a very rare case. She did not recall anything being wrong with Resident # 3's pacemaker when she saw him on 12/20/24. A chest CT would have shown a problem with any lead or displacement. She also did not think a problem with a pacemaker could lead to a hip contusion as well. It was her medical opinion that Resident # 3's injuries were more consistent with some sort of trauma that had occurred to him. On 3/24/25 at 8:55 PM the Administrator was notified of Immediate Jeopardy. The Administrator submitted the following Credible Allegation of Immediate Jeopardy Removal Plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance While under the care of employee #1 (non- licensed employee) resident # 3 was found to have an injury of unknown origin. Resident #3 was noted with significant bruising to his chest and arms. The bruises were reddish with faint deeper purple, located over the right clavicle extending to the upper chest over the pacemaker site. The bruising was noted to be an irregular shape measuring 7cmx 6cm in the largest area. In addition to the bruising to the chest, a night shift NA (NA #5) wrote in her statement in the facility's investigative file that she saw that the resident had swelling and appeared uncomfortable with positioning. NA #5 failed to notify any nurse of the significant bruising and the resident's discomfort. This failure of notification resulted in a delay in assessment and treatment of Resident #3's bruising and discomfort by the provider. On 12/18/24 at 7:20am the unit coordinator noted the bruising to resident #3's chest and arm area. The unit coordinator then reported the bruising to the DON. The DON then instructed the unit coordinator to complete and send two-hour initial report of injury of unknown origin to North Carolina Department of Health and Human Services (NCDHHS). The DON began the investigation into Resident #3's injury of unknown origin. The investigation revealed that the resident had not had any injury that would have contributed to the bruising. On 2/6/2025 the unit 300 nurse coordinator and wound care nurse conducted body audits on all residents who received care from employee #1 on unit 300. No signs or symptoms of injuries or new skin abnormalities were noted in any resident on the 300 unit. On 2/6/25-2/7/25 a review of all resident hospital transfers and recorded incidents/events (events include reported falls, skin tears, and infections) to ensure completeness of the documentation, proper notification of the resident representative and provider, and follow-up interventions were implemented. Audit included the timeframes/shifts employee #1 worked from 11/5/24 to 2/6/25 was conducted by the nurse consultant to identify any care concerns. The review of hospital transfers and reported falls, skin tears, or infections did not reveal any obvious care concerns. 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. On 3/26/25 and 3/27/25 The Director of Nursing, SDC, and Administrator completed education with all staff on recognizing and reporting injuries or changes in resident condition; including the chain of reporting. All st [TRUNCATED]

Based on record review, resident interview, staff interview and Physician Interview the facility failed to complete a thorough investigation related to unexplained swelling, discomfort, and bruising Resident # 3 experienced although there had been no reported accident and the resident was not on an anticoagulant. Review of the facility's completed investigation revealed the facility 1) failed to identify a hospital CT (computerized tomography) showed the resident's bruising extended to his hip area which they had not identified in their investigation 2) failed to investigate discrepancies further which were noted by reviewing Employee # 1's statements with other employees' statements and the resident's record and 3) failed to further question and clarify who had obtained a weight on the resident during the shift when the injuries were first identified in order to determine if something had happened while the resident was weighed. The findings included: Resident # 3 was admitted to the facility on [DATE]. The resident's diagnoses in part included dementia, congestive heart failure, Parkinsons, atrial fibrillation, anxiety, and dysphagia. Resident # 3's annual Minimum Data Set (MDS) assessment, dated 10/14/24, coded the resident as severely cognitively impaired and as needing total staff assistance for bathing, dressing, and hygiene needs. Resident # 3 was coded as needing partial to moderate assistance to roll from side to side in bed and as needing substantial to maximum assistance to transfer. The resident was coded as using a manual wheelchair to roll 50 feet after set-up assistance. The resident was not coded as having falls during the assessment period. Review of Resident # 3's medical record revealed no falls in December 2024 were documented. Review of Resident # 3's medication regimen for December 2024 revealed Resident # 3 was not on an anticoagulant. Review of the facility's investigative file for reportable incidents of injuries for which there was no known cause revealed the following information. On 12/18/24 the facility submitted an initial report, which was completed by Unit Coordinator # 1, to the state agency noting that at 7:20 AM on 12/18/24 Resident # 3 had been identified with a baseball size bruise on the front right shoulder, large hematoma to his left side under arm, swelling and bruising on his left upper chest and below clavicle. The report also noted the resident was unable to lift his left arm without pain and there was swelling. Review of Employee # 1's statement, which was located in the facility's investigative file read, I was collecting [Resident # 3's] routine 02 (oxygen) when I notice he had some bruising to his right shoulder as well as some to his left. No fall or bruising was reported from the previous shift to me in report so my next thought was to bring it to our unit coordinators attn. (attention) that he had bruising on him. Before I could bring it to [Unit Coordinator's] attention it was brought to my attention once more by the next shift and when the unit coordinator got here I immediately let her know my findings so it could be documented properly. A review of Resident # 3's vital sign log revealed Employee # 1 documented Resident # 3's oxygen level was checked at 12/18/24 at 12:56 AM. (According to Employee # 1's statement this was when she noticed the bruises.) The reading was 94%. There was no notation it was taken again on Employee # 1's shift. Employee # 1 also documented Resident # 3's weight was 127 pounds at 6:38 AM on 12/18/24. According to staffing sheets, NA # 5 was assigned to care for Resident # 3 on the night shift which began at 11:00 PM on 12/17/24. NA # 5's written statement within the facility's investigative file read, When I was doing my 3:00 AM rounds, upon entering [Resident # 3's] room I noticed he had removed his gown and blanket which he usually does. However I notice some bruising on his arm and chest along with some swelling. Upon me waking him up he seemed startled (more than usual) but he eventually calmed down after I talked with him. I notice while turning him to his left he jerked himself back and became uncomfortable so I turned him back on his back and since he had not soiled himself, I put the gown and blanket back over him. When I came back around 5 AM I did change him but made sure not to roll him on his left arm since that is where his bruise that I noticed was located. Moving forward I will make sure to have another aid to do a walk through with me and/or assist with changes. No matter how minor or major it be if I notice ANYTHING it will be reported to the NURSE and I will leave written reports to the DON. NA # 5 was interviewed on 3/21/25 at 11:25 AM and reported the following information about her 12/17/24 shift which began at 11:00 PM. When she arrived at work, she got report and had been told that Resident # 3 had been washed up by the 2nd shift. He was asleep in bed on first rounds and again at 1:00 AM and she did not disturb him. Around 3:00 AM she noticed Resident # 3 had bruising. There was a golf ball sized bruise on his arm which appeared light reddish and turning purple. There was bruising on his chest which was larger than what was on his arm, but his gown partially covered the bruise, and she did not pull the gown down to look at the extent of the bruising. She assumed the bruising had happened earlier during another shift. Nothing had happened on her shift. She did not tell Employee # 1, who she thought was a nurse. She thought Employee # 1 had been in Resident # 3's room before her (NA # 5) at some time during the night shift but she did not see Employee # 1 go into Resident # 3's room. During a follow up interview with NA # 5 on 3/24/25 at 1:02 PM, NA # 5 reported she had not obtained Resident # 3's weight that had been documented on 12/18/24 at 6:38 AM. Review of the facility's investigative file revealed a statement from NA # 6 which showed that Employee # 1 had claimed she knew nothing about the bruises when Nurse Aide # 6 approached her about the bruises at breakfast time on 12/18/24, although in Employee # 1's written statement she had written she was aware of them when she checked the resident's oxygen level during the night. NA # 6's statement read, On 12/18/24 I came to work passing the trays (breakfast trays). I got [Resident # 3's] tray. As soon I drop it off, I saw him with no shirt on. I saw bruises on his right shoulder, left upper quadrant. As soon I saw the bruises I talked to 3rd shift nurse [Employee # 1]. I saw her go to [Resident # 3's] room and showed her the bruises. She told me that this first time seeing this, that they had no falls last night. Employee # 1 was interviewed on 3/25/25 at 2:57 PM and reported she had been working as a nurse at the facility but had no license as a nurse and had not completed any formal health care program. Employee # 1 acknowledged she had falsely provided information to the facility and given them another individual's nursing license. Employee # 1 was interviewed regarding Resident #3's injury and reported she had called the DON at 12 something when she did the oxygen level and saw bruising. Employee # 1 reported she did not know who obtained Resident # 3's weight which she had recorded. Interview with Unit Coodinator # 1 revealed she first became aware of the bruising on the morning of 12/18/24. She had been stopped in the hallway but did not recall who told her about it. She knew that Employee # 1 had been aware of the bruising and had said she had just seen it. A review of nursing notes revealed the first entry documenting the resident's bruising was on 12/18/24 at 7:32 AM by Nurse # 1. The entry was entered into the record as a late entry on the date of 12/19/24 at 8:08 AM. The entry read, Resident able to make needs writer made aware during report that resident had bruising to left side of chest, armpits, and arms. VS 128/77 (blood pressure), 97 % on RA (room air), 18 (respirations), 97.9 (temperature), 63 (pulse.) No s/s (signs and symptoms) of SOB (shortness of breath), wheezing or labored breathing . Facial grimacing noted when resident move his left arm. Resident refused to be repositioned . Nurse # 1 further noted Resident # 3 had an order for Tylenol 325 mg (milligrams) 2 tabs every 6 hours. Nurse # 1 also noted the physician was notified and orders were obtained for a stat x-ray on the chest, right arm and left arm. The DON, Unit Coordinator, and social worker were also notified. Review of nursing notes revealed on 12/20/24 at 2:21 PM the Unit Coordinator noted that Resident # 3's bruising was spreading from his bilateral shoulders down into his abdomen, left arm, and left side rib cage and he was being transferred to the hospital for further evaluation. Review of 12/20/24 ED (Emergency Department) notes revealed the following information was documented. Resident # 3 had extensive chest and abdominal wall ecchymosis. A CT (computerized tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma underlying pacer control box measuring 9.5 X 5.2 cm. 2) Superficial soft tissue contusion of the left flank and hip 3) No other CT evidence of acute traumatic injury to the chest, abdomen, or pelvis. 4) emphysema, 5) coronary artery disease. Upon preparing for discharge, the ED physician did not note any further comments about the hip contusion. The ED physician did note CT scan obtained demonstrating hematoma around his pacemaker site but otherwise superficial contusion. There was no notation regarding how the hematoma could have formed around the pacemaker site. The resident was noted to be stable for discharge from the ED with a final diagnosis of chest wall hematoma, left and superficial bruising of back, left. Resident # 3's physician was interviewed on 3/21/25 at 3:13 PM and reported the following information. When she evaluated Resident # 3 on 12/18/24 the bruising was all on his upper body which included areas on his arms and chest wall which wrapped around some on his torso. She did not recall any bruising extending to his hip when she examined him on 12/18/24. He was also having some left shoulder pain. Prior to 12/18/24 there had been no history the resident had a pacemaker. The resident was thin and on the date of 12/18/24 the pacemaker was noticeable and appeared to be turned more to a lateral position and more towards the antecubital area. The resident had poor safety awareness and was not able to explain how the bruising occurred when she talked to him. If he had told the staff he had fallen, she was not sure the staff could go totally by what the resident had said because of his confusion. He was sent to the ED to be reviewed also, but the ED physician did not make mention of problems with the pacemaker itself. The ED physician also had not put anything in his notes about the contusion to the left hip which had shown up on the CT scan. It had not been brought to her attention that the CT in the ED showed a contusion to the left hip. She was unsure if the contusion to the left hip was related to the 12/18/24 incident or a separate event. They had made a referral for a cardiologist, but the son had canceled the appointment. She (the physician) was not a cardiologist and was not aware of what type of stiches had been placed when the pacemaker had originally been placed. She would think that over time scar tissue would help hold the pacemaker in place. She could not say 100 % for sure, but would think that something would have had to happen to cause a pacemaker to move if it had done so. She did not know how far it could be moved. She would have to refer to a cardiologist's opinion. Resident # 3 was interviewed on 3/20/25 at 2:45 PM and was unable to report how the injury had occurred. Interview with the DON and Administrator on 3/21/25 at 5:30 PM revealed the following information. They had conducted their investigation following the identification of the bruising on 12/18/24. Employee # 1 had never called on her shift to report any injury. It was not reported until the dayshift on 12/18/24 and at that time they did an investigation and reported the incident to the state. None of the staff had reported they witnessed Resident # 3 to fall or have an accident for them to conclude a particular cause to the bruising. They thought something had happened to the pacemaker spontaneously, which had caused bleeding under the skin and had spread downwards. They had not been aware that the hospital CT showed there was a contusion of the hip also and had not included that in their investigation. The ED report had been sent to them and scanned into their computer without this being drawn to their attention. During a follow up interview with the Administrator on 3/24/25 at 4:15 PM the Administrator reported they did not look into who actually did Resident # 3's weight on the shift on which he was identified to have the injury. The Administrator reported he assumed Employee # 1 did the weight since she noted it in the record. Review of the facility's five-day report to the state agency revealed the DON submitted the report on 12/20/24 without any mention of the ED's findings that there had been a contusion to Resident # 3's left hip identified. Also, there was no mention in the five-day completed report that the facility had noted that by Employee # 1 writing that she had noted the bruises when she checked the resident's oxygen level, this would have indicated discrepancies in statements and the resident's record. According to Employee # 1's statement she knew about the bruises when she checked his oxygen level. According to NA # 6's statement, Employee # 1 denied she knew anything about the bruises when they were pointed out to her at breakfast time on 12/18/24. There was no indication Employee # 1 was further questioned in the five-day report and discrepancies accounted for.

Based on resident interviews, staff interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 residents reviewed for physical abuse. Resident #84 was sent to the emergency room for evaluation due an injury. Resident #84 was hit in the mouth resulting in treatment with Dermabond on his upper lip and a referral was sent to the dentist due to missing tooth on the resident's bridge. (Resident # 84). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses of neurogenic bladder, cognitive communication deficit, gastrostomy, chronic kidney disease, diabetes, and wounds on the heels. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 was severely cognitively impaired. Review of Resident #82's care plan dated 10/25/23 revealed the focus area that Resident #82 was at risk for behaviors: socially inappropriate/disruptive behavior by voicing thoughts of self-harm related to neurocognitive disorder and history of alcohol abuse. Resident #82 was at risk for isolation related to history of resident-to-resident altercation and dementia. The goal included episodes of inappropriate aggressive and/or disruptive behaviors would decrease by 50% within specified time frame. The intervention included to talk in calm voice when behavior was disruptive. Remove from public area when behavior is disruptive and unacceptable. Identify causes for behavior and reduce factors that may provoke aggressive behaviors. An interview was conducted on 07/30/24 08:34 AM with Resident #82 who stated he did not recall an incident of hitting another resident and he would not hit anyone unless provoked. He reported he treated everyone well with respect. He was pleasantly confused. Resident #84 was admitted to the facility on [DATE] with the diagnoses of benign prostatic hyperplasia dementia, psychotic and mood disturbance, and cognitive communication deficit. The quarterly Minimum Data Set(MDS) 5/21/24 , indicated Resident #84 was severely cognitively impaired and no behaviors. Review of Resident #84's care plan dated 6/26/24 revealed the focus area Resident #84 had tendencies to be verbally antagonizing others and physical towards his roommate and others. The goal included episodes of aggressive behaviors would decrease by 50% within specified time frame. The interventions included approach resident of unacceptability of verbal abuse and reinforce positive behavior. Administer behavior medications as ordered by physician, monitor and document target behaviors using aggression alleviation method., provide diversional activities when resident is having problems, monitor resident in intervals as indicated, removed resident from public area when behaviors is disruptive and unacceptable, praise for demonstration desired behavior, monitor target behaviors and talk in a calm voice when behaviors is disruptive. An interview was conducted on 07/29/24 at 1:53 PM with Resident #84 who stated he and his former roommate did have an altercation based on some words they had between each other. Resident #84 stated they had been roommates for a while and he did not have any issues with Resident #82 before the incident, he did not have a real reason for making the statements he did to the other resident. He was aware the roommate had some life issues, and the conversation went too far between them. Resident #84 stated he was hit in the face and had some light bleeding nothing serious resulted in a cut on his lip and a missing tooth. Resident #84 further stated they were separated, and he went to the hospital to get checked out. He reported he had no hard feelings with the other resident and there had been no further interaction. Resident #84 declined feelings of being unsafe or demonstrated any changes in behaviors. He indicated he had no issues on how the facility handled things. He was moved to a different room and things have been fine. The initial facility investigation summary dated 10/23/23 revealed the alleged victim was Resident #84, his roommate Resident #82 was the perpetrator. The following stated agencies and responsible persons were notified on 10/23/23 at 11:30 AM. The resident -to- resident altercation assessment was done for both residents. Resident #82 was observed by staff hitting Resident #84 in the mouth. Staff immediately interceded and were able to separate Resident #82 and Resident # 84. Resident #84 was sent to the emergency roiagnom on [DATE] for treatment of an open wound to upper lip with Dermabond to the outer surface. emergency room recommendations revealed the use of ice to help with swelling and pain. Resident #84 received an antibiotic to help prevent an infection and neuro- checks should be initiated at the facility. Resident #84 also lost a tooth from his bridge and was sent to the dentist for repairs on 10/27/23, with follow-up visits on 11/6/23 and 11/9/23. There were no other alterations. Resident #84 was placed on 15-minute neuro checks upon return from the emergency room . Resident #82 was moved to another room on a different hall in the facility and placed on one- to- one monitoring. The responsible person and medical director were notified on behalf of both residents. Review of the hospital summary report dated 10/23/23 revealed Resident #84 was treated for an open wound of his upper lip today. The outer surface was closed using Dermabond. Try to keep Resident #84 from playing or picking at the area. He should apply ice to help with swelling and pain. The open area inside of his mouth should heal but I have placed him on antibiotic to help prevent an infection. Initiate neuro checks at facility and call the on-call provider to have the antibiotic approved to start today. If the areas opened up he should go to ER for stitches. The 5-day summary investigation dated 10/228/23 read in part: revealed on 10/23//23 it was reported to the Social Worker two roommates had an altercation. Staff heard yelling on A hall wing and observed Resident #82 was on the A wing hallway when he hit Resident #84. Resident #84 was verbally insulting Resident #82 when he stood from the wheelchair and hit Resident #84 in the mouth. Both residents were separated immediately for safety. Resident #82 stated that he did hit Resident #84 because he was calling him names. Resident #84 did admit to this allegation and stated, he is brown nosing. Resident #82 was immediately placed on 1 to 1 and moved to another room on a different hall. Resident #84 was transferred to the emergency room for further evaluation due to cut lip and missing tooth. Resident #84 did receive Dermabond treatment at the emergency room . Resident #84 was sent to the dentist for bridge repair for the missing tooth. Care plan for both residents were updated. Both residents were referred to psych services including talk therapy. Resident #82 agreed to a room change. The abuse protocol in-service was completed. Resident interviews for alert and oriented residents were conducted on abuse. Resident #84 had several dental follow-ups to repair bridge. There were no other altercations between the two residents. Review of the nursing note dated 10/24/2023 revealed Resident #82 was ambulating via wheelchair up hallway and was involved in altercation with another resident. Separated for safety placed on one to one. A referral for psychiatric service place in the physician notebook. The responsible person was made aware of the altercation and the provider would follow up today. Review of the Nurse Practitioner note dated 10/24/23 revealed Resident #84 was seen for follow-up visit due to recent treatment at urgent care for an open wound on his upper lip. Following and altercation with another resident who hit him in the face. This caused his upper lip to split, and he lost a tooth. He went to fast med and the laceration on his lip was closed with Dermabond. He was started on antibiotic prophylactically. He has no acute complaints at this time and no concerns were addressed by nursing staff. Review of the statement written by dietary staff revealed both residents were on the hall when staff was providing coffee to another resident. Resident #84 was antagonizing Resident #82. Resident #82 attacked Resident #84. The two residents were separated immediately. Resident #84 was bleeding from the mouth. There was no further description of the actual events of the attack. The dietary staff was unavailable for interview. An interview was conducted on 8/1/24 at 9:59 AM with Staff Development Coordinator who stated she was working in the dining room and heard the end of the resident conversations/interactions, Staff had already separated the two residents and they were taken to their rooms. She noticed Resident #84 had light bleeding around the mouth around the top of lip and missing tooth. The Staff Development Coordinator further stated Resident #84 did wear dentures. She reported she cleaned the lip and applied a steri-strip. Resident#84 was sent to the emergency room for further evaluation and sent to the dentist a few days later. The social worker met with both residents and a decision was made to move residents to different halls. She reported there had been no further incidents between the two residents prior to the altercation or after they were moved to different halls. Nurse stated she did not directly see what happen but provided the treatment following the altercation. An interview was conducted on 8/1/24 at 10:00 AM with Nurse #6 who stated a nurse aide reported some words were passed between the two residents and Resident #82 hit Resident #84 in the mouth. Nurse #6 reported there had been no prior altercations between the two residents. Resident #84 was assessed and sent to the hospital and later to the dentist due to a missing tooth. Resident #84 was moved to another part of the facility. An interview was conducted on 8/1/24 at 10:30 AM with the Social Worker who stated she was called to the dining area due to a resident- to- resident altercation between Resident #82 and Resident #84. The Social Worker stated it had been reported Resident #84 had been verbally insulting Resident #82 when Resident #82 became upset and stated he was tired of being bullied by the resident and hit the resident in the mouth. Resident #82 only hit Resident #84 once and staff separated the two individuals immediately. Social Worker stated during her investigation there was no report if Resident #84 was hit with an open hand or closed hand. The employee that initially saw the incident and separated the resident was unavailable for interview. Resident #84 had a slight cut on his lip and a tooth was missing. The nursing staff cleaned the lip and sent the resident to the hospital and later to the dentist. She reported Resident #82 was moved to another part of the building to prevent further interaction. She further stated there had been no incidents or behaviors between the two residents prior to the incident. The Social Worker reported she had spoken with Resident #84 about why he was verbally insulting Resident #82. Resident #84 indicated he felt like Resident #82 was a weak person and he did not have a real reason to be saying the things he did. Both residents were referred for psych services and provided with talk therapy to address any emotional concerns. She reported during the interview with Resident #84 he had no ill feelings toward Resident #82. Resident #82 was upset with Resident #84 about being insulted and he had not done anything to him, so he popped him in the mouth to shut him up. Resident #82 reported during the interview he had never had a problem before when they were roommates, and he did not understand why the other resident was saying those things to him. The Social Worker reported since the two residents were moved to another part of the building and had limited contact there had been no further incidents between the two. She reported both families were notified of the incident and were satisfied with decision to move Resident #82's room. She further stated both residents were also placed on 15-minute checks for a few days and there was no new development or behaviors. Administrator #1 who was working at the time of incident was not available for interview. A telephone interview was conducted on 8/1/24 at 1:20 PM with Nurse Aide #10 who stated the two residents were in the hallway, Resident #84 made verbal insults toward Resident #82. Resident #84 was known to make verbal insults toward Resident #82 and other residents, but the two never had any physical altercations before. Resident # 82 who was very quiet person got tired of Resident #84's verbal insults and he stood up from his wheelchair and hit him hard enough to knock his tooth out and Resident #82 made a statement he was tired of being bullied. Based on the position of both resident Nurse Aide #10 could not tell if the hand was open or closed but it was hard enough for the tooth to fall out. She and a nurse whom she could not recall the name immediately separated the two residents. Resident #82 was moved to another hall. The nurse assessed Resident #84 clean the mouth and he was sent to the emergency room and/or dentist. An interview was conducted on 8/1/24 at 2:50 PM with Administrator #3 who stated he was not employed at the facility during the incident. Upon inquiry the facility administrator was unable to identify a performance plan that was implemented at the time of the altercation.

Based on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of a controlled substance medication, oxycodone, which was prescribed for Resident #9 and a combination medication containing oxycodone and acetaminophen prescribed to treat pain which was prescribed for Resident #225. The facility also failed to protect a resident's right to be free from the misappropriation of a bottle of alcohol prescribed for the resident (Resident #42). This occurred for 3 of 3 residents reviewed for misappropriation of property. Findings included: 1. Resident #9 was readmitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was admitted on [DATE]. The assessment indicated the resident was assessed as cognitively impaired. Resident #9 had an order dated 12/9/23 for oxycodone 5 milligrams (mg) every 6 hours. Review of Resident #9's Medication Administration Record (MAR) for January 2024 revealed the medication was documented as administered every 6 hours as ordered by the physician. Review of Resident #9's Individual Resident's Narcotics Record (used to keep track of declining inventory/ doses of oxycodone) from 12/27/23 to 1/11/24 revealed as of 1/4/24 at 6 PM the amount of oxycodone 5 mg remaining was 33 pills. Review of the initial report regarding diversion of facility drugs dated 1/12/24 revealed the facility was made aware of missing medications on 1/11/24 at 2:30 PM. The report details read in part Narcotics were delivered to cart 2 Nurses [Nurse #11 delivered the Narcotic to Nurse #6 and Nurse #12]. Witnessed being delivered at shift change. Number was correct. After the day shift nurse (Nurse #6) left, the night shift nurse (Nurse #12) did not place medication in the medication drawer and count sheet was not placed in the book. The report documented law enforcement was notified. Review of the Pharmacy consolidation delivery sheet dated 1/4/24 revealed 120 tablets of oxycodone 5 mg were delivered to the facility for the resident. This was signed by Nurse #10 and dated 1/4/24. Review of the Investigation Report dated 1/18/24, revealed the incident was investigated under diversion of facility drugs. The incident occurred on 1/5/24 and the facility was made aware of the incident on 1/11/24 at 2:20 PM. The medication was delivered to A1 wing medication cart. The medication was oxycodone 5 mg x 120 (the count of pills). Resident #9 had more medication in the drawer and did not go without medication. Nurse #12 was suspended for investigation and later terminated. The allegation was substantiated. During an interview on 7/31/24 at 4:45 PM, Nurse #9 stated she was the weekend supervisor. Nurse #9 stated it was during one of the weekends in January (date unknown) the nurse (name unknown) had contacted the pharmacy for Resident #9's medication refills of oxycodone. Nurse #9 indicated the nurse was informed by the pharmacy the medications were refilled recently and delivered to the facility. Nurse #9 indicated she was notified by the nurse (name unknown). Nurse #9 stated the previous Director of Nursing (DON) was immediately notified about the medications (oxycodone) had been delivered to the facility but were unavailable on the cart. Nurse #9 indicated Resident #9 had some medication (oxycodone) and was never without any medication (oxycodone). It was only because the medications (oxycodone) were running low, the pharmacy was called for a refill. Nurse #9 stated the previous DON did an investigation regarding missing narcotic medications. During an interview on 7/31/24 at 2:28 PM, Nurse Practitioner #1 stated the resident had a diagnosis of stiff person syndrome. Oxycodone was administered for pain management. Nurse Practitioner #1 further stated that a nurse (name unknown) had requested a refill. The resident was on scheduled oxycodone medication at that time and 120 medication pills were ordered. Nurse Practitioner #1 indicated it was a week later, when she received another request for a refill. Nurse Practitioner #1 stated she made the facility aware that the medication prescription order was recently filled on 1/4/24. It was then the facility became aware of the missing Narcotics and started to investigate. The medications were delivered to the facility on [DATE] but were not placed in the medication cart. Nurse Practitioner #1 indicated the resident never went without pain medication and her pain was controlled. Resident #9 received all her medications as ordered. A new prescription refill was provided due to drug diversion. During a telephone interview on 7/31/24 at 11:00 AM, the Pharmacist with the dispensing pharmacy stated on 1/4/24 the dispensing pharmacy sent out to the facility a continuation of schedule medication therapy form. This was a form from that the dispensing pharmacy computer system would print and send to the facility when their current prescription was going to expire. A new prescription was needed for a refill. This form would then be completed by the facility physician along with the re-order and faxed back to the pharmacy. The new medication would then be sent out to the facility. The Pharmacist stated they received the form back from the facility on 1/4/24 that was signed by the Nurse Practitioner #1. The Pharmacist indicated based on the physician orders in January 2024, Resident #9 was on oxycodone 5 mg, one table every 6 hours. 120 pills of oxycodone 5 mg medication were dispensed in the resident's name and sent to the facility on the night of 1/4/24. The Pharmacist further stated that on 1/12/24 she received an internal email related to drug diversion and a copy of the initial investigation report sent to the North Carolina Department of Health Regulations. There was also a note from the Director of Nursing to bill the facility and not the resident due to drug diversion. The medication was refilled and sent to the facility. During a telephone interview on 7/30/24 at 3:05 PM, the previous Director of Nursing (DON) stated she was made aware of missing oxycodone medication when the nurse (name unknown) tried to reorder the medication (oxycodone) over the weekend (date unknown). The pharmacy had indicated they had delivered the medications to the facility on [DATE]. Nurse #11 (Unit Supervisor for C- wing) had given these medications to A1 cart nurses on 1/5/24. The incoming nurse (Nurse #12) was now in-charge of the A1 medication cart, and he did not place the medications in the cart or log the medications in the Narcotic sheet. The next day Nurse #12 was off on a vacation for about a week. DON stated the medications were delivered to the medication cart on 1/5/24 and the facility became aware of the medications missing on 1/11/24. The resident did not go without medication as she had an adequate supply of medication at that time in the medication cart. The DON indicated there were 120 tablets of oxycodone 5 mg missing. The DON stated she immediately started her investigation of drug diversion (oxycodone 120 tablets). She indicated a drug test was done on the nurses who were involved with the resident's missing medication. Nurse #12 was suspended pending investigation due to being the last person who was known for being responsible for the missing medication. State Agencies and Law enforcement were notified about facility drug diversion. Nurse #11 and Nurse #12 were unavailable for interviews. 3 . Resident #42 was readmitted to the facility on [DATE] Review of Physician orders for Resident #42 dated 12/5/22 read in part, 3 ounces of [NAME] [alcohol] by mouth at bedtime as needed for sleep/pleasure. Review of the Petty Cash Receipt dated 11/28/23 revealed the facility repurchased 750 milliliter (ml) bottle of [NAME] (alcohol) for Resident #42. An amount of appropriately 20 dollars was paid from the facility petty cash. Review of the Grievance log from October 2023 to June 2024 revealed Resident #42 had no grievances filed. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was admitted on [DATE]. The resident was assessed as cognitively intact. During an interview on 07/31/24 03:41 PM, Resident #42 indicated he received alcohol when he requested and had no concerns. The resident further indicated the nursing staff was providing him with alcohol as ordered by the physician. During an interview on 7/31/24 at 9:50 AM, the Social Worker Director stated Resident #42 had a prescription from the physician for 3 ounces of alcohol as needed. The Social Worker Director further stated she purchased the alcohol for the resident using his personal fund. The Social Worker stated based on the receipts, she had made one purchase between November 2023 to January 2024. The alcohol was stored in the medication storage room in the locked refrigerator. The nurses had access to the locked medication room and could administer the alcohol upon request. During a telephone interview on 8/1/24 at 2:30 PM, Nurse #8 stated he worked weekends from 7 AM - 7 PM and was assigned to the C- wing. He indicated there was a resident on the C-wing who had an order for alcohol and was supposed to receive alcohol as he needed. Nurse #8 stated on a weekend (date unknown) when he was taking alcohol for the resident, he noticed there was a little amount that was remaining in a bottle and there was no new bottle in the refrigerator. Nurse #8 stated the Social Worker Director was notified as she frequently purchased alcohol for the resident. The Social worker when contacted indicated she had recently purchased a new bottle and given it to a nurse (name unknown). Nurse #8 further stated he was unable find the new bottle of alcohol and an investigation was conducted by the previous DON. He indicated he had provided a written statement regarding the incident. The Social Worker Director was interviewed again on 8/1/24 at 8:14 AM. She indicated she was contacted by the previous Director of Nursing (DON) on a weekend (date unknown) requesting her to purchase a bottle of [NAME] for the resident. The Social Worker Director stated based on the receipt she had purchased a new 750 ml bottle of [NAME] on 10/17/23 and 11/21/23. She further stated she notified the previous DON that a bottle was purchased recently and was given to a nurse (name unknown). The Social Worker Director indicated based on the receipt a new bottle of alcohol was purchased using facility funds on 11/27/23 as the previous bottle was not found. The Social Worker Director stated no further information was provided to her by the previous DON. The Social Worker Director further stated the facility funds were used to replace the missing bottle. During a telephone interview on 8/1/24 at 8:00 AM, the previous Director of Nursing (DON) stated she did recall a resident residing at the facility with a physician order for alcohol as needed. The previous DON indicated the alcohol bottle was placed in the locked refrigerator in the medication room. The nurses assigned to the medication carts had access to the locked medication room and the locked refrigerator. She further indicated that on one occasion (date unknown), over the weekend, she was made aware by Nurse #9 that the resident needed a new bottle of alcohol as the bottle in the refrigerator was almost empty. The DON stated she did contact the Social Worker Director to purchase a new bottle of alcohol for the resident so that it was available to the resident the next time he requested it. The DON indicated she was informed by the Social Worker Director that she had recently purchased a bottle of alcohol for the resident and had given the bottle to a nurse (name unknown) to be placed in the medication refrigerator. The previous DON stated she wrote a grievance in the name of resident and an investigation was conducted. During the investigation she could not identify the staff who had taken the bottle of alcohol. Staff were interviewed and written statements were taken. The facility replaced the bottle of alcohol for the resident at the cost of the facility. 32394 2. Resident #225 was admitted to the facility on [DATE] from a hospital. His cumulative diagnosis included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and lower extremity lymphedema (swelling caused by a buildup of lymph fluid in the body between the skin and muscle). A review of the resident's electronic medical record (EMR) revealed his physician's orders included an order dated 8/16/23 for 10 milligrams (mg) / 325 mg oxycodone / acetaminophen (a combination medication containing an opioid and an over-the-counter pain medication) to be administered as one tablet by mouth every 8 hours as needed (PRN) for pain for 14 days. This combination medication containing oxycodone is a controlled substance medication. A telephone interview conducted on 7/31/24 at 10:43 AM with a dispensing pharmacist at the facility's contracted pharmacy revealed 42 tablets of 10 mg / 325 mg oxycodone / acetaminophen were dispensed from the pharmacy for Resident #225 on 8/16/23. Resident #225's August 2023 Medication Administration Record (MAR) indicated one tablet of the prescribed oxycodone / acetaminophen was given to the resident on 8/17/23 at 7:51 AM. On 8/19/23 at 1:29 PM, Nurse #13 documented she administered one dose of oxycodone / acetaminophen to Resident #225. According to the MAR, Resident #225 did not receive any doses of oxycodone / acetaminophen on 8/20/23 or 8/21/23. A Facility Investigation Report dated 8/22/23 and signed by the facility's Director of Nursing (DON) revealed the facility became aware of an allegation of the misappropriation of Resident #225's property on 8/22/23 at 1:05 PM. The summary of the Investigation Report read in part, Interviewed resident that stated he requested pain medicine. Nurse told resident he no longer had a prescription . Nurse #13 was identified as the Accused Employee for the diversion of the resident's medication. The allegation details reported Nurse #13 was interviewed and verbally admitted to taking 42 tablets of Resident #225's oxycodone / acetaminophen from the medication cart. The nurse came to the facility and returned 25 of the tablets. The Investigation Report indicated Nurse #13 was immediately terminated on 8/22/23. This report also noted the nurse was reported to the local law enforcement, State Bureau of Investigation (SBI), and the Board of Nursing. An interview was conducted on 7/30/24 at 1:21 PM with the facility's Administrator. During the interview, the Administrator reported he came to work at the facility on 11/30/23 (after the incident involving the misappropriation of Resident #225's medication had occurred). When asked, the Administrator stated the facility could not locate any record(s) related to this incident. A telephone interview could not be conducted with Nurse #13. No current contact information was available. A telephone interview was conducted on 7/31/24 at 12:10 PM with the former Director of Nursing (DON) who submitted the Facility Investigation Report regarding the misappropriation of Resident #225's controlled substance medication. During the interview, the former DON recalled the situation and stated the nursing staff knew the resident's medication had been delivered by the pharmacy. She reported that after talking with Resident #225, she called Nurse #13. The nurse met her in the facility's parking lot and returned some of the missing tablets. When asked as to whether the resident experienced pain due to the misappropriation of his oxycodone / acetaminophen, the former DON reported he was kept comfortable until the medication was replaced. At that time, this medication was not kept in the facility's Emergency medication kit. She stated the facility's Nurse Practitioner was in the building when the oxycodone / acetaminophen was identified as missing so she wrote a new prescription for Resident #225 medication. The facility's back-up pharmacy filled this prescription, and the former DON picked it up from the pharmacy on 8/22/23 to ensure the resident had the medication available when needed. She added that she herself kept checking on him to be sure he was comfortable and she reiterated that he was. Upon inquiry, the former DON recalled that in addition to the local law enforcement, SBI, and the Board of Nursing, the misappropriation of Resident #225's controlled substance medication was also reported to the Drug Enforcement Agency (DEA). During a telephone interview conducted on 7/31/24 at 10:43 AM, a dispensing pharmacist at the facility's contracted pharmacy confirmed 15 tablets of 10 mg / 325 mg oxycodone / acetaminophen were dispensed from the back-up pharmacy for Resident #225 on 8/22/23. An interview was conducted on 8/1/24 at 4:05 PM with the facility's Assistant Business Office Manager in the presence of the Admissions Coordinator. During the interview, the staff members reported the facility paid for the replacement of Resident #225's oxycodone / acetaminophen. The facility's former Administrator was not available for an interview. A follow-up interview was conducted on 8/1/24 at 5:11 PM with the facility's current Administrator. He confirmed there was no documentation of this incident available for review, stating, The entire file is gone. The Administrator reported that since he was not working at the facility in August of 2023, he could not address what was done (or should have been done) with regards to the misappropriation of Resident #225's medication.

Based on staff interviews and record reviews, the facility failed to follow their policy on Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents to maintain documented evidence of a thorough investigation of an allegation of abuse for 1 of 5 residents (Resident #175) reviewed for abuse and of an allegation related to the misappropriation (diversion) of medication for 1 of 3 residents (Resident #225) reviewed for the misappropriation of property. The facility also failed to implement measures to prevent further potential for abuse and maintain documented evidence of the corrective action taken after the misappropriation was verified (including whether more systemic actions were necessary to prevent recurrence of the situation) during these investigations. In addition, the facility failed to implement their policy in the areas of reporting by not submitting the Initial and Investigation Report to the State Regulatory Agency after the facility became aware of a bottle of alcohol prescribed for the resident missing for 1 of 3 resident (Resident #42) reviewed for the misappropriation of property. The deficient practice had the potential to affect other facility residents. The findings included: 1. Review of the annual abuse neglect policy that was updated 5/7/24 read in part: revealed the facility protocol included an investigation checklist which included a review of the staff schedule, interview(s) of employees directly involved and witness(es) who observed or had knowledge of the alleged incident or injury and complete statements of the event, interview the resident, other residents, visitors, vendors, and complete witness(es) statements of the event. A telephone interview on 7/31/24 at 1:57 PM with Administrator #2 indicated the abuse policy dated 5/7/24 was the same policy that was in place in August of 2023. Resident # 175 was admitted to the facility on [DATE]. The annual Minimum Data Set(MDS) dated [DATE] revealed Resident #175's cognition was moderately impaired. The facility 24- hour incident report dated 8/31/23 at 11:00 AM, revealed the facility was made aware by Resident #175 that Nurse Aide #7 had hit him in the chest, face and legs. A telephone interview was conducted on 7/30/24 at 12:15 PM with the responding officer who stated he responded to the call at the facility on 8/31/24 for an allegation of abuse by staff. He reported the resident was interviewed and pictures were taken, no evidence of physical abuse was observed per nursing assessment or pictures. The 5-day summary of investigation completed by the previous Administrator #1, on 8/31/23 revealed no evidence a written statement was obtained from Resident #175 or Nurse Aide #7 and no evidence of interviews or written statements with witnesses (Nurse Aide #8, Nurse Aide #9 or Nurse #7) who observed or had knowledge of the alleged incident or injury or interviews with other residents who may have had contact with the Nurse Aide #7. A telephone interview was conducted on 7/30/24 at 12:15 PM with the responding officer who stated he responded to the call at the facility on 8/31/24 for an allegation of abuse by staff. He reported the resident was interviewed and pictures were taken, no evidence of physical abuse was observed per nursing assessment or pictures. An interview was conducted on 7/31/24 at 8:58 AM, with Nurse #7 who stated Administrator #1, previous Director of Nursing and Social Worker were notified at the time of incident of the allegation of abuse on 8/31/24. The Social Worker came to the facility and interviewed the resident and staff. All the staff involved reported verbally and wrote they did not witness any alleged abuse by Nurse Aide #7. Nurse Aide #7 was sent home following the interview. Nurse #7 stated full body assessments were done on residents that received care by the alleged Nurse Aides and all the information was submitted to management. She was unaware of what happened to the information after submission to management. An interview was conducted on 7/31/24 at 9:11 AM with the Social Worker who stated she spoke with Nurse Aide #7 on 8/31/23 about the allegation of abuse. The Social Worker stated Nurse Aide #7 wrote in a statement on 8/31/23 , he did not hit Resident #175 and Nurse Aide #7 was upset about assisting Nurse Aide #8 and Nurse Aide #9. Nurse Aide #7 was not specific about anything happening during the care. She further stated she was unable to find any of the information related to the investigation that had been completed in the former administration or director of nursing files. Resident #175 was not available for interview. A telephone interview was conducted on 7/31/24 at 7:30 AM, the Nurse Aide #7 who stated he did not recall any incident where he was alleged to hit a resident. He stated he had not worked at the facility for a long time. A telephone interview was conducted on 7/30/24 at 1:10 PM, with Nurse Aide #8 who stated she wrote a statement on 8/31/24 when asked about Nurse Aide #7 abusing Resident #175. Nurse Aide #8 stated she did not observe Nurse Aide #7 do anything to the resident. A telephone interview was conducted on 7/31/24 at 8:05 AM with Nurse Aide #9 who stated on 8/31/23 she was providing care for Resident #175 with Nurse Aide #7 and #8. She stated at no time was the resident hit or abused by anyone in the room. Nurse Aide #9 stated she wrote a statement stating that she did not see Nurse #7 hit the resident. A telephone interview was conducted on 7/31/24 at 1:46 PM with the former Director of Nursing who stated she obtained statements on 8/31/23 from all the employees involved in the allegation of abuse and the police department came and interviewed Resident #175 and took pictures, skin assessments were done on all the residents on the hall the resident resided on, and the Social Worker did interviews with the residents. She indicated the information was given to Administrator #1 who did all the reports to the state agencies. She was unaware of what happened to the investigation reports. A telephone interview on 7/31/24 at 1:57 PM, with Administrator #2 who stated the abuse file was kept in the file cabinet in the administrator's office and there were staff statements, training records and the reportable information. Administrator #2 stated the full investigation was completed by Administrator #1. Administrator #1 was not available for interview. An interview was conducted on 7/31/24 at 8:36 AM with the current Administrator who stated he was unable to find any part of the investigation for this 8/31/23 abuse allegation for Resident #175. He indicated the only information available was what was submitted to the state. 32394 2. The facility's Policy and Procedure entitled Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents (Revised 5/2017; Reviewed on 5/7/2024) specified that neglect, abuse, exploitation, mistreatment, threatened or alleged abuse of residents included Misappropriation of resident property. Misappropriation of resident property was defined as meaning the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The Investigative Procedures outlined within this Policy and Procedure indicated the facility's Investigative Process for an Unknown Cause or Alleged Abuse included placing details of the investigation in an investigation file and taking corrective action. Resident #225 was admitted to the facility on [DATE] from a hospital. His cumulative diagnosis included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and lower extremity lymphedema (swelling caused by a buildup of lymph fluid in the body between the skin and muscle). A Facility Investigation Report dated 8/22/23 revealed the facility became aware of an allegation of the misappropriation of Resident #225's property (related to drug diversion) on 8/22/23 at 1:05 PM. The summary of the Investigation Report read in part, Interviewed resident that stated he requested pain medicine. Nurse told resident he no longer had a prescription . Nurse #13 was identified as the Accused Employee for the diversion of the resident's medication. The allegation details reported Nurse #13 was interviewed and verbally admitted to taking 42 tablets of Resident #225's oxycodone / acetaminophen from the medication cart. The nurse came to the facility and returned 25 of the tablets. The Investigation Report indicated Nurse #13 was immediately terminated on 8/22/23. The Facility Investigation Report also noted the following: Corrective Actions taken following the incident: --Called Nurse [Nurse #13] back to facility, met with Admin. [Administrator and] DON [Director of Nursing] --Terminated --Reported to [local] Police Dept. [Department] --Reported to NC BON [North Carolina Board of Nursing] --Reported to NC SBI [North Carolina State Bureau of Investigation]. An interview was conducted on 7/30/24 at 1:21 PM with the facility's Administrator. During the interview, the Administrator reported he came to the facility on [DATE] (after the incident involving misappropriation of Resident #225's medication). When asked, the Administrator stated the facility could not locate any record(s) related to this incident. A follow-up interview was conducted with the Administrator on 7/31/24 at 8:35 AM to inquire if any information related to the facility's investigation and corrective action for the diversion of Resident #225's medications had been located. The Administrator stated, I have nothing for that, it's just not here. On 8/1/24 at 12:30 PM, an interview was conducted with the Administrator. At that time, additional information on the facility's Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents (Revised 5/2017; Reviewed on 5/7/2024) Policy and Procedure was provided. When specifically asked, the Administrator reported this Policy and Procedure also applied to the misappropriation of a resident's property. Another follow-up interview was conducted on 8/1/24 at 5:11 PM with the Administrator. At that time, the Administrator reiterated the facility did not have information on the investigation or corrective action taken with regards to the misappropriation of Resident #225's medication. The Administrator explained that since he was not working at the facility in August of 2023 when this incident occurred, he did not know what may have been put into place following this incident. 38077 3 . The facility's Policy and Procedure entitled Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents (Revised 5/2017; Reviewed on 5/7/2024) specified that neglect, abuse, exploitation, mistreatment, threatened or alleged abuse of residents included Misappropriation of resident property. Misappropriation of resident property was defined as meaning the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility's Policy and Procedure entitled Plan for the prevention of Elder Abuse (reviewed on 5/7/24) specified that it was the responsibility of all employees to promptly report theft or misappropriation of the resident property to facility management. The policy read in part The report of the initial investigation will be telephoned or faxed to the appropriate State Agency. The facility would complete the investigation following investigation procedures outlined in the abuse and neglect manual. A five (5 ) day report would be filed to the State Agency summarizing the investigation, corrective action taken and outcome of the investigation. Review of Physician Orders for Resident #42 read in part 3 ounces of [NAME] by mouth at bedtime as needed for sleep/pleasure. Review of the Petty Cash Receipt dated 11/28/23 revealed a replacement bottle of [NAME] was purchased for Resident #42. The 750 milliliter (ml) bottle of [NAME] costed approximately 20 dollars and was paid by the facility. During a telephone interview on 8/1/24 at 8:00 AM, Previous Director of Nursing (DON) stated she did recall a resident residing at the facility with a physician order for alcohol as needed. DON indicated the alcohol bottle was placed in the locked refrigerator in the medication room. The nurses on the medication cart had access to the locked medication room and the refrigerator. She further indicated that on one occasion (date unknown), over the weekend, she was made aware by Nurse #9 that Resident #49's alcohol bottle was almost empty, and a new bottle of alcohol was needed to be purchased for future use. The DON stated she did contact the Social Worker Director to purchase a new bottle of alcohol for the resident so that it was available to the resident the next time he requested it. The DON indicated she was informed by the Social Worker Director that she had recently purchased a bottle of alcohol for the resident and was given to a nurse (name unknown) to be placed in the medication refrigerator. The DON stated she wrote a grievance in the name of resident and an investigation was conducted. During the investigation she could not identify the staff who had taken the bottle of alcohol. Staff were interviewed and written statements were taken. The DON stated she was unable to identify the staff responsible for missing alcohol bottle. The facility replaced the bottle of alcohol for the resident. DON indicated she did not submit any initial or investigation report to the State Agency. During an interview on 7/31/24 at 9:50 AM, the Social Worker Director stated Resident #42 had a prescription from the physician for 3 ounces of alcohol as needed. The Social Worker Director further stated she purchased the alcohol for the resident using his personal fund. The Social Worker stated based on the receipts, she had made one purchase between November 2023 to January 2024. The alcohol was stored in the medication storage room in the locked refrigerator. The nurses had access to the locked medication room and could administer the alcohol upon request. The Social Worker Director was interviewed again on 8/1/24 at 8:14 AM. She indicated she was contacted by the previous Director of Nursing (DON) on a weekend (date unknown) requesting her to purchase a bottle of alcohol for the resident. The Social Worker Director stated based on the receipt she had purchased a new bottle of alcohol on 10/17/23 and 11/21/23. She further stated she notified the previous DON that a bottle was purchased recently and was given to a nurse (name unknown). The Social Worker Director indicated based on the receipt a new bottle of alcohol was purchased using facility funds on 11/27/23 as the previous bottle was not found. The facility funds were used to replace the missing bottle. During an interview with the Administrator on 8/01/24 at 10:06 AM, he was hired end of November 2023, but immediately after hire was out due to COVID-19. He indicated he was unaware of any bottle of alcohol that was missing. He stated that if the previous DON had done an investigation, then the facility was unable to find and/or provide the surveyor any files or written documents related to the missing bottle of alcohol.

Based on observation, record review and staff interview the facility failed to label and date foods brought in by resident's family member and failed to maintain the nourishment refrigerators clean for 3 of 3 Nourishment refrigerators (Nourishment refrigerator #1, Nourishment refrigerator #2 and Nourishment refrigerator #3). The facility failed to maintain the ice scoop clean in 1 of 3 nourishment rooms (C wing Nourishment room). These practices had the potential to affect food served to residents. Findings included: Review of the policy Food Brought into facility for resident revealed foods should be stored in clean, sealed air-tight containers in the refrigerator. The container should be labeled and dated. The policy indicated the food may be stored in the refrigerator for up to 3 day. Foods improperly stored or labeled or stored for more than 3 days would be discarded by the nursing staff. 1 a. Observation of the nourishment refrigerator #1 (B Wing) on 7/29/24 at 10:13 AM, revealed a plastic grocery bag with takeout food container with no label or date. A plastic bag containing a plastic container with cut fruit with no label or date. The Dietary Manager indicated the cut fruit was watermelon. The refrigerator also contained a 16-ounce (oz.) plastic container with baked beans with no label or date. There was a 16 oz. plastic container with yellow color food with just resident name indicated on the box. There was no date as to when this container was placed in the refrigerator. There was a 12 oz opened energy drink can with straw in it. The refrigerator also contained an opened 48 oz carton of orange juice with no open date on it. The refrigerator shelves were observed to be sticky. The plastic bags containing resident's food were stuck to the shelves. During an interview on 7/29/24 at 10:15 AM, the Dietary Manager stated it was the responsibility of the nurses to ensure all the food placed in the nourishment refrigerator was labeled and dated. The refrigerator was to be cleaned and all food more than 3 days should be discarded by the night shift nurse. The Dietary Manager indicated that employees should not be using the nourishment refrigerator to store their personal food. The Dietary Manager stated it was the responsibility of the nursing staff to ensure the nourishment refrigerator was maintained clean and all food was labeled and dated. 1b. Observation of the nourishment refrigerator #2 (A Wing) on 7/29/24 at 10:19 AM, revealed yellow stains on the floor of the refrigerator and yellow stains on the inside of the freezer door. During an interview on 7/29/24 at 10:19 AM, the Dietary Manager indicated it was the responsibility of the nursing staff to keep the refrigerator clean. 1 c. Observation of the nourishment refrigerator #3 (C Wing) on 7/29/24 at 10:21 AM, revealed a plastic grocery bag containing a plastic box with cut watermelon with a sell by date 7/26/24. There was no label on it. A 16 oz plastic container with salad and sliced boiled egg and a 12 oz store brought dip with expiration date 8/12/24 with no label or date. The refrigerator also contained two opened 48 oz. cartons labeled apple juice and one opened 48 oz. carton labeled orange juice with no open date. The floor of the refrigerator had yellow sticky stains. The bottom drawers were stuck to the floor of the refrigerator and would not slide open. Observation of the freezer revealed a grocery bag containing two disposable plates with frozen cake. A fast food 20 oz drink that was half filled and frozen. There was no label or date on them. 2. Observation of the ice machine on 7/29/24 at 10:25 AM in the nourishment room on C Wing revealed the ice scoop was placed on few paper towels. The paper towels were wet. There was no ice scoop holder near the ice machine. During an interview on 7/29/24 at 10:25 AM, the Dietary Manager stated the ice scoop should be placed in the ice scoop holder and not on paper towels. The Dietary Manager was unsure where the ice scoop holder was. She indicated she would place a new ice scoop holder in the room. During an interview on 8/1/24 at 2:20 PM, the Director of Nursing (DON) indicated the Nurse aides on each Wing were assigned to clean the pantry daily. The Nurse aides who were assigned to this task were responsible to ensure they clean the refrigerator during their assigned days. The Dietary department should also be cleaning the refrigerator when snacks were placed in the refrigerator, and clean spills. The DON indicated the resident's family members who regularly brought in food for the resident were made aware to label and date the food. The DON stated food should be brought in small, airtight containers. She further stated nursing staff who were placing the food in the nourishment refrigerator should also be ensuring that the food was labeled and dated. Food that was not dated and labeled should be discarded by the nursing staff. The DON stated all juice containers that were opened should be dated by an open by date. These should be discarded within 72 hours of opening. During an interview on 8/1/24 at 5:09 AM, the Administrator stated the nourishment refrigerators should be maintained clean, and all food should be labeled and dated. Any food that was not labeled or dated should be discarded.

Based on record review, observation, and staff interviews, the facility failed to provide nail care to a resident dependent on staff. This occurred for 1 of 4 residents (Resident #16) reviewed for activities of daily living (ADL) care. The findings included: Resident # 16 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the recent admission Minimum Data Set (MDS) assessment, dated 6/18/24, revealed him as having intact cognition. The resident required extensive assistance with activities of daily living (ADL), including personal hygiene. He had no behaviors or rejection of care. Review of the plan of care, dated 7/11/24, revealed that Resident #16 had ADL selfcare performance deficit, with goals and interventions, including for staff to provide assistance with bathing and personal hygiene. On 7/29/24 at 11:05 AM, during the observation/interview, Resident #16 was in bed, dressed and groomed. His bilateral fingernails were observed to be long (approximately one inch extended over the edge of his fingertip) with a visible dark substance under his nails. This observation was for 8 of 10 fingernails. The resident indicated that he asked the staff last week (did not recall the date or staff member name) to trim his fingernails. The staff member promised to do it later and never did. On 7/30/24 at 1:25 PM, during an observation/interview, 8 of 10 of Resident #16's fingernails were observed to be long with a visible dark substance under them. The resident indicated that nobody trimmed his fingernails on the day of the interview. On 7/31/24 at 10:00 AM, during an interview, Nurse Aide #1 indicated she was assigned for Resident #16 at first shift on 7/29/24, 7/30/24 and 7/31/24. Nurse Aide #1 stated she was aware Resident #16's fingernails were long with a visible dark substance underneath the nails. Nurse Aide #1 continued that Resident 16's fingernails should be checked every shift for cleanliness and trimmed if needed. She said Resident #16's nail care was not completed and his fingernails needed to be trimmed and cleaned. On 7/31/24 at 10:15 AM, during an interview, Nurse #1 indicated she was assigned for Resident #16. She mentioned that Resident 16's nails should be checked daily, trimmed and cleaned if needed. On 7/31/24 at 10:30 AM, during an interview, Nurse #2, Unit Manager, indicated that nail care should occur as needed. Nurse #2 stated Resident 16's fingernails should be trimmed and checked for cleanliness. On 8/1/24 at 10:00 AM, during an interview, the Administrator expected the staff to monitor residents' nails and trim them on time.

Based on record review and interviews with the Responsible Party and facility staff the facility failed to ensure 1 of 1 resident (Resident #76) was transported to a scheduled oncology follow-up appointment. Findings included: Resident #76 was admitted to the facility on [DATE] with diagnosis of dementia and cancer. Review of Resident #76's medical record revealed she had a Physician's Order for Anastrozole one milligram once daily for chemotherapy related to breast cancer. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #76 was severely cognitively impaired. During an interview with the Responsible Party on 7/29/2024 at 11:29 am he stated Resident #76 was not transported to a previously scheduled oncology appointment for follow-up for breast cancer on 2/6/2024. The Responsible party stated Resident #76 was taking an oral chemotherapy drug and saw the oncologist for follow-up, but the facility failed to have her at the appointment as planned. The Responsible Party stated he called the facility and left a message after the appointment was missed but no one returned his call. The Social Services Director was interviewed on 7/31/2024 at 5:24 pm and she stated Resident #76 was scheduled for an appointment scheduled for 9/5/2024 at the cancer center but she was not aware of Resident #76 having a missed appointment for oncology follow-up. The Social Services Director stated the Transportation Scheduler would be responsible for scheduling transportation and ensuring residents were transported to their appointments. On 7/31/2024 at 5:36 pm the Transportation Scheduler was interviewed, and she stated she failed to transport Resident #76 to her oncology appointment. The Transportation Scheduler stated she was transitioning into the role of Transportation Scheduler when Resident #76 was scheduled for her oncology appointment and the previous Transportation Scheduler did not put the appointment on the calendar which caused the appointment to be missed. The Transportation Scheduler stated Resident #76 was rescheduled for her appointment on 3/4/2024 and she was transported to the appointment. During an interview with the Administrator on 8/1/2024 at 5:04 pm he stated he was not aware Resident #76, or any other residents had missed their scheduled appointments. The Administrator further stated the facility was responsible for ensuring residents are scheduled and transported to their appointments and Resident #76 should not have missed her oncology appointment.

Based on staff and consultant pharmacist interviews and record reviews, the facility failed to: 1) Maintain documentation of the pharmacist's Monthly Medication Reviews (MMRs) within the facility and readily available for review; and 2) Retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record. This occurred for 1 of 5 residents reviewed for Unnecessary Medications (Resident #20). The findings included: Resident #20 was initially admitted to the facility on [DATE] with re-entry on 12/26/23 from a hospital. Her cumulative diagnoses included epilepsy, anxiety disorder, dementia, and mild neurocognitive disorder (a collection of syndromes in which the primary clinical feature is a decline in cognitive functioning) with behavior disturbances. A review of the resident's electronic medical record (EMR) revealed a medication order was received on 12/26/23 for 2.5 milligrams (mg) olanzapine (an antipsychotic medication) to be given as 1 tablet by mouth every day (scheduled for 8:00 AM daily) for unspecified symptoms and signs with cognitive functions and awareness. On 5/13/24, a physician's order was also received for 5 mg olanzapine to be given as one tablet by mouth daily (scheduled for 2:00 PM). Resident #20's most recent Minimum Data Set (MDS) was an assessment for a significant change in status (dated 7/2/24). Resident #20 was reported to have moderately impaired cognition with verbal behavioral symptoms on 1-3 days during the 7-day look back period. The Medication section of the MDS reported Resident #20 received an antipsychotic medication during the 7-day look back period. A review of Resident #20's paper medical record was conducted and included the Pharmacist Progress Notes with the monthly Medication Regiment Review (MRR) completed by the facility's consultant pharmacist. This review revealed MRRs were documented as completed during the past year on each of the following dates: 7/18/23, 11/13/23, 12/19/23, 12/28/23 (upon the resident's re-admission to the facility), 1/15/24, 2/13/24, 4/15/24, 5/13/24, and 6/13/24. Resident #20's paper medical record did not include the monthly MRRs for 8/23, 9/23, 10/23, and 3/24 nor the signed provider's review and response (documented on a Prescriber Recommendation Form) for any pharmacist's findings / recommendations generated on these dates. An interview was conducted on 7/31/24 at 4:22 PM with the facility's Administrator. Upon inquiry, the Administrator reported all of the consultant pharmacist's MRRs should be stored in the resident's paper medical record. A telephone interview was conducted on 8/1/24 at 11:53 AM with the facility's consultant pharmacist. During the interview, the pharmacist reported a Pharmacist Progress Note with the monthly MRR was supposed to be filed in each resident's paper medical record. If a recommendation was made, then a signed provider note (a Prescriber Recommendation Form) with the physician's review and response to the pharmacist's findings / recommendations would also be put into the paper medical record by the administrative nursing staff. When the missing pharmacist MRRs from 8/23, 9/23, 10/23, and 3/24 for Resident #20 were discussed, the pharmacist stated during this period of time there was a huge changeover with the facility's administrative staff. The pharmacist was able to pull up the pharmacy's electronic medical records and confirmed MRRs were completed for each of the 4 months in question. The pharmacist reported the following information was included on the missing MRRs for Resident #20: --The MRR dated 8/29/23 indicated no irregularities were noted; --The MRR dated 9/19/23 indicated no irregularities were noted; --The MRR dated 10/24/23 provided a cautionary note to the prescriber regarding the use of olanzapine for a resident with a history of seizures; --The MRR dated 3/14/24 recommended consideration of gradual dose reduction (GDR) for olanzapine. When asked where the pharmacist's MRRs and signed Prescriber Recommendation Forms should be kept, the pharmacist stated they should all be under the section tabbed for Pharmacy in the resident's paper medical record. A follow-up interview was conducted on 8/1/24 at 5:18 PM with the facility's Administrator. During the interview, the Administrator reiterated the facility was not able to locate any additional MRRs or signed Prescriber Recommendation Forms for Resident #20. Upon inquiry, the Administrator reported he would have expected these forms to have been stored in the resident's paper medical record.

Based on record review and staff interviews, the facility failed to ensure staff who performed a job responsibility of a nurse aide (NA) had completed a training and competency evaluation program and was competent to provide nursing and nursing related services when the Maintenance Director assisted NA #2 with transferring Resident #1 from her wheelchair to bed utilizing a mechanical lift on 5/16/24. This deficient practice was for 1 of 7 staff reviewed who performed nursing related services. The findings included: Resident #1 was admitted to the facility on [DATE]. An interview was conducted on 6/05/24 at 1:45 pm with the Activity Assistant who revealed that during the late afternoon on 5/16/24 she observed the Maintenance Director operate the mechanical lift to put Resident #1 in bed. She reported she was not sure if another staff member was present with the Maintenance Director at the time of the observation because the privacy curtain was pulled. The Activity Assistant stated she also worked as a NA at the facility, and she reported that she had to complete mechanical lift training and take a test before she could begin working with the residents. An interview with the Maintenance Director on 6/05/24 at 3:13 pm revealed she was completing maintenance on a wheelchair in the hall in the afternoon on 5/16/24 when NA #2 asked her to assist with the Resident #1's transfer back to bed with the mechanical lift. The Maintenance Director stated she did not tell NA #2 she was not trained to operate the mechanical lift because she did not know she needed to be trained. The Maintenance Director confirmed she had not received training in the use of the mechanical lift, and she was not trained to work as a nurse aide. Review of NA #2's written statement provided to the facility (no date) revealed that on 5/16/24 on the 7:00 am-3:00 pm shift she completed a head-to-toe bath and prepared Resident #1 for transfer with the mechanical lift. NA #2 stated she popped her head out into the hall for assistance and the Maintenance Director asked if she needed assistance. NA #2 stated she was very unaware of the fact that the Maintenance Director was not officially lift trained so she accepted her offer to assist. NA #2 stated the Maintenance Director used the remote of the mechanical lift to raise Resident #1 and place her in the wheelchair. A telephone interview was conducted on 6/05/24 at 2:49 pm with Nurse Aide (NA) #2 who reported she was assigned to Resident #1 on 5/16/24 during the 7:00 am-3:00 pm shift. NA #2 stated on 5/16/24 she was ready to transfer Resident #1 with the mechanical lift when she looked in the hall for another staff member to assist and the Maintenance Director was in the hall outside the room. NA #2 stated she told the Maintenance Director she was ready to transfer Resident #1 with the mechanical lift and was looking for someone to assist. NA #2 stated the Maintenance Director offered to assist with Resident #1's transfer so NA #2 accepted the Maintenance Director's assistance since Resident #1 was ready to be transferred. NA #2 stated she was not aware the Maintenance Director was not trained to operate the mechanical lift and the Maintenance Director did not report she was not trained when she offered to assist with Resident #1's mechanical lift transfer. NA #2 stated the Maintenance Director operated the mechanical lift to assist with the transfer under her direction while she positioned Resident #1 on the bed. An interview was conducted on 6/06/24 at 9:53 am with the Safety Nurse who revealed she was responsible along with the Staff Development Coordinator to train staff on the use of the mechanical lift. The Safety Nurse reported she had not trained the Maintenance Director on the use of the mechanical lift, and she stated staff were not to operate the lifts until trained. During an interview on 6/06/24 at 5:30 pm the Staff Development Coordinator reported she trained staff on the use of mechanical lifts with the Safety Nurse during orientation. The Staff Development Coordinator stated once the training was completed, staff were competent to use the mechanical lifts. She stated she had not provided training to the Maintenance Director for use of the mechanical lifts. The Staff Development Coordinator stated mechanical lift training was important to ensure that residents and staff were safe and avoid injury when using the mechanical lift. An interview with the Director of Nursing (DON) on 6/05/24 at 2:43 pm revealed she was notified by staff that the Maintenance Director assisted NA #2 to get Resident #1 back to bed on 5/16/24 with a mechanical lift. The DON stated the Maintenance Director was not trained to use the mechanical lifts, she was not trained to work as a nurse aide, and she was not allowed to assist NA #2 with Resident #1's transfer. An interview was conducted on 6/06/24 at 11:19 am with the Administrator who revealed the Maintenance Director was competent to use the lift because she understood how to use the mechanical lift and maintained the lifts, but she should not have assisted NA #2 with Resident #1's mechanical lift transfer. The Administrator reported he spoke with the Maintenance Director and reviewed the scope of her job description, and she was notified that involvement with nursing services was out of her scope.

Based on record review and staff interviews the facility failed to use the service of a registered nurse (RN) for at least 8 consecutive hours (hrs.) a day for 4 of 52 days reviewed (5/6/23, 5/7/23, 5/13/23 and 5/14/23). Findings included: Review of staffing sheets from 5/1/23 through 6/21/23 revealed the following: On 5/6/23 the staffing sheets indicated 0 (zero) RN on duty. On 5/7/23 the staffing sheets indicated 0 (zero) RN on duty. On 5/13/23 the staffing sheets indicated 0 (zero) RN on duty. On 5/14/23 the staffing sheets indicated 0 (zero) RN on duty. During an interview on 6/22/23 at 9:04 AM, the Staff Development Coordinator (SDC) stated that she was handling the scheduler position since 6/9/23 The SDC further stated the facility had 3 RNs and all efforts were made to ensure there was at least one RN working 8 hours per day. The SDC indicated the facility had contract with 4 staffing agencies and these agencies were contacted when there was no RN available working at least 8 consecutive hours a day. She acknowledged that based on the staffing schedule on 5/6/23, 5/7/23, 5/13/23 and 5/14/23 there was no RN on duty. During an interview on 6/22/23 at 9:13 AM, the Director of Nursing (DON) stated the facility had contracts with 4 staffing agencies. The DON indicated the previous scheduler was not making efforts to staff RNs. On days when there was no RN on the schedule, the DON stated she would come to the facility to provide supervision over Licensed Practice Nurse (LPNs) and Med Aides. She stated she did not work on the medication cart when she had come in when there was no RN. She explained she was covering the RN requirement for 8 hours as needed. The DON stated the facility was making every effort to ensure there was a Registered nurse for 8 hrs. a day. The previous scheduler was no longer employed by the facility and was unavailable for interview.

Based on record review and staff, resident and resident representative interviews, the facility failed to conduct care plan meetings with residents or resident representatives for 2 of 24 sampled residents reviewed for care plans. (Resident #91 and Resident #34) Finding include: 1.Resident #91 was readmitted on [DATE]. A record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was admitted on [DATE] and was assessed as cognitively intact. Review of Resident #91's care plan revealed the care plan was reviewed and revised on 4/19/23, but there was no indication that resident participated in the care plan meeting or development of the care plan. During an interview on 6/19/23 at 9:55 AM, Resident #91 indicated he had not been invited to attend a care plan meeting and did not recall participating in development of his plan of care. During an interview on 6/21/23 at 10:15 AM, the Social Worker (SW), indicated she was hired in April 2023. She further indicated the MDS nurses would send out a monthly schedule for care plan meetings. A letter was sent out to the families and residents regarding the care plan meetings based on the schedule provided. The SW stated based on the documentation available, Resident #91's previous care plan meeting was conducted on 1/4/22. The Social Worker indicated there was no documentation regarding other care plan meetings and she was unable to confirm if there was one conducted in past few months for Resident #91. She stated she was unsure if there was any social worker available in the facility to complete the care plan meeting. During an interview on 6/22/23 at 9:42 AM, MDS Nurse #1 and MDS Nurse #2 both indicated they did not conduct some care plan meetings when there was no social worker available in the facility. They indicated the facility SW was responsible for setting up care plan meetings with the residents and their family members. Both MDS Nurses stated when the facility did not have any SW, the unit managers were talking to families visiting the residents regarding their medication and any changes. They stated those unit managers were no longer worked for the facility. MDS Nurse #1 and Nurse #2 stated they could not confirm if any care plan meetings were conducted for Resident #91. During an interview on 6/21/23 at 1:15 PM, The Director of Nursing (DON) stated the facility's Social Workers had each quit their position in mid-January 2023. A new Social Worker was hired to this position in April 2023. The DON indicated the SW was working part-time for the facility prior to her hire as the facility's full time social worker. The facility did not have a social worker on a full-time basis from mid-January to March 2023 and some of the care plan conferences were not conducted at that time. During an interview on 6/22/23 at 10:34 AM, the Social Services Consultant (Corporate) stated, the facility had two qualified staff working as part time social workers and were assisting with the residents' MDS assessments. The MDS staff were supposed to arrange the care plan meetings in the absence of the social worker, and they had not been conducting them. The Social Services Consultant stated this impacted some of the care plan conferences during that time. 2. Resident #34 was admitted on [DATE]. A record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was assessed as cognitively impaired. Review of Resident #34's care plan revealed the care plan was reviewed and revised on 3/14/23, but there was no indication that resident representative participated in the care plan meeting or development of the care plan. During an interview on 6/19/23 at 2:45 PM, Resident #34' representative indicated she had not been participating in the care plan meeting. She stated she did receive a letter regarding the date for when the meeting was scheduled to be held, but on that date, there was no one to conduct the care plan meeting. She further stated the staff member who regularly conducted care plan meetings had quit her job and hence no one was conducting the care plan meetings. During an interview on 6/21/23 at 10:15 AM, the Social Worker (SW), indicated she was hired in April 2023. She further indicated the MDS nurses would send out a monthly schedule for care plan meetings. A letter was sent out to the families and residents regarding the care plan meetings based on the schedule provided. The SW stated Resident #34's was scheduled for a care plan meeting in June and an invitation letter to the resident's representative would be mailed out soon. The Social Worker indicated there was no documentation regarding other care plan meetings and she was unable to confirm if there was one conducted in past few months for Resident #34. She stated she was unsure if there was any social worker available in the facility to complete the previous care plan meeting. During an interview on 6/22/23 at 9:42 AM, MDS Nurse #1 and MDS Nurse #2 both indicated they did not conduct some care plan meetings when there was no social worker available in the facility. They indicated the facility SW was responsible for setting up care plan meetings with the residents and their family members. Both MDS Nurses stated when the facility did not have any SW, the unit managers were talking to families visiting the residents regarding their medication and any changes. They stated those unit managers no longer worked for the facility. MDS Nurse #1 and Nurse #2 stated they could not confirm if any care plan meetings were conducted for Resident #34. During an interview on 6/21/23 at 1:15 PM, The Director of Nursing (DON) stated the facility's Social Workers had each quit their position in mid-January 2023. A new Social Worker was hired to this position in April 2023. The DON indicated the SW was working parttime for the facility prior to her hire as the facility's full time social worker. The facility did not have a social worker on a full-time basis from mid-January to March 2023 and some of the care plan conferences were not conducted at that time. During an interview on 6/22/23 at 10:34 AM, the Social Services Consultant (Corporate) stated, the facility had 2 qualified staff working as part time social workers and were assisting with the residents' MDS assessments. The MDS staff were supposed to arrange the care plan meetings in the absence of the social worker, and they had not been conducting them. The Social Services Consultant stated this impacted some of the care plan conferences during that time.

Based on observation, resident and staff interviews and record review, the facility failed to safely transfer a resident from his bed to the wheelchair, failed to immediately notify the nurse of a fall when the resident was lowered to the floor by a staff member during the transfer and failed to investigate the cause of the fall by not interviewing the staff member who was present during the fall. This affected 1 of 11 residents (Resident #60) reviewed for accidents. Findings included: Resident #60 was readmitted to the facility on [DATE]. Diagnoses included, in part, hemiplegia and cerebrovascular accident. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact. He required extensive assistance with the help of two people for transfers. The care plan included a focus area of risk for falls. A care plan intervention dated 1/13/23 stated, Two person pivot transfers. An Occurrence Report dated 5/4/23 and completed by Nurse #7 stated the following: Date of occurrence 5/3/23. The resident stated to the writer that yesterday around 9:00 AM the agency Nursing Assistant (NA) dropped the resident on the floor. The resident stated that the NA did not use a lift to get resident out of the bed. The resident stated that the wheelchair was not locked. The resident stated that he was on the floor waiting for help. There was no apparent injury. Additional information included in the report indicated the agency NA had not assisted with the transfer; rather, a Hospice NA had assisted Resident #60. The falls care plan was updated 5/8/23 and included an intervention of transfer resident out of bed as per facility protocol. The Safe Resident Handling Data Collection form, located in Resident #60's paper chart, was reviewed (not dated) and indicated a total lift was required when transferring Resident #60. On 6/21/23 at 1:00 PM an observation of Resident #60's room door revealed a sticker on the wall next to his name that had a picture of a mechanical lift and indicated two staff were needed to operate the lift to transfer the resident. During an interview with Resident #60 on 6/21/23 at 1:08 PM, he shared normally there were two staff members who assisted him with transfers and they used a mechanical lift. He recalled on 5/3/23 there was one NA who helped with his transfer from the bed to his wheelchair. The NA had not used the mechanical lift during the transfer. He stated during the transfer, the wheelchair slid away and the NA assisted him to the floor. Resident #60 said the NA left the room and got another staff member to help. He added the NA called a man to help her put him back in the bed. He stated he was not injured when he was assisted to the floor and didn't think the NA told the nurse about the fall. NA #10 was interviewed on 6/21/23 at 11:15 AM. She said she worked on the day Resident #60 fell but had not worked with the resident that day. She recalled Hospice NA #1 was in the building and did not want to work with her assigned Hospice resident since the Hospice resident's roommate had COVID. NA #10 stated she thought Hospice NA #1 and NA #11 (an agency NA who was assigned to Resident #60) switched residents and Hospice NA #1 assisted Resident #60 with his care. When NA #10 came to work on 5/4/23 she heard Resident #60 had fallen during a transfer. She said she didn't think anyone reported the fall until Resident #60 said something to staff on 5/4/23. NA #10 explained that typically, if a resident fell or was assisted to the ground, staff immediately notified the nurse before the resident was moved back into bed. Attempts to interview NA #11 and Hospice NA #1 were unsuccessful. On 6/21/23 at 1:59 PM an interview was conducted with Floor Technician #1. He confirmed he worked at the facility on 5/3/23. He recalled the NA came out of Resident #60's room and asked him if there was anyone at the nurse's station that could help her. Floor Technician #1 said there wasn't anyone at the nurse's station and the NA asked if he could help her. He informed the NA he wasn't permitted to lift any resident. He entered Resident #60's room and observed the resident seated on the floor next to the bed and was leaned up against the side of the bed. The wheelchair was next to the bed. Floor Technician #1 explained he locked the wheels on the wheelchair and then held on to the handles at the back of the wheelchair while the NA attempted to lift Resident #60 up into the wheelchair. He said the NA still had problems lifting him up to the chair. Floor Technician #1 said he then left the room and added the next time he saw Resident #60 was about 5-10 minutes later and he was seated in the wheelchair. A telephone interview was conducted with Nurse #8 on 6/21/23 at 2:22 PM. She verified she was Resident #60's nurse on 5/3/23. She was unable to recall the events of the day but added she didn't think anyone notified her of Resident #60's fall. She explained when a resident fell , she immediately went to the resident's room and completed an assessment before the resident was moved. In a telephone interview with Nurse #7 on 6/20/23 at 4:03 PM, she said when she worked with Resident #60 on 5/4/23, he told her about the fall that occurred on 5/3/23. She began an incident report when the resident informed her about the fall. Nurse #7 said she was told by other staff that a Hospice NA had been in Resident #60's room helping another NA. She then stated she mistakenly put Hospice NA on the report instead of an agency NA. She added the NAs went to transfer Resident #60 into a wheelchair but had not used the mechanical lift; the wheelchair was not locked and Resident #60 was lowered down to the floor. Unit Manager #1 was interviewed on 6/20/23 at 12:07 PM, 6/21/23 at 9:24 AM, and 6/21/23 at 1:38 PM. She explained staff identified a resident's transfer status when they looked at the picture on the sticker to the side of the resident's door. She said on 5/3/23 Hospice NA #1 was in Resident #60's room and tried to assist him with a transfer but didn't know his lift status. She said Hospice NA #1 tried to transfer the resident by herself and when she put him in the wheelchair, it was not locked, rolled away and she assisted Resident #60 to the floor. She stated the resident was not injured. Unit Manager #1 further added she worked the day he fell and recalled during shift change in the afternoon she overheard a NA comment about Resident #60's fall. She heard that NA #11 and Hospice NA #1 had switched a resident assignment and that Hospice NA #1 assisted Resident #60 with the transfer. After she heard about his fall, Unit Manager #1 said she got busy with her work and forgot to check on Resident #60, then was off work for two days. She recalled Nurse #7 called her on 5/4/23 and asked about the fall. On 6/22/23 at 8:56 AM an interview was conducted with the Safety Nurse. She explained when a resident was admitted to the facility, the admission nurse assessed the resident and determined how much help was required to safely transfer a resident. Once the transfer status was identified, a sticker was put on the resident's door. Information about the transfer status was also included in the resident's paper chart. The Safety Nurse shared that Resident #60 had been identified as needing a mechanical lift for quite a while and staff utilized a mechanical lift in May 2023, prior to the fall. She stated when a resident fell , the nurse on duty started documentation on the incident/occurrence report. Unit Coordinators then reported the fall in the morning meeting and the interdisciplinary team discussed fall prevention interventions. An investigation was completed and information from the investigation went to the care plan nurse and then was forwarded to the Director of Nursing (DON) and Administrator who signed off on the investigations. The DON and Unit Manager #1 were interviewed on 6/21/23 at 1:46 PM. Unit Manager #1 stated any time a resident fell , the nurse assessed the resident prior to the resident being moved back into bed. The assessment included vital signs, neurological checks, range of motion evaluation and resident interview about what happened. The DON added, We are a no lift facility, and explained, after a fall, a resident was to be transferred back into bed with a mechanical lift. During an interview with the DON, Administrator and Corporate Nurse on 6/22/23 at 1:19 PM, the DON revealed at the time of the survey she learned Hospice NA#1 and NA #11 had switched part of their assigned duties and Hospice NA #1 assisted Resident #60 with the transfer. She shared other staff informed her that Hospice NA #1 hadn't assisted her assigned Hospice resident because the Hospice resident's roommate had COVID and Hospice NA #1 didn't want to enter the room and so she switched room assignments with NA #11. The DON thought at the time of the fall, Resident #60 was a two person stand and pivot assist, and not a mechanical lift. She explained when a resident fell , the nurse initiated an incident report which was brought to the interdisciplinary team for review and discussion. Part of the discussions included implementing a new intervention for fall prevention. The DON said she thought two nurse aides had assisted with the transfer but had not interviewed the NAs as part of the facility's investigation of the fall. She added the facility completed education with all nursing staff regarding identifying transfer status, use of mechanical lifts for transfers and notifying the charge nurse immediately after a resident fell .

Based on resident, staff, nurse practitioner and physician interviews and record review, the facility failed to assess the resident after a nursing aide (NA) reported a pop sound during activity of daily living (ADL) for 1 of 4 residents reviewed for accidents. (Resident #121). The following day Resident #121's right leg was X-rayed and showed the resident had a distal femur fracture. Findings included: Resident #121 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most comprehensive Minimum Data Set ((MDS) dated [DATE] revealed, Resident # 121 was cognitively intact. Resident #121 was coded as needing extensive assistance with 2 people for toileting, extensive assistance with one person for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was also coded as being impaired on both sides of lower extremities. Review of the care plan dated 10/15/19 revealed the resident had a care plan for restorative nursing program activities of daily living (ADL) related to muscle weakness due to [MEDICAL CONDITION]. The goal was initiated on 3/18/19. Intervention included was to notify charge nurse if pain was noted with ADL care and care stopped immediately. During an interview on 1/13/19 at 11:10 AM, Resident # 121 stated on 12/18/19, nurse aide (NA) #1 was assisting her with putting on pants. NA #1 had put on the pants to left mid-calf first and was trying to put it on the right leg. NA tried to bend the leg. Resident # 121 stated the NA was told that her leg does not bend, however the NA continued to bend the leg. Resident # 121 stated both the resident and NA#1 heard a pop sound. Resident # 121 stated she was not assessed by nursing staff and proceeded to go to her dental appointment. Resident # 121 indicated she had mild pain. Resident #121 indicated on 12/19/19 (the following day), the resident complained of pain and was assessed by Nurse Practitioner (NP). An X-ray was ordered, and results indicated femur fracture. Review of nursing note dated 12/18/19 at 10:44 PM revealed Resident # 121 refused evening ADL care, stating her leg was hurting. Resident refused to be turned. As needed (PRN) pain medication was offered but was refused. Review of nursing note dated 12/19/19 at 12:12 AM revealed Resident# 121 was complaining of leg pain. The nursing note read in part pain medication administered. Note left in physician communication book. During an interview on 1/14/19 at 4:30 PM, NA #1 stated on 12/18/19, resident had a dental appointment at around 11 and was assisting the resident getting dressed. NA stated the resident was in bed when she first placed resident's left foot in the pant. The pant just crossed /past the left foot, when NA attempted to raise the right leg, that was when both resident and NA heard a pop sound. Resident stated Oh! my leg. NA #1 confirmed she did notify Nurse # 3 immediately when the incident occurred, however the nurse had not come in to do the assessment or check on the resident when the incident was reported. NA stated she continued to dress the resident. The resident did not complain of any pain at that time. After assisting the resident with dressing, NA # 1 stated she requested NA # 2 to assist her with mechanical lift to transfer resident from her bed to the wheelchair. NA #1 indicated during the transfer the resident requested NA #2 to hold her legs as her leg was hurting. NA #1 continued that few minutes later Nurse#3 requested her to bring in the mechanical lift to B hallway to reposition the resident in her wheelchair again. NA #1 stated with the assistance of Nurse #3 and other nurses in the hallway, the resident was raised in the mechanical lift, and repositioned. The resident did not complain of any pain or discomfort at this time and proceeded to her appointment. During an interview on 1/14/20 at 11:18 AM, Nurse # 3 indicated she was assigned to the resident on 12/18/19 from 7AM - 3 PM. Nurse # 3 stated on 12/18/19 (unsure of the exact time) the resident was scheduled for a dental appointment. Nurse indicated NA # 2 had informed her about hearing a pop sound while resident was being dressed. Nurse# 3 stated prior to the resident leaving the facility for her appointment, she along with NA # 1 and other hall nurses assisted with repositioning Resident # 121 in her wheelchair with the aid of mechanical lift in the hallway. Nurse indicated after transfer the resident's leg was observed by pressing on the upper thigh and along the leg. The resident denied pain when pressed. Nurse #3 stated as the resident did not convey any pain, a full assessment was not completed. Nurse # 3 indicated she did not document the incident but provided a verbal report to the nurse supervisor and incoming staff. During an interview on 1/14/19 at 4:15 PM, Nurse # 4 indicated she was assigned to the resident on 12/18/19 from 3 PM to 11 PM. Nurse # 4 stated she did not receive any report about staff hearing a pop sound in the leg while the resident was being dressed earlier that day. Nurse # 4 further stated the resident later that night had complained of pain and was offered Tylenol, which was declined. Nurse stated when she asked the resident where the resident was having pain, the resident indicated all over. Nurse # 4 stated she does recollect the resident indicated a pain scale of 7. Nurse stated as the resident reported overall pain no assessment was complete. During a telephone interview on 1/16/20 at 7:53 AM, NA #5 indicated she was assigned to the resident on 12/18/19 from 11 PM - 7 AM. NA stated during shift change, she was made aware by the previous shift NA that the resident was refusing ADL care that night as her leg was hurting. NA #5 stated when she entered the resident's room, the resident indicated she got hurt earlier that day and her leg was really sore. Resident#121 had stated she did not want the previous shift NA to provide incontinent care and was waiting for NA #5 to complete her ADL care. NA #5 stated Nurse#5 was notified immediately. Nurse spoke with the resident and provided her with pain medication. NA stated the resident was sore when she tried to turn and change the resident. Resident was verbalizing pain. NA# 5 with the help of another NA (name unknow) completed ADL care for the resident. During a telephone interview with Nurse # 5 on 1/15/20 at 8:59 AM, Nurse indicated she was assigned to the resident on 12/18/19 from 11 AM to 7 PM. Nurse # 5 stated the resident was complaining her leg was hurting. Nurse indicated the resident never complained before of any pain or discomfort and did not like to be woken up. Nurse # 5 stated this was unusual for the resident to be awake, complaining of pain, so a note was written in the doctor's communication book for the physician to assess the resident the following day. Nurse # 5 confirmed she did not call the physician. Nurse indicated she did not assess the resident or move the leg. Nurse # 5 stated no information related to any incident that occurred during the day was given to her during the shift report. During an interview on 1/14/20 at 11:18 AM, Nurse # 3 indicated she was assigned to the resident on 12/19/19 from 7 AM to 3 PM. Nurse # 3 stated that during the shift report, she was made aware about the resident's leg pain and pain medication administered during the night. Nurse indicated according to Resident #121, while NA #1 was trying to put her legs in her pants and assisting her with dressing the previous day, they heard a pop sound. Nurse # 3 stated she notified the unit manager who assessed the resident. Nurse confirmed she did not complete any assessment. Nurse confirmed the resident was in pain at that time. During an interview on 1/16/20 at 9:00 AM, the unit manager indicated on 12/19/19 during morning shift report she was made aware that Resident # 121 was complaining of pain the previous night. The unit manager indicated she observed resident's leg in her room, which appeared to be swollen. The unit manager confirmed the resident was in pain and that she did not conduct the head to toe assessment but gave a verbal report to the Nurse Practitioner (NP). Record review revealed there was no documentation of the resident assessment / nursing assessment on 12/18/19 and on 12/19/19. Review of nursing note dated 12/19/19 at 8:56 AM revealed the resident was complaining of pain to her right knee and lower leg. Note read in part Stated when she was getting dressed yesterday, she felt her knee pop. Nurse Practitioner (NP) notified. Orders for X-ray of right knee, tib/fib and ankle was received. During an interview on 1/14/20 at 4:30 PM, NA #1 indicated she was assigned to the resident on 12/19/19 from 7 AM to 3 PM. NA # 1 stated on 12/19/19 during ADL care the resident had indicated her leg was hurting. Nurse #1 was notified about resident's pain. Review of the radiology report of the right knee, right tibia/fibula and ankle dated 12/19/19 revealed mildly impacted distal femur fracture. Soft tissue swelling present. Review of the Nurse Practitioner (NP) note dated 12/19/19 revealed resident had an evaluation of right leg pain. Note read in part the resident states that when been changed yesterday and when her pant was been pulled up, she felt a pop. Experienced pain 6/10, aching from her right knee up to her thigh. Resident has a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] which put the resident at risk for fracture. An x-ray was obtained on her right leg which revealed right femur fracture. Resident was placed on [MEDICATION NAME] for pain. Physician orders [REDACTED]. Review of the updated care plan dated 12/20/19 revealed the resident had a care plan risk of increased level of pain related right distal femur fracture. Interventions included administration of pain medication as ordered and assessing pain level using 1-10 scale. Review of Medication Administration Record [REDACTED]. From 12/19/19 to 1/17/19, there was no pain assessment documentation that indicated the pain scale before or after medication administration. During an interview on 1/16/20 at 9:00 AM, the unit manager stated the pain scale documentation was only required prior to any as need pain medication administration. Unit manager further stated she was unaware of Resident # 121's updated care plan that indicated the pain scale 1-10 should be documented daily. She confirmed no follow-up assessments were completed after the incident and no monitoring tools were put in place. During an interview on 1/16/20 at 9:27 AM, the Director of Nursing (DON) stated she was made aware of the incident on 12/20/19. DON stated when the nurse was made aware of the popping sound, the nurse should have completed an assessment, which should include physical assessment of leg and should be documented. After assessment if the resident was not in distress and leg was not deformed or any issues/ deviation from normal then the resident could go ahead with her daily routine. DON further stated the nurse should document the incident in chart. During an acute episode all staff should document any observations or conditions of the resident and able to demonstrate ongoing monitoring of the resident. The Unit manager should coordinate care. The resident should have been monitored for 72 hour for acute episode like a fracture and this included the effectiveness of any pain medication. During an interview with the Physician in presence of the NP on 1/16/20 on 10:01 AM, Physician indicated if the resident complained of pain then an evaluation should be completed. The resident should be evaluated by the nurse prior to transfer, if there was popping sound accompanied by pain which included Ouch my leg hurts. NP stated the resident was bed bound and very rarely moves out of bed except to get her hair done. The physician stated that the resident was prone to a pathological fracture when her legs were moved due to resident's [DIAGNOSES REDACTED]. Both NP and physician indicated that they did not consider that the resident had a delay in treatment. The resident was assessed, X-ray ordered and sent to Ortho clinic when results indicated a fracture. NP added that the resident was not a surgical candidate and consider the ortho consult recommendations to be appropriate. Related to pain medication, Physician stated when narcotics were administered as pain medication, the nursing staff should indicate the pain scale to indicated if the medication was effective or non-effective. Physician stated the Physician or NP should be notified prior to the resident leaving to the dental appointment when the pop sound was heard, and pain indicated. Both further indicated that the nursing staff should communication to them via phone when not available in the facility. Physician stated the nursing staff should be monitoring the resident for 72 hours after the incident.

Based on record review, staff, resident, nurse practitioner interviews and physician interview, the facility failed to provide care in a manner to a dependent resident, who required extensive assistance with dressing, to prevent injury for 1 of 4 sampled residents reviewed for accidents (Resident #121). Resident #121 had informed the nurse aide (NA), who was assisting her to put on her pants that her leg would not bend, The NA continued to dress the resident, when both Resident #121 and the NA heard a pop sound. The resident experienced pain in her leg. The following day an x-ray of the resident's leg revealed Resident #121 sustained a femur fracture. Findings include: Resident #121 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set ((MDS) dated [DATE] revealed, Resident # 121 was cognitively intact. Resident #121 was coded as needing extensive assistance with 2 people for toileting, extensive assistance with one person for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was also coded as being impaired on both sides of lower extremities. During the look back period, Resident #121 was on restorative program for bed mobility and dressing for 3 of 7 days. The care plan dated 10/15/19 revealed the resident had a care plan for restorative nursing program activities of daily living (ADL) related to muscle weakness due to [MEDICAL CONDITION]. The goal was initiated on 3/18/19. Interventions included were 1) restorative nurse to be notified if resident refused, declined or had inability to assist with ADL care. 2) Charge nurse to be notified if pain was noted during ADL care. ADL care to be stopped immediately. During an interview on 1/13/19 at 11:10 AM, Resident # 121 stated on 12/18/19, nurse aide (NA) #1 was assisting her with putting on pants. NA #1 had put on the pants to left mid-calf first and was trying to put it on the right leg. NA tried to bend the leg. Resident # 121 stated the NA was told that her leg does not bend, however the NA continued to bend the leg. Resident # 121 stated both the resident and NA#1 heard a pop sound and she felt pain in her leg. Resident#121 further stated the X-ray indicated a broken femur bone to her right leg. Resident #121 stated on 12/31/19, the facility social worker (SW) had assisted her in filing a grievance related to the incident. The Resident #121 stated she did inform the administrator that the NA#1 was reckless and yanked her leg in order to assist her with putting on her pants. The grievance report dated 12/31/19 read in part on 12/18/19, the NA while putting pants on left leg they weren't all the way on when she tried to twist the right leg and foot. NA grabbed the right foot and leg and yanked it while holding the leg in her hand and trying to bend it. Resident heard a pop and thought there was a break. Resident hollered, but NA kept trying to force the right leg in the pants. Resident was very disappointed about this and being caused a lot of pain and grief. During an interview on 1/14/19 at 4:30 PM, NA #1 indicated she was assigned to the resident on 12/18/19. NA#1 stated on 12/18/19, Resident #121 had a dental appointment at around 11 AM and she was assisting the resident to get dressed. NA #1 stated the resident was in bed when she first placed resident's left foot in the pant. The pant just crossed /past the left foot, when NA attempted to raise the right leg, that was when both resident and NA heard a pop sound. Resident stated Oh! my leg. NA stated she requested the resident to give her a second and she went to notify Nurse # 3 who was assigned to the resident. Nurse# 3 was notified that she and the resident heard a pop while dressing the resident. NA stated she returned to the resident's room and she continued to dress the resident. NA #1 stated the resident did not complain of any pain at that time. After assisting the resident with dressing, NA # 1 stated she requested NA # 2 assistance with transferring the resident from her bed to the wheelchair using a mechanical lift. NA #1 indicated during the transfer the resident requested NA #2 to hold her legs as her leg was hurting. NA #1 further stated a few minutes later Nurse #3 requested her to bring the mechanical lift to the B hallway because Resident #121 needed to be repositioned in her wheelchair. NA #1 stated with the assistance of Nurse #3 and other nurses in the hallway, the resident was raised in the mechanical lift, and repositioned. The resident did not complain of any pain or discomfort at this time and proceeded to her scheduled dental appointment. During an interview on 1/14/19 at 11:50 AM, NA # 2 stated on 12/18/19, NA# 1 had requested her (unsure of the time) to assist Resident #121 with transfer from her bed to her wheelchair using the mechanical lift. NA #2 stated during the transfer process Resident #121 was requesting NA # 2 to hold her legs and not let her legs down as her leg was hurting. NA # 2 stated after the transfer, NA #1 had informed her that while trying to get the pants on Resident #121 they heard a pop sound and resident was complaining of pain. Nursing note, dated 12/19/19 at 8:56 AM, read in part Resident complaining of pain to right knee and lower leg. Stated when she was getting dressed yesterday, she felt her knee pop. Nurse practitioner (NP) was notified, new orders received for X-ray of right knee, tibia/fibula and ankle. The radiologist report dated 12/19/19 revealed Resident #121 had a mildly impacted [MEDICAL CONDITION] femur. with soft tissue swelling present. The Nurse Practitioner (NP) note dated 12/19/19 revealed, the resident was seen as acute visit for evaluation of right leg pain. Note read in part the resident states that was been changed yesterday and when her pant was been pulled up she felt a pop. Hours later she experienced pain 6/10 aching from her right knee up to her thigh. Resident has a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] which put her at risk for fracture. An x-ray was obtained on her right leg which revealed right femur fracture. Resident has an appointment with Orthopedic Clinic. During an interview on 1/14/20 at 12:07 PM, the Nurse Practitioner #1 (NP), stated when she arrived to at the facility on 12/19/19, she was informed by a nurse (name unknown) that the resident was complaining of pain in her leg. NP stated she was made aware that when the resident was changed, the pants were pulled quickly, and the staff heard a pop sound. NP indicated she had ordered a STAT X-ray due to the resident [DIAGNOSES REDACTED]. The Orthopedic clinic consultation report dated 12/19/19 revealed, the resident had right distal femur fracture with mild impaction and angulation. During an interview on 1/14/20 at 11:18 AM, Nurse # 3 stated on 12/18/19 the resident was scheduled for a dental appointment. Nurse indicated NA # 2 had informed her about the hearing a pop sound while resident was being dressed for the appointment. Nurse# 3 stated prior to the resident leaving the facility for her appointment, Nurse #3, NA #1 and other nurses assisted the resident with repositioning on her wheelchair with the aid of mechanical lift. Resident #121 proceeded to her dental appointment after been repositioned. During an interview on 1/14/120 at 4:54 PM, the NA # 3 confirmed she accompanied the resident to the dental appointment on 12/18/18. NA #3 stated while the resident was repositioned on the wheelchair with the help of a mechanical lift on the hallway, the resident had indicated aloud that her foot hurts. Resident#121 had indicated that somebody bumped her foot. NA #3 stated she assumed the assigned staff who were assisting the resident with transfer were aware about the pain, and she did not report it to anyone. During an interview on 1/17/20 at 12:36 PM, the restorative nurse coordinator stated the resident was in restorative program which included bed mobility and activities of daily living related to dressing. Resident #121 can communicate her needs and able to let staff know which position may hurt her. Restorative nurse indicated no special training related to Resident # 121's dressing / care was provided to NAs . She added all NAs were trained regarding ADL care when acquiring their license. During an interview with the Physician on 1/16/20 on 10:01 AM, Physician indicated the resident should be evaluated by the nurse prior to be transferred in mechanical lift, if there was popping sound accompanied by pain which included Ouch my leg hurts. The physician stated that the resident was prone to a pathological fracture when her legs were moved due to resident [DIAGNOSES REDACTED]. During a telephone interview with the Orthopedic Clinic Physician on 1/16/20 at 3:20 PM, the Orthopedic Physician stated the resident has [MEDICAL CONDITION], hadn't walked in 8 years, and her bones were paper thin. The Orthopedic Physician stated the fracture was not unusual and not related to care concerns, trauma or force. He added that this occurrence could happen during routine care. During an interview on 01/17/20 10:11 AM, the Administrator stated the incident happened on 12/18/19 or 12/19/19. She stated the incident was discussed in the morning meeting, about hearing a pop sound while the resident was getting dressed. Administrator added the NP was notified, X-ray ordered, and the resident was sent to the Orthopedic Clinic and returned back to the facility with a brace to her leg. Administrator stated that after any incident the staff were in-serviced on residents' safety, to remind staff how fragile residents were, to be extra cautious and to ask for extra help if needed.

Based on staff interview, record review, and observation the facility failed to safely transfer 1 of 3 residents (Resident #2) with the mechanical lift which resulted in a large open deep tissue wound that required surgical debridement with a wound drain to promote healing. Findings included: A video (titled the name of the facility) provided by the facility on safe mechanical lift transfers during staff orientation revealed; the section of the video presented by the manufacture included the ideal way to retrieve a resident off the floor was to have the resident ' s head at the mast and for the care giver to protect the resident ' s extremities from any injury. Resident #2 had multiple admissions to the facility since 2011 with [DIAGNOSES REDACTED]. She had a history of [REDACTED]. The annual Minimum (MDS) data set [DATE] revealed Resident #2 was moderately cognitively intact. Resident #2 was able to recall the correct year, month and day of week. She required extensive assist with two persons physical assistance for transfers; and required limited assistance with one person physical assistance with toilet use. Resident #2 was independent with locomotion on the unit. A 12/17/2014 care plan identified Resident # 2 as being at risk for falls due to history of falls. The care plan specified " Requires extensive to total assistance with all ADL ' s (activities of daily living) and requires mechanical lift for transfer (sit to stand with transfer). " One person assistants required during all transfer. An incident report on 1/28/2015 at 7:45 PM included: Resident #2 usually requested assistance with toileting but did not. She slipped and fell when independently transferring herself from commode to wheelchair. During a mechanical lift transfer by staff Resident #2 ' s right lower leg, outer aspect, scraped over a latch and tore her skin. Resident #2 ' s injuries were an above the right knee V-shaped 2cm (centimeter) x 2cm laceration (skin tear) and a right lower leg, outer aspect, large open deep tissue wound. Resident #2 was sent to the emergency room for an evaluation. A statement from Nurse Assistant # 1 dated 1/28/2015 at 7:45 PM included Resident #2 yelled for help. Resident #2 was on bathroom floor on her back. Nurse Assistant #1 called for Nurse #3 and Nursing Assistant #2 to assist in getting Resident#2 off the floor. Nurse Assistant #1 got the total (mechanical) lift. Once Resident#2 was lifted off floor Resident#2 ' s leg was bleeding and skin was torn. " Nurse called EMS (emergency medical services). " A statement from Nurse Assistant #2 dated 1/28/2015 (no time given) included " I (Nurse Assistant #2) was at the head of the resident (Resident #2) holding the lift pad and looking down at her and talking to her trying to comfort her when all of a sudden the resident (Resident #2) started to yell and I (Nurse Assistant #2) looked up to see the resident ' s leg to have a hole in it then the Nurse (Nurse #3) wrapped a towel around the wound and lifted the resident (Resident #2) up with the total lift and got her to her room then I (Nurse Assistant #2) exited the room because there were nurses in the room taking care of the resident. " A record review of a progress note written by Nurse # 3 on 1/28/2015 at 7:45 PM for Resident #2 included Nurse #3 was called to Resident #2 ' s bathroom and observed Resident #2 lying on her back. Resident #2 reported she went to the bathroom unassisted and fell trying to get in the wheelchair. Nurse #3 reported a small superficial skin tear above the right knee. Resident #3 was rolled onto a bed sheet and pulled out of bathroom into a larger open space. Resident#3 was rolled onto a lift pad and while she was being lifted Resident #3 said " Oh, my leg. " Nurse #3 documented: Outer aspect of the lower right leg examined and noted to have a large open, deep tissue wound. Small amount of bleeding noted. Leg wrapped with towel. Staff x 3 continued to lift resident into bed without further incident. Nurse #3 included the family notified the facility to report Resident#2 was going to surgery to have the wound surgically repaired. On 2/1/2015 and on 2/2/2015 at 11:27 AM the Director of Nursing (DON) reported the policy was for staff to proceed with a total lift transfer (mechanical lift) after a fall. On 2/1/2015 at 12:00 PM an interview with Resident #2 revealed she recalled the fall in the bathroom. She was in the bathroom attempting to transfer her self and knew she was not supposed to. When she was transferring herself she lost her balance and fell to the ground. Resident #2 did not know how she was injured. She did reveal that she shouted " ouch " when she was being lifted off the floor with the mechanical lift. On 2/2/2015 in the AM an interview with Nurse Assistant #2 revealed he was coming out of the break room and was called for assistance by Nurse assistant #1 to lift a resident off the floor with a mechanical lift. He reported he was at Resident #2 ' s head during the lift and Nursing Assistant #1 was at Resident #2 ' s feet and the controls during the lift. He did not see what happened. On 2/2/2015 at 10:30 AM and interview with Nursing Assistant #1 revealed she was making her rounds and heard Resident #2 yell for help. Nursing Assistant #1 found Resident #2 lying on the bathroom floor. Nursing Assistant #1 reported she " looked over " Resident #2 and did not see any injury. Nurse Assistant #1 went out of the room and retrieved Nurse #3 and Nurse Assistant #2. Nurse #3 did her assessment. The staff members put a sheet under Resident #2 and pulled her out of the bathroom and into a room. Nurse Assistant #1 brought the lift in and rolled Resident #2 on to the lift pad. Nurse Assistant #1 held the feet at the mast, Nurse Assistant #2 was at Resident #2 ' s head, and Nurse #3 was in the middle. Nurse Assistant #1 reported she put Resident #2 ' s legs together in the lift pad for support because Resident #2 had injuries to her right leg. Nurse Assistant #1 worked the controls for the mechanical lift and reported there was no problem with the control function on the mechanical lift. Nurse Assistant #1 revealed when she was lifting Resident #2 with the mechanical lift, Resident #2 said " ouch " and Nurse Assistant #1 stopped the lifting control. Nurse Assistant #1 reported she did not see Resident #2 ' s leg (right) hit anything. Nurse #3 looked at Resident #2 ' s leg and said " get a towel " . The three staff members put Resident #2 in the bed and Nurse #3 called EMS. A record review of hospital records date of admission was 1/28/2015 revealed Resident #2 presented with a complex traumatic laceration following an injury obtained during transfer. The laceration was too large to be closed in the emergency room . Resident #2 was taken to the operating room for a partial closure and debridement of the wound. A JP drain (used to promote wound healing) was left in place. Resident #2 was placed on antibiotics. On 2/2/2015 at 10:40 an interview with Nurse #3 revealed during her first assessment of Resident #2 there was no blood just a small skin tear above the right knee. There were three staff members to lift Resident #2 with the mechanical lift. Resident #2 hit her leg on a latch on the base of the lift during the lift. Nurse #3 reported Resident #2 said " oh my leg " then Nurse #3 assessed a wound on the right lower leg. Nurse #3 reported she knew Resident #2 ' s leg caught on the latch because Nurse #3 identified there was flesh and blood on the latch. Nurse #3 showed the surveyor the latch (identified as the locking handle on the base of the lift mast in the manufacture guide for the mechanical lift). Nurse #3 revealed when she assessed Resident #2 in the bathroom the wound was not there. Nurse #3 reported that Resident #2 ' s injury could have been prevented by having a forth staff member assist in Resident #2 ' s transfer with the mechanical lift. On 2/1/2015 and 2/2/2015 at 12:16 PM an Interview with Nurse #1 who was the restorative coordinator revealed he was in-servicing staff on the proper technique for mechanical lift and he and the DON were working on QI (quality improvement) for the best way to transfer Resident #3. Nurse #1 was observed on 2/1/2014 at 10:50 AM performing an audit of staff members using a mechanical lift. He provided instruction to the staff members. Nurse #1 was asked where his knowledge of the proper way to transfer a resident with a mechanical lift came from. Nurse #1 revealed his instructions were from his own knowledge and there was no facility procedure he followed for the education provided in the staff in-service. Nurse #1 reported he had not watched the manufacture video instructions since his facility orientation in November of 2010 and he had not read the manufacture instruction for the mechanical lift. Nurse #1 was unaware of the manufacture instructions for the ideal way to lift a resident off the floor was to have the resident ' s head at the mast. On 2/2/2015 at 1:24 PM an interview with the DON revealed her expectation was for the staff member/individual who provided the in-service was to know the process (how to use the mechanical lift and educate on safety to prevent the same injury) and in-service accordingly. On 2/2/2015 at 1:25 PM the Administrator agreed with the DON ' s expectation.