Hickory Falls Health And Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Nurse Practitioner and Medical Director interviews, the facility failed to maintain a complete and accurate medical record when identification of a new pressure injury and the completion of wound treatments were not documented in the medical record for 1 of 3 residents reviewed for accurate medical record (Resident #303).
The findings included:
Resident #303 was admitted to the facility on [DATE].
A physician's order dated 1/3/2025 read: Cleanse sacrum with wound cleanser, pat dry, apply betadine and secure with foam patch once a day was written by the Wound Nurse.
Review of the medical record revealed no documentation regarding a change in Resident #303's skin integrity on 1/3/2025.
A physician's order dated 1/15/2025 that read cleanse sacrum with wound cleanser, pat dry, apply calcium alginate and secure with foam patch once a day.
Review of Resident #303's January Treatment Administration Record (TAR) revealed there were two days when ordered treatments had no documentation on the TAR (1/16/2025 and 1/17/2025) and four days documented as not administered other (1/6/2025, 1/8/2025, 1/13/2025, and 1/24/2025).
During a telephone interview on 05/21/25 8:35 AM NA #2 stated she was familiar with Resident #303. NA #2 stated Resident #303 had frequent loose bowel movements and redness to her bottom and a barrier cream was applied. NA # 2 stated she remembered reporting a new skin issue for Resident #303 to the Wound Nurse on 1/3/2025, but did not recall what the skin issue was. NA #2 explained if she reported it to the Wound Nurse, it would have been more than redness because that is why the barrier cream was applied.
During an interview on 5/20/2025 at 2:59 PM the Wound Nurse stated she was notified of a new skin issue for Resident #303 on 1/3/2025. The Wound Nurse stated she assessed Resident #303 and must have seen a dark purple spot on Resident #303's sacrum since the order that was obtained was for betadine and a cover dressing, which is the treatment normally utilized for deep tissue injury wounds. The Wound Nurse stated she measured the area, obtained an order for treatment and notified the MDS department so the care plan would be updated. The Wound Nurse stated she did not know why she did not document the new pressure injury for Resident #303 on 1/3/2025 and stated she normally documents new skin issues. The Wound Nurse verified the documentation on Resident #303's TAR showed no treatment completed on 1/16/2025 and 1/17/2025, and documentation on 1/6/2025, 1/8/2025, 1/13/2025 and 1/24/2025 that revealed the ordered treatment was documented and not administered other. The wound nurse stated if she was working the treatments were completed, but she may not have signed the TAR. The wound nurse stated she is normally in the facility until around 4:45 PM but the treatment orders show on the electronic medication administration record as late after 3:00 PM and sometimes the second shift nurses sign it off as not administered to remove it from their screen.
Review of the facility's daily staffing sheets from January 2025 revealed the wound nurse was scheduled on 1/6/2025, 1/8/2025, 1/13/2025, 1/16/2025, 1/17/2025, and 1/24/2025.
During a telephone interview with Nurse #2 she verified when she signed not administered other on 1/8/2025, 1/13/2025 and 1/24/2025 she had not completed the treatment because it was ordered for 1st shift and showing not completed on her screen.
During an interview on 5/20/2025 at 4:45 PM the Nurse Practitioner (NP) stated a new skin issue should be documented in the medical record when it was discovered.
During a telephone interview on 5/21/2025 at 8:19 AM the Medical Director stated he would expect the nurses to complete documentation to the best of their ability when a new pressure injury was identified. The Medical Director stated he expected ordered treatments be documented accurately to the best ability of the nurse.
During an interview with the Director of Nursing (DON) on 5/20/2025 at 4:35 PM the DON stated she expected the TAR to be completed accurately and for documentation to reflect care provided.
During an interview on 5/21/2025 at 10:03 AM the Administrator stated he expected for the medical record documentation to be complete and accurate.

Based on observations, record review and staff interviews, the facility failed to clean and disinfect an individually assigned glucometer per manufacturer recommendations and the facility also failed to follow their infection control policy when staff wore a torn glove during blood glucose check for 1 of 3 staff observed during blood glucose monitoring (Nurse #3).
Findings included:
A review of facility policy entitled Blood Glucose Monitoring last updated 01/02/25 stated the nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Individual glucometers for residents must have proper identification to distinguish between residents and these should not be shared between residents.
A review of facility policy entitled Personal Protective Equipment last updated 01/02/25 under section indications/consideration for PPE - gloves stated change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn.
A review of the manufacturer's cleaning and disinfection procedure guide, the glucometer should be cleaned with an Environmental Protection Act (EPA) approved disinfectant after use on each patient. Hand sanitizing wipes were not listed as an appropriate disinfectant for glucometers on the manufacture's guide. Super Sani-cloth Germicidal disposable wipes were listed as an approved disinfectant on the manufacturer's cleaning instructions, and the facility had these wipes available on the medication cart.
An observation of Nurse #3 who performed blood glucose check on Resident #109 on 05/19/25 at 11:57 AM revealed that Nurse #3 obtained Resident #109's glucometer from the drawer on medication cart. Glucometer was stored in the protective case labeled with Resident #109's name. Nurse #3 then cleaned the individually assigned glucometer with alcohol-based hand disinfectant wipes prior to use. She was observed applying gloves and the glove on left hand was torn over the entire palm area. She entered the room to check Resident #109's blood glucose level. Blood glucose check was performed while Nurse #3 wore the torn glove. An error message on glucometer indicated insufficient sample and she was not able to obtain glucose level on the first attempt. Nurse #3 wore the same torn glove to obtain a new glucometer test strip out of container to recheck blood glucose a second time. She then performed the blood glucose check again. Nurse #3 was able to obtain blood glucose level on second attempt. The glove remained torn during both blood glucose checks. She removed the torn, used gloves after completion of procedure and disposed of them in the trash. She then cleaned the glucometer with the alcohol-based hand disinfectant wipes after use. The glucometer was returned to the individual case labeled with Resident #109's name and stored in the drawer in the medication cart.
During an interview with Nurse #3 on 05/19/25 at 12:11 PM she stated that she was not aware that her glove was torn during the blood glucose check. She stated that her understanding of the disinfection of glucometers was to use sani wipes and the disinfecting hand wipes say sani on them, so she thought that was sufficient. She stated she thought the disinfectant hand wipes were adequate and she was not familiar with the manufacturer's glucometer disinfection recommendations.
An interview with the Director of Nursing on 05/19/25 at 1:06 PM revealed that the expectation was for the facility's blood glucose monitoring policy to be implemented during blood glucose checks. Intact gloves were to be worn during the procedure. Her expectation would be that the nurse would stop and change out glove if torn or damaged. According to the manufacturer's directions, alcohol-based hand disinfectant wipes were not approved to disinfect the glucometer and purple top disinfectant wipes were to be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff, NP and Law Enforcement Detective interviews the facility failed to protect a resident's right to be free from physical abuse when Nurse Aide (NA) #1 punched Resident #1 in the face. On 5/9/24 Resident #1 was sent to the Emergency Department (ED) for evaluation where it was noted the resident had significant bruising around the left eye and a small laceration at the corner of the left eye. A CT (computed tomography) scan of the head was completed and confirmed comminuted fractures (fracture in at least 2 places) of the left nasal bone, left maxillary sinus wall, left maxilla (the bone that forms the upper jaw) and left orbital rim (broken bone in the outer edge of the eye socket). Resident #1 returned to the facility on 5/10/24. Resident #1 was seen by an ENT (ear, nose, and throat) Provider on 5/21/24 and was scheduled for surgical repair of the fracture of left nasal septum (the thin wall that separates the nostrils) on 6/5/24. A reasonable person would expect to be free from physical abuse in their own home and could experience anger, fear, apathy and depression. This affected 1 of 3 residents reviewed for abuse (Resident #1).
The findings included:
Resident #1 was admitted to the facility on [DATE] with a diagnosis of dementia.
A quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #1 had severe cognitive impairment; dependent with toileting hygiene, showering, and dressing; maximal assistance with personal hygiene, bed mobility, sit to stand, lying to sitting on side of the bed, chair/bed to chair transfers; dependent on staff for transfers to toilet and shower; and rejected care 1 to 3 days.
Resident #1 was care planned for the following:
9/11/23 - mood- At risk for combative behaviors during direct care with interventions to administer medications according to physician orders, be alerted to mood changes, sleep pattern, appetite, and behaviors; explain procedures prior to doing care.
8/31/23 - behavioral symptoms- Maintain a calm environment and approach the resident.
During a phone interview on 5/22/24 at 11:14 am Nurse Aide (NA) #2 revealed she worked on 5/9/24 (3:00 pm -11:00 pm shift) and as she entered Resident #1's room about 3:15 pm to pass ice she observed Resident #1 with blood on his face, shirt, bed rail facing the room door and bed sheet. NA #2 further revealed she went to the hall to call for assistance and Nurse #1, the Director of Nursing (DON), and Administrator responded, checked his body and surroundings in the room to see how he could have been injured. NA #2 stated after she assisted the Administrator with cleaning Resident #1's face and changed the sheets, as she was leaving the room, she overheard someone tell Nurse #1 the DON would notify the family that the resident had a fall and take care of the incident report. NA #2 stated about 4:00 pm she informed Nurse #1 that she was going on break before dinner trays came out. NA #2 stated when she returned from break, she checked on Resident #1 and found him lying on his left side and there was projectile vomit on the wall, floor and bed. NA #2 revealed she went to get Nurse #1 who came into the room and stated she was going to call the DON to have the resident sent out to the emergency room. NA #2 further revealed she cleaned up the vomit, returned to the hall to continue working and she observed Resident #1's family member arrived on the hall. NA #2 stated the family member asked her to walk with her to the room and wanted to know what happened. When the family member entered the room and observed the resident, she became upset and stated, 'there's no way this was a fall.'
A review of a nurse's progress note dated 5/9/24 indicated Nurse #1 was approached by a nurse aide (NA) at the beginning of the shift to report resident was bleeding from his face. Nurse #1 walked down the hall with the NA and found the Resident #1 laying in the bed with blood on the sheets and siderail. The resident was bleeding from the left side of face and noted resident had bruising and swelling around left eye, small laceration to left side of face, and right front tooth to be broken and loose. The note further indicated, after evaluating resident Nurse #1 immediately went to get management. Management came to evaluate the resident and stated the resident was in stable condition and they would do a fall report as well as neuro checks every hour. Resident #1 was provided with first aid and ice was applied to left eye. The resident's vitals taken BP 166/82, pulse 79, O2 95 % on room air and temp 98.5. While Nurse #1 was rounding resident was found with emesis in bed and on resident's floor after another assessment from Nurse #1. The DON was notified of the resident's condition and Nurse #1's concerns. Nurse #1 recommended that he be sent out for further evaluation. The DON stated Nurse #1 could send him out via EMS to hospital for further evaluation. The family member arrived at the facility shortly after and stated she would like him sent to the hospital for further evaluation. Resident was sent to local ED for further evaluation.
During a phone interview on 5/24/24 at 9:58 am Nurse #1 indicated she was assigned to Resident #1 on 5/9/24 (3:00 pm -11:00 pm shift) and NA #2 came to get her about 3:45 pm to check on Resident #1. Nurse #1 further indicated she directed an NA to get the first aide cart and bring it to Resident #1's room. Nurse #1 stated when she arrived at the resident's room, she observed the resident to have a laceration under the left eye that was swollen and bruised, and a right upper front tooth was broken. Nurse #1 stated the resident's bed was positioned at waist level. Nurse #1 stated she went to get the DON and the Administrator who responded and took over to find out what happened. Nurse #1 was instructed to get an ice pack for the resident's eye then assisted the nurse aides clean Resident #1 and change his bed linen that was stained with blood. Nurse #1 stated the DON indicated she would write the nursing note and contact Resident #1's family to report the incident instead of Nurse #1 writing the note and contacting the family. Nurse #1 stated she started hourly neurological checks (assesses neurological functions, motor and sensory response, and level of consciousness) on the resident and about 5:30 pm she and NA #2 went to the resident's room and discovered the resident had vomited on the wall and fall mat near the window. Nurse #1 stated she messaged the DON because she felt the resident needed to be sent out to the emergency room for further evaluation. Nurse #1 stated the resident's family member arrived at the same time the DON gave permission for the resident to be sent out. Nurse #1 stated she contacted 911 emergency services and first responders (medics) arrived within minutes to transport the resident to the hospital. Nurse #1 stated she could not recall the exact time she called 911.
A review of hospital records indicated Resident #1 was transferred from the facility to the emergency department on 5/9/24 after being found in bed with left eye hematoma (significant bruising) and swelling around the left eye due to possible fall but unknown how the injury occurred. The ED Physician observed significant bruising around the left eye and a small laceration at the corner of the left eye. A CT scan of the head noted a comminuted fracturing of the left nasal bone, anterior left maxillary sinus wall, and left maxilla with extension into the root of the left posterior maxillary molars. It was noted that the fracturing extended into the inferior left orbital rim. The ED Physician consulted with an ENT (ear, nose, and throat) Specialist who suggested treatment with Keflex (antibiotic) follow up with his office on 5/13/24 or 5/14/24.
A nursing note dated 5/10/24 entered by Nurse #5 revealed Resident #1 returned to the facility after a short-term emergency room visit with a new order received from emergency room visit for Keflex (an antibiotic) 500mg (milligrams), take 2 capsules by mouth twice a day for 10 days. Nurse #5 also noted the resident had a right front tooth missing; denied any pain and voiced no complaints. The resident was unable to describe the incident or hospital visit.
A review of NA #1's written statement dated 5/9/24 indicated he went into Resident #1's room around 2:20 pm during the NA's last round and found the resident had already put himself in bed. The statement further indicated the resident was in his wheelchair prior. NA #1 changed the resident's brief and when he left resident's room, the resident was awake and in his bed with no injury to his face. NA #1's statement also indicated Resident #1 self-transferred several times per day.
During a phone interview on 5/21/24 at 5:23 pm NA #1 stated he worked on 5/9/24 and was assigned to Resident #1 on the 7:00 am - 3:00 pm shift. The NA revealed towards the end of his shift, he entered Resident #1's room to change the resident's brief but the resident did not want to be changed and lunged at NA #1. NA #1 stated he pushed Resident #1 backwards in the bed and the Resident hit his head on the side rail of the bed causing a skin tear and blood in the corner of his eye. NA #1 stated he then wiped the blood from the resident's face, continued with incontinent care and left the room. NA #1 stated after he left the faciity on 5/9/24, he received a call from the DON and was asked about his interaction with Resident #1. NA #1 stated he lied to the DON and Administrator about not knowing what happened to Resident #1. NA #1 stated after he was re-interviewed by law enforcement 5/13/24 and 5/14/24, he agreed to take a polygraph test on 5/15/24 and did not pass it. NA #1 stated after he did not pass the polygraph test, he told law enforcement he pushed Resident #1 causing injuries to his face when he hit his head on the bed rail. NA #1 stated he was re-interviewed via telephone by the Administrator on 5/15/24 and was terminated from the facility after he told her that he pushed the resident.
During a phone interview on 5/21/24 at 6:02 pm NA #4 indicated she worked 7 am - 3 pm on 5/9/24 and stated she last observed Resident #1's feet in bed but did not see his face because the curtain was pulled when she and other NAs walked the hall together to give report to the next shift. NA #4 stated when she asked who put the resident to bed and changed him, NA #1 stated when he put the resident to bed and changed him, everything was good.
During a phone interview on 5/21/24 at 6:46 pm NA #5 revealed she worked 7 am - 3 pm on 5/9/24 and completed rounds (around 2:55 pm) by performing brief changes and checking on her residents before her shift ended. She completed walk-downs (walked past each resident's room with the next shift and gave report) with the next shift. NA #5 further revealed she observed Resident #1's lower half of his body covered with a blanket and the curtain was drawn halfway. NA #5 stated she did not see the resident's face. She did not do rounds on resident because NA #1 stated he already rounded on the resident.
During an interview on 5/22/24 at 12:09 pm Resident #1's family member revealed she received a phone call from a nurse at the facility on 5/9/24 about 4:00 pm and was told multiple times during the call that everything was okay but Resident #1 face planted (fell on his face). The family member stated she lost it when she walked into the room and saw Resident #1's injuries. The family member then stated Resident #1 hardly ever complained of pain because his dementia was so bad, and she could tell Resident #1's injuries did not look like the results of a fall while trying to get out of his wheelchair and into bed and hitting his head on the bed rail. The family member stated she went to speak with Nurse # 1 to inquire why Resident #1 had not been transported to the hospital and Nurse #1 stated she was in the process of having the resident sent out to the hospital. The family member stated she went to the hospital after the resident was transported via medic and she was informed the Resident sustained a broken nose, cheek and bone in the eye area. The family member stated she took pictures of the resident before he left the facility and after he arrived at the hospital. The family member stated the resident also lost a tooth and another tooth was cracked/loosened. The family member stated she contacted law enforcement about the incident while she was still at the hospital, and they went to the facility to investigate. The family member stated she received a voicemail message from the DON about 10:00 pm the same evening. The family member recalled she met with the Director of Nursing (DON) and the Administrator on the following morning of 5/10/24 to discuss the incident and the family member informed the DON and Administrator that while at the hospital, she contacted law enforcement about the incident because the explanation on how Resident #1's injuries occurred, just did not add up. The family member stated the resident was discharged from the hospital and was transported back to the facility after 3:00 am on 5/10/24. The family member recalled during the meeting with the DON and Administrator, they informed her that the first shift staff did not find the resident with injuries. The family member indicated when she arrived at the facility to pick up the resident for the appointment with the ENT Provider, he did not feel good, and the appointment was rescheduled to 5/21/24. As a result of the rescheduled follow-up appointment, it was determined the resident would need surgery to place stents (a sinus stent is a device that can be implanted in the sinus cavity after surgery to help maintain the surgical openings) in his nose to remove the bone that was blocking the nasal passageway and surgery was scheduled for 6/5/24.
A review of the ENT provider examination dated 5/21/24 indicated Resident #1 had complete obstruction of his left nasal cavity, moderate severe left septal deviation at the nasal valve region on left side. Recommendations: undergo open reduction internal fixation of nasal septal fracture (the nasal septum is the thin wall that separates the nostrils) and bilateral turbinoplasty (surgical procedure that shrinks the size of the small, bony structures inside your nose to improve airflow and breathing); hold aspirin one week prior to surgery, get clearance from his facility physician.
During an interview on 5/21/24 at 7:00 pm the Administrator indicated Nurse #3 came to her office on 5/9/24 about 3:20 pm and informed her that she needed to go to Resident #1's room. Upon arrival, the Administrator stated she observed the Resident in bed with his face leaning against the assist bar and there was blood coming from a cut under his left eye/ check bone. The Administrator indicated she asked the resident what happened, and the resident stated, I hope she falls just like I did and dies. The Administrator stated she sent for the DON, who came to the room. The Administrator recalled the DON removed Resident #1's right front tooth that was dangling to prevent him from swallowing it. The Administrator stated while nursing staff was cleaning up the resident, she instructed the DON to contact all first shift staff to inquire about their contact with Resident #1 that day. The Administrator revealed the DON contacted NA #1 who stated Resident #1 had already self-transferred back to bed when NA #1 arrived and was not combative when NA #1 provided incontinent care about 2:20 pm on 5/9/24. The Administrator further revealed all staff from the 1st and 2nd shift were interviewed appropriately, Resident #1's family was contacted, and it was determined Resident #1 had an unwitnessed fall. Neuro checks were initiated and about 7:00 pm the Administrator received a call from the DON that Resident #1 had a change in condition related to drowsiness/vomiting and was being sent out to the hospital. The Administrator stated the DON contacted her on 5/9/24 at 9:56 pm and informed her law enforcement arrived at the facility to investigate the resident's injuries related to an unwitnessed fall. The Administrator stated on 5/9/24 at 10:15 pm she received an update from the DON who had received a copy of the hospital CAT scan that showed a fractured left nasal bone, left maxillary sinus wall and left maxilla with extension into the root of the left maxillary molars, fracturing extends into the interior left orbital rim. The Administrator stated she and the DON met with the family member the following morning of 5/10/24 at 10:15 am and the family member did not indicate she called law enforcement because she suspected abuse. The Administrator noted the facility had already taken steps to schedule a follow up appointment with the eye/sinus/allergy provider as well as the dentist who was scheduled to be in the facility on 5/10/24.
A review of the DON's written statement dated 5/16/24 indicated on 5/9/24 at approximately 3:15 pm/ 3:20 pm Nurse #4 came to tell her that she was needed in Resident #1's room with the Administrator. The DON stated upon entering the resident's room, she recalled Nurse #1, NA #2, the Administrator, and Nurse # 4 were present, and she noticed a small amount of blood coming from the corner of the resident's left eye, a cut under his left eye, and his right front tooth was dangling. The DON stated she asked the resident what happened, and he responded, 'a girl threw a rock and hit his eye from Afghanistan.' The DON's statement also indicated she asked the resident if he fell and he replied 'no.' She then asked the resident if someone hurt him and the resident replied 'no, a girl in a truck spinning rocks.' The DON obtained and applied a bag of ice wrapped in a towel to the resident's eye until the resident could no longer tolerate it. The DON's written statement indicated she began calling the three NAs who worked the first shift (NA #1, NA #4 and NA #5) to get a timeline and to see if any of them knew anything about the resident. The written statement further indicated the DON and other staff started investigating what could have happened and concluded that the resident must have self-transferred and fell or hit the side rail. The DON's written statement indicated the Administrator asked the DON to make the nurse's note and to contact the resident's family. The written statement indicated the DON contacted the family member around 3:45 pm, informed her of the resident's injuries and she would be notified if anything changed. The DON was notified by the facility that law enforcement had arrived at the facility between 9:45 pm and 10:00 pm on 5/9/24 and they were told to contact the DON or Administrator. The law enforcement detective returned to the facility on 5/13/24 around 11:00 am, then spoke with the Administrator and the resident before going to the resident's room to observe where the incident occurred. The law enforcement detective met with the DON and Administrator then returned to get employee names and phone numbers. The DON contacted NA #3, NA #4, and NA #5 to let them know the detective would be contacting them for a statement. In addition, the detective interviewed other employees that were present.
Attempts to contact the DON by phone were not successful and she did respond to voice mails.
During an interview on 5/23/24 at 1:43 pm the Nurse Practitioner (NP) revealed on 5/13/24 she reviewed Resident #1's hospital discharge note that indicated three fractured facial bones and recommendation for surgery to repair the resident's nose. The NP stated she was made aware Resident #1 initially suffered an unwitnessed fall on 5/9/24 and she was later made aware there was an allegation of abuse. The NP stated although she believed what she was told, she was surprised the resident was found in bed with those injuries. The NP stated on 5/13/24, she assessed the resident post readmission while he was sitting in a wheelchair at the nurse's station, and he did not present with any pain. The NP further revealed the left side of Resident #1's face was swollen, bruised and the laceration under his left eye was scabbed over. The NP stated she cleared the resident for nose surgery scheduled for 6/5/24.
During a follow- up interview on 5/22/24 at 10:03 am the Administrator revealed on 5/14/24 she spoke with the law enforcement detective to determine the status of their investigation and the Administrator was told by the detective abuse was being alleged and NA #1 had agreed to take a polygraph exam on 5/15/24. The Administrator then stated she received a call from law enforcement on 5/15/24 and was informed NA #1 failed the polygraph exam then confessed that he pushed Resident #1, causing injuries to his face. The Administrator indicated she contacted NA #1, reinterviewed him and terminated his employment after the NA confirmed he did push Resident #1 on 5/9/24, causing injuries to the face. The Administrator stated it was her expectation that all residents are free from abuse and neglect. The Administrator stated she initiated the abuse investigation, followed protocol for abuse and alleged past non-compliance.
During an interview on 5/21/24 at 12:45 pm the Law Enforcement Detective indicated he charged NA #1 with abuse on 5/15/24, after the NA failed a voluntary polygraph test then admitted that he had not been truthful about what had occurred on 5/9/24 with Resident #1, when he was previously interviewed by law enforcement on 5/13/24 and 5/14/24. The Law Enforcement Detective further indicated during an interview on 5/13/24, NA #1 stated on 5/9/24 his last interaction with the resident was when he went into the resident's room at shift change, to change the resident's brief, the resident was flopped (lying in bed kind of sideways with his legs hanging off) in bed. The Law Enforcement Detective stated NA #1 reported he straightened (repositioned) the resident and changed his brief. The Law Enforcement Detective NA #1 then reported the resident was fine and he left the resident in bed with no injuries. The Law Enforcement Detective revealed he re-interviewed NA #1 on 5/14/24 because he struggled with the details on how the resident had an unwitnessed fall and got back in bed by himself, if a previous interview with NA #5 indicated she had assisted a therapist with getting the resident out of bed around 12:30 that day. The Law Enforcement Detective stated NA #1 reported the resident did not get out of bed when he left him at 2:20 pm and was found in bed by the next shift. The Law Enforcement Detective then asked NA #1 if the resident was still in bed and never got out of bed, how did the resident get injured. The Law Enforcement Detective stated when NA #1 did not provide a definitive answer, he asked NA #1 to submit to a polygraph test and NA #1 stated yes. The Law Enforcement Detective indicated NA #1 submitted to a polygraph test on 5/15/24 and failed the test. During a post polygraph interview on 5/15/24, the Law Enforcement Detective indicated NA #1 told a different version of the incident once he was informed, he failed the test. The Law Enforcement Detective stated NA #1 admitted to pushing Resident #1 when he became aggressive toward him, then the resident fell back onto the bed and was unharmed when NA #1 left the room. The Law Enforcement Detective stated after NA #1 was questioned further about the resident's injuries, NA #1 admitted to pushing the resident, who hit the side rail on his bed and there was blood on the resident's face. NA #1 reported to the Law Enforcement Detective he wiped the blood off the resident's face and left him in the bed because he looked fine. The Law Enforcement Detective also stated NA #1 reported he knew the policy of the facility was to disengage and not go hands on and that was why he lied. The Law Enforcement Detective stated he asked the NA if any complaints had been filed against him in the past and the NA stated there were complaints that had been investigated and closed.
During a follow up phone call on 5/24/24 at 10:16 am the Law Enforcement Detective revealed after he viewed pictures of Resident #1's injuries on 5/23/24, he determined the injuries were probably not consistent with a push backwards in the bed. The Law Enforcement Detective reinterviewed NA #1 in person on 5/24/24 and showed him the pictures. As a result, NA #1 stated he had been thinking about things for the past few days and it was time for him to stop lying because God had been talking to him. NA #1 admitted he punched the resident one time (instead of pushing him), saw the blood on his face, wiped it off since the resident was not fighting anymore, thought the resident was fine and left the room. instead of pushing him, as he previously stated on 5/15/24.
The Administrator was notified of the immediate jeopardy on 5/23/24 at 6:20 pm.
The facility provided the following corrective action plan.
How will the corrective action be accomplished for those residents found to have been affected by the deficient practice.
On May 9th, 2024, Resident #1 sustained a 0.3 mm (approximately 0.01 in) laceration on the inferior portion of the nose just proximal to the left eye, comminuted fracture of the left nasal bone, and fracturing of the left maxilla with extension into the left orbital rim. The facility initiated an investigation of the incident and suspected the injury occurred from Resident #1 attempting to self-transfer resulting in an unwitnessed fall. The hospital discharge report under Emergency Department (ED) Course and Medical Decision-making revealed that it appeared that resident had fallen and injured the left side of his face. Nurse Aides (NAs) were interviewed including NA #1 and revealed Resident #1 was last seen at 2:20pm by NA#1 and he was in bed with no concerns noted.
A police officer arrived at the facility on May 9th, 2024, at approximately 10:45pm to follow up with a report they had received regarding Resident #1. He briefly interviewed multiple staff and asked if the Administrator was the same and who was the Director of Nursing. The staff gave him the Director of Nursing's information. No calls from the officers were made to the Administrator or the Director of Nursing on May 9th, 2024, nor did the officer request the presence of the Administrator or Director of Nursing at the facility.
On May 10th, 2024, at approximately 10:00am, the Administrator and Director of Nursing met with Resident #1's family member to discuss the incident. Per Administrator and Director of Nursing report, Resident #1's family member stated that she called the police per instruction from another family member. She stated she had no specific complaints or allegations with specific person but thought the police could investigate to find the cause of the injury. The Administrator and Director of Nursing stated during the meeting that they suspected that resident sustained an unwitnessed fall while trying to get into bed, resulting in documented injury. At approximately 4:15pm, two employees from Adult Protective Services (APS) entered the facility and interviewed the Administrator and Director of Nursing regarding Resident #1. Health care records for Resident #1 were provided per request. The APS employees visited Resident #1 in his room and exited the building with no allegation or concern of abuse made.
On May 13th, 2024, a Detective with the police department arrived at the facility around 11:00 AM to begin investigation on the report filed on May 9th, 2024. Several staff members were interviewed in-person and via telephone by the Detective at this time. The Detective indicated to the Administrator that he was just investigating the incident and did not indicate abuse had been alleged.
On May 14th, 2024, the Detective entered the facility at approximately 11:00 AM to further interview Nurse Aide (NA) #1, NA #1 was the last one to provide care to Resident #1 before NA #2 found him with injuries. The Detective informed the Administrator there were inconsistencies regarding his investigation. Upon the Detectives exit, the Regional Operator put in a call to the [NAME] Detective to try and obtain further detail as to what was being alleged on May 14th at approximately 4:30pm. It was reported they were investigating abuse per what was reported from Resident#1's family member to the police on 5/9/24. Nurse Aide #1 was suspended pending investigation. The facility began abuse investigation and submitted 24-hour report to DHSR. Resident's responsible party, law enforcement, Ombudsman and Adult Protective Services were notified that facility investigation of abuse was initiated.
On May 15, 2024, the facility was notified that during Nurse Aide#1's voluntary polygraph test he told the detective he pushed Resident #1 when he became combative during care. Nurse Aide #1 was terminated effective May 15, 2024, and was interviewed during a call with Administrator to notify of termination. During interview with NA#1, he stated, I went in to change Resident#1 and he was already in bed. He lunged at me, and I pushed him back and he hit the bed rail. He had one little skin tear with a small amount of blood, and I wiped it with a paper towel. He appeared fine and I left the room.
On May 15, 2024, facility abuse investigation continues. Staff interviews were conducted. They were asked if they were aware of any abuse, neglect or exploitation of residents and if they were aware of any concerns related to abuse. Staff working on Resident #1's unit (B Hall) provided written statements regarding this allegation and day.
On May 17, 2024, a 5-day investigation report was made to DHSR which included the facility investigation.
How the facility will identify other residents having the potential to be affected by the same deficient practice.
All other residents are at risk of suffering from the deficient practice and residents who are resistive to care were identified as more at risk for abuse.
On May 15, 2024, all residents with a Brief Interview of Mental Status (BIMS) of 12 or above were interviewed by the Administrator or designee to determine if they have experienced any type of resident abuse or were fearful in any way. No concerns were found.
On May 15, 2024, an audit consisting of thorough skin assessment of all residents with a BIMS of 11 or less was completed by licensed nurses to determine if there is evidence of abuse. No concerns were found.
An ad hoc Quality Assurance (QA) meeting was held on May 15, 2024, to discuss the deficient practice and to initiate a plan of correction and education for staff regarding abuse and neglect, audits and inclusion in QA.
What measures will be put in place or systemic changes will be made to ensure deficient practice will not recur.
0n May 15, 2024, education was provided to the Administrator and the Assistant Director of Nursing by the Regional Operations Manager, regarding the definition of abuse as defined in the abuse policy and the resident's right to be free from abuse.
On May 15, 2024, after being reeducated as outlined above, education for all staff was completed in person and via phone by the Administrator or designee. The education consisted of the following:
- The definition of abuse, neglect and misappropriation of property and the need to immediately notify the Administrator or Director of Nursing of all issues related to these infractions. If Administrator or Director of Nursing are not present in the facility, supervisors must be notified, and they must inform the Administrator or Director of Nursing immediately in person or by phone.
- Signs and symptoms of abuse and mental anguish such as loss of interest, change in routine, mood alterations, or difficulty eating.
- Our facility does not condone and has zero tolerance for resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals.
- The education focused on tactics to deal with difficult residents such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to protect a resident from verbal and physical abuse when Nurse Aide (NA) #2 proceeded to provide care to a resident (Resident #257) while he was agitated and combative. NA #2 taunted, aggressively pushed, aggressively turned, slapped the resident on the hip, and grabbed his arms and held them on his neck resulting in the resident asking, are you trying to choke me, and leaving a bruise on his right hand and redness to his chest for 1 of 3 residents reviewed for abuse (Resident #257).
The findings included:
Resident #257 was admitted to the facility on [DATE] with diagnoses which included progressive neurological progression, dementia, and muscle weakness
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #257 moderately cognitively impaired and required extensive assistance for majority of activities of daily living (ADL). The MDS further revealed Resident #257 was not coded for behaviors.
Resident #257's care plan dated 4/25/22 revealed the resident was at risk for episodes of being upset and was cognitively impaired. The care plan's goal indicated Resident #257's mood and behaviors would be stable. Interventions included to administer medicines per medical director and monitor effectiveness and be alerted to changes in mood, sleep pattern, appetite, cognition, behaviors and keep MD informed.
Review of the facility initial allegation report dated 6/14/22 revealed on 6/13/22 at 10:30 PM an employee, NA #2, was changing the brief of a combative Resident #257, and slapped the resident on his hip and pressed the resident's arm to the resident's throat. The report further revealed NA #1 witnessed the incident and NA #2, was suspended pending investigation on 6/13/22. The facility substantiated abuse and NA #2 was terminated.
Review of the investigation completed by the Administrator on 6/13/22 related to Resident #257's incident revealed the following:
-Nurse Aide (NA) #1 statement dated 6/13/22 revealed NA #1 saw NA #2 hit Resident #257 while they were changing him. NA #1 further revealed resident #257 was combative, but NA #2 rolled him and slapped him hard on the hip. The statement indicated NA #1 tried to calm the resident down and NA #2 rolled Resident #257 back and he began to hit at NA #2. NA #2 grabbed Resident #257 arms and held them on his neck, and he stated, what, are you choking me? NA #1 revealed care was completed on Resident #257 and NA #2 stated to NA #1 what are you doing? You work to much. NA #1 indicated she cared too much for the residents and the incident was very upsetting.
A phone interview conducted with Nurse Aide (NA) #1 on 9/13/22 at 3:35 PM revealed she and NA #2 entered Resident #257's room on 6/13/22 after 7:00 PM to give care. NA #1 revealed NA #2 went to the right side of the bed and NA #1 went to the left side. NA #1 stated NA #2 started to pull down the sheet to give care and Resident #257 was grabbing at the sheet and appeared to be agitated muttering. NA #1 stated Resident #257 was commonly agitated when given care and his speech was unclear. NA #1 revealed NA #2 continued to give care by undoing the brief and Resident #257 tried to grab at NA #2. NA #2 then aggressively pushed Resident #257 on his left hip by placing one hand on his shoulder and the other on his hip. Resident #254 became more agitated and pushed against NA #2 and NA #2 took her right open hand and smacked the resident on the hip. NA #1 revealed it was a loud smack and she was in shock of what had happened. NA #2 stated, You can't do anything? What you going to do? taunting Resident #257. NA #1 revealed NA #2 observed to be frustrated and angry and laid the resident on his back aggressively. Resident #257 was muttering more words and was gritting his teeth and observed to be very angry. Resident #257 grabbed at NA #2 and NA #2 immediately grabbed the resident's wrist and placed them down on his chest under his neck in a forceful way. NA #1 indicated Resident #257 stated what are you doing? Are you trying to chock me? NA #1 revealed Resident #257 had quit being combative and observed eyes to be wide like he was scared. Resident #257 quit fighting the NAs and eyes appeared to be wide and in shock. NA #1 revealed NA #2 at this time let go of his wrist and completed care. NA #1 further revealed NA #2 wanted to move Resident #257 up in the bed. NA #1 stated she told NA #2 to stop and that they needed to go get help. NA #1 stated NA #2 threw the cover up on Resident #257 and stated, you are awful mean for someone who pisses on themselves. NA #1 indicated they left the room and she reported to the charge nurse within 15 minutes.
A follow up phone interview conducted on 9/16/22 at 2:08 PM revealed NA #1 wanted to clarify her previous statement. NA #1 revealed she and NA #2 entered Resident #257's room and he began to grab at NA #2 when starting care. NA#1 indicated NA #2 rolled the resident on his left hip to give care and slapped the resident with her right open hand. NA #2 rolled the resident on his back and immediately grabbed both his hands and the resident stated, what are you doing choking me? NA #1 stated NA #2 wanted to pull him up in the bed and NA #1 said, stop and let's get someone in here to help. NA #2 pulled the sheet over Resident #257 and left the room together. As they were walking out of the room NA #1 stated NA #2 made the comment you sure are mean for someone who pisses himself. NA #1 and NA #2 stated they had walked out of the room at the same time and NA #1 reported the incident to the charge nurse. NA #1 was asked to clarify when she said stop to NA #2 during the incident. NA #1 was unable to be specific when she had told NA #2 to stop giving care to Resident #257. NA #1 continued to state the incident happened so quick that when NA #2 slapped the resident and grabbed the resident's wrist it appeared to be one motion.
-Nurse Aide (NA) #2 statement dated 6/14/22 revealed NA #2 and NA #1 entered Resident #257's room to change him. NA #2 further revealed the NAs moved resident #257 and he hit both NAs with his hands and feet. NA #2 noted she held Resident #257's arms under hers to keep him from hitting both NAs. Resident #257 stated he couldn't breathe, and NA #2 removed her hands from the resident's arms. NA #2 noted Resident #257 hit her with his fist and NA #2 had a reflex and hit Resident #257's hip not meaning too. NA #2 indicated both NAs rolled Resident #257 and NA #1 put the residents brief on, lowered the bed, and left the room.
A phone interview with Nurse Aide (NA) #2 was unable to be completed after several attempts.
-Unit Charge Nurse statement dated 6/14/22 revealed NA #1 had come to her last night around 10:00 PM and stated that NA #1 and NA #2 were providing care to Resident #257 and he became combative and NA #2 hit the resident. The statement further revealed the Unit Charge Nurse went and assessed the resident immediately, called the Director of Nursing (DON), and was instructed to have NA #1 write a statement, and to send NA #2 immediately and that a staff member would be in contact with her the next day.
Review of the skin assessment completed by the Unit Charge Nurse dated 6/13/22 revealed redness noted on the resident's chest and a bruise forming on the right hand.
An interview conducted with the Unit Charge Nurse dated 9/14/22 at 3:24 PM revealed NA #1 had disclosed NA #2 hit Resident #257 on the hip at 10:30 PM on 6/13/22. The Nurse further revealed she contacted the DON immediately and was instructed to complete an assessment on Resident #257, and NA #1 write a statement on what had happened and send NA #2 home immediately. NA #2 was in the shower room cleaning and had not worked with any other residents. The Unit Charge Nurse's assessment revealed Resident #257 had a quarter size bruise forming on his right hand and did not show any kind of emotions of being sad, scared, or angry. The Nurse indicated Resident #257 was unable to recall the incident. She revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. The Nurse also indicated the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, and wait till they are calm, to complete care.
An interview conducted with the Assistant Director of Nursing (ADON) on 9/14/22 at 5:09 PM revealed the Administrator and the DON joined her at the facility right after the incident occurred on 6/13/22. The ADON revealed she assisted the Administrator and DON with body checks and attempted to interview Resident #257, but the resident was not interviewable.
An interview conducted with the Director of Nursing (DON) on 9/14/22 at 4:00 PM revealed she came to the facility when she was notified of the abuse by the Unit Charge Nurse and assessed Resident #257. The DON further revealed Resident #257 had a small bruise on his right hand and a small red mark on his chest from the pressure where NA #2 had held his arms down. The DON stated NA #2 admitted to slapping and holding down the resident and knew that it wasn't acceptable. NA #2 disclosed to the DON it was the reaction of Resident #257 being combative. The DON indicated Resident #257 was unable to recall the incident when interviewed. DON revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. The DON also indicated the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, or wait until they calm, to complete care.
An interview conducted with the Administrator on 9/14/22 at 5:55 PM revealed she arrived at the facility on 6/13/22 and NA #2 had already been sent home. The Administrator revealed full body checks and resident interviews were completed that night. The Administrator indicated Resident #257 was unable to disclose information about the incident. The Administrator revealed she interviewed NA #1 and NA #2 the next day. It was further revealed NA #2 denied any incident at first the Administrator, but then admitted to the Administrator that she had smacked him but didn ' t ' t mean to and held his hands down but did not think it was hard. The Administrator interviewed NA#1 who revealed she and NA #2 were giving care to Resident #257 who became agitated and aggressive and NA #2 slapped Resident #257 on the hip and then proceeded to grab his wrist and hold his arms down on his chest. The Administrator indicated Resident #257 was the last resident to need care and NA #2 did not work with any other residents that shift. It was revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. She reported the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, and wait till they are calm, to complete care.
The Administrator was notified of immediate jeopardy on 9/15/22 at 9:00 AM.
The corrective action plan for noncompliance dated 6/15/22 was as followed:
On 6/13/22, the Director of Nursing and Administrative Nurse initiated a skin sweep on 100% of all in house residents assessing for any signs of abuse, as all residents have the potential to be affected. This sweep was completed on 6/14/22, approximately at 3:00am. No additional concerns were identified. On 6/14/22, the Social Worker and Administrator interviewed all in-house alert and oriented residents with a BIMS of 10 or higher, to ensure no allegations of abuse were reported. No residents verbalized concerns. The Licensed Social Worker observed Resident #1 for any behaviors that would alert to any mental anguish, fear or pain from 6/14/22 to 6/16/22. Residents who are cognitively impaired and have combative behaviors during care are at higher risk to be affected by this deficient practice.
Education on the abuse policy, preventing, protecting, and reporting, and caring for residents with aggressive behavior in long term care continued 6/13/22 through 6/15/22 for 100% staff and therapy contract staff by the Director of Nursing, Nurse Supervisors and Administrative Departmental Managers. Any staff member who did not receive an education by 6-15-22 was not allowed to work until this education was provided. The abuse policy, prevention, protecting, and reporting will continue to be provided during new hire orientation. Education on caring for residents with aggressive behaviors was added to the new hire orientation education on 6-15-22 and will be completed by the Director of Nursing or a member of the Nursing Administration team. The Director of Nursing and the members of the Nursing Administration team was notified on 6-14-22 by the Administrator of the new process.
Education on the abuse policy, preventing, protecting, and reporting, and caring for residents with aggressive behaviors in long term care will be provided in the monthly All-Staff meeting by the Administrator or Director of Nursing to staff x 6 months. The next staff meeting was held on July 13 th, 2022 and is ongoing monthly.
The Director of Nursing and Nursing Administration team conduct random observations of staff while providing care and interacting with residents with a cognitive impairment and combative behaviors. These routine audits have been on-going prior to the 6/13/22 allegation and will continue. The Director of Nursing and Nursing Administration team were educated by the Administrator on 6/14/22 to continue and begin documenting their observations of staff while providing care and interacting with residents with a cognitive impairment and combative behaviors. Documentation of the observations will continue until a pattern of compliance is sustained.
To ensure continued compliance, The Director of Nursing will be responsible for bringing the special focus audits and observations on care provided to residents with a cognitive impairment and combative behavior to the Quality Assurance team for further review and to make any needed changes to our audit process for three consecutive months or until a pattern of compliance is sustained.
Date of Immediate Jeopardy Removal: 6-15-22
On 9/20/22, the facility's credible allegation for immediate jeopardy removal effective 6/15/22 was validated by the following: Staff interviews revealed they had received education on resident abuse and how to care for aggressive and combative residents. Skin assessments were conducted on all residents and identified, and alert and oriented residents were interviewed with no concerns identified.
The facility's action plan was validated to be completed as of 6/15/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to intervene to stop verbal and physical abuse and/or failed to immediately call for assistance from administrative staff or licensed staff to stop the abuse. The facility policies and procedures failed to include reporting abuse to the state survey agency, APS and local law enforcement. The facility failed to report the abuse to APS and to the state survey agency, and local law enforcement within the required timeframes for 1 of 3 residents reviewed for staff to resident abuse (Resident # 257).
Immediate Jeopardy began on 6/13/22 when the facility witnessed verbal and physical abuse and did not intervene to stop it, or immediately call for licensed staff or administrative staff to stop it. Immediate Jeopardy was removed on 9/18/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place effective.
Findings Included:
A review of the facility policy and procedure titled Reporting Abuse to Facility Management, with a revised date of April 2010, read in part it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The Policy Interpretation and Implementation section specified in part: 2a. 4. Employee's facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to the facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. The policy did not indicate time frames of reporting to outside agencies.
Resident #257 was admitted to the facility on [DATE] with diagnoses which included progressive neurological progression, dementia, muscle weakness, and hypertension.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #257 was moderately cognitively impaired and required extensive assistance for majority of activities of daily living (ADL).
Review of the facility initial allegation report dated 6/14/22 revealed on 6/13/22 at 10:30 PM an employee, NA #2, was changing the brief of a combative Resident #257, and slapped the resident on his hip and pressed the resident's arm to the resident's throat. The report further revealed NA #1 witnessed the incident and NA #2, was suspended pending investigation on 6/13/22. The facility substantiated abuse and NA #2 was terminated. The report revealed law enforcement and adult protective services (APS) were not contacted.
Review of the investigation completed by the Administrator 6/13/22 related to Resident #257's incident revealed the following:
-Nurse Aide (NA) #1 statement dated 6/13/22 revealed NA #1 saw NA #2 hit Resident #257 while they were changing him. NA #1 further revealed Resident #257 was combative, but NA #2 rolled him and slapped him hard on the hip. The statement indicated NA #1 tried to calm the resident down and NA #2 rolled Resident #257 back and he began to hit at NA #2. NA #2 grabbed Resident #257 arms and held them on his neck, and he stated, what, are you choking me? NA #1 revealed care was completed on Resident #257 and NA #2 stated to NA #1 what are you doing? You work to much. NA #1 indicated she cared too much for the residents and the incident was very upsetting.
A phone interview conducted with Nurse Aide (NA) #1 on 9/13/22 at 3:35 PM revealed she and NA #2 entered Resident #257's room on 6/13/22 after 7:00 PM to give care. NA #1 revealed NA #2 went to the right side of the bed and NA #1 went to the left side. NA #1 stated NA #2 started to pull down the sheet to give care and Resident #257 was grabbing at the sheet and appeared to be agitated muttering. NA #1 stated Resident #257 was commonly agitated when given care and his speech was unclear. NA #1 revealed NA #2 continued to give care by undoing the brief and Resident #257 tried to grab at NA #2. NA #2 then aggressively pushed Resident #257 on his left hip by placing one hand on his shoulder and the other on his hip. Resident #254 became more agitated and pushed against NA #2 and NA #2 took her right open hand and smacked the resident on the hip. NA #1 revealed it was a loud smack and she was in shock of what had happened. NA #2 stated You can't do anything? What you going to do? taunting Resident #257. NA #1 revealed NA #2 observed to be frustrated and angry and laid the resident on his back aggressively. Resident #257 was muttering more words and was gritting his teeth and observed to be very angry. Resident #257 grabbed at NA #2 and NA #2 immediately grabbed the resident's wrist and placed them down on his chest under his neck in a forceful way. NA #1 indicated Resident #257 stated what are you doing? Are you trying to chock me? NA #1 revealed Resident #257 had quit being combative and observed to be scared. Resident #257 quit fighting the NAs and eyes appeared to be wide and in shock. NA #1 revealed NA #2 at this time let go of his wrist and completed care. NA #1 further revealed NA #2 wanted to move Resident #257 up in the bed. NA #1 stated she told NA #2 to stop and that they needed to go get help. NA #1 stated NA #2 threw the cover up on Resident #257 and stated, you are awful mean for someone who pisses on themselves. NA #1 indicated they left the room and she reported to the charge nurse within 15 minutes. NA #1 revealed she did not intervene during care because she was in shock and was scared of retaliation from NA #2.
A follow up phone interview conducted on 9/16/22 at 2:08 PM revealed NA #1 wanted to clarify her previous statement. NA #1 revealed she and NA #2 entered Resident #257's room and he began to grab at NA #2 when starting care. NA#1 indicated NA #2 rolled the resident on his left hip to give care and slapped the resident with her right open hand. NA #2 rolled the resident on his back and immediately grabbed both his hands and the resident stated, what are you doing choking me? NA #1 stated NA #2 wanted to pull him up in the bed and NA #1 said, stop and let's get someone in here to help. NA #2 pulled the sheet over Resident #257 and left the room together. As they were walking out of the room NA #1 stated NA #2 made the comment you sure are mean for someone who pisses himself. NA #1 and NA #2 stated they had walked out of the room at the same time and NA #1 reported the incident to the charge nurse. NA #1 was asked to clarify when she said stop to NA #2 during the incident. NA #1 was unable to be specific when she had told NA #2 to stop giving care to Resident #257. NA #1 continued to state the incident happened so quick that it appeared to be one motion.
-Nurse Aide (NA) #2 statement dated 6/14/22 revealed NA #2 and NA #1 entered Resident #257's room to change him. NA #2 further revealed the NAs moved resident #257 and he hit both NAs with his hands and feet. NA #2 noted she held Resident #257's arms under hers to keep him from hitting both NAs. Resident #257 stated he couldn't breathe, and NA #2 removed her hands from the resident's arms. NA #2 noted Resident #257 hit her with his fist and NA #2 had a reflex and hit Resident #257's hip not meaning too. NA #2 indicated both NAs rolled Resident #257 and NA #1 put the residents brief on, lowered the bed, and left the room.
A phone interview with Nurse Aide (NA) #2 was unable to be completed after several attempts.
-Unit Charge Nurse statement dated 6/14/22 revealed NA #1 had come to her last night around 10:00 PM and stated that NA #1 and NA #2 were providing care to Resident #257 and he became combative and NA #2 hit the resident. The statement further revealed the Unit Charge Nurse went and assessed the resident immediately, called the Director of Nursing (DON), and was instructed to have NA #1 write a statement, and to send NA #2 immediately home and that a staff member would be in contact with her the next day.
- Review of skin assessment completed by the Unit Charge Nurse dated 6/13/22 revealed redness noted on the resident's chest and a bruise forming on the right hand.
An interview conducted with the Unit Charge Nurse dated 9/14/22 at 3:24 PM revealed NA #1 had disclosed NA #2 hit Resident #257 on the hip during 2nd shift on 6/13/22. The Nurse further revealed she contacted the DON immediately and was instructed to complete an assessment on Resident #257, NA #1 write a statement on what had happened, and send NA #2 home immediately. NA #2 was in the shower room cleaning and had not worked with any other residents. The assessment revealed Resident #257 had a quarter size bruise forming on his right hand and did not show any kind of emotions of being sad, scared, or angry. The Nurse indicated Resident #257 was unable to recall the incident. She revealed both NAs had worked with Resident #257 numerous times and knew he could be combative sometimes. The Nurse also indicated the NAs had been educated that anytime Resident #257 or an aggressive resident became combative to either walk away, wait till they are calm, or get another employee to complete care.
An interview conducted with the Director of Nursing (DON) on 9/14/22 at 4:00 PM revealed she believed NA #1 was upset and scared of NA #2 and is the reason NA #1 did not intervene to stop NA #2. The DON completed the initial investigation and did not complete a report to the state, adult protective services, or law enforcement within two hours. The DON stated she had spoken to law enforcement the next day, but a report was not made. The DON indicated a report was not made to APS. The DON indicated she was not aware that the initial intake report had to be sent in within two hours. The DON further revealed she believed to have 24 hours to report the incident. The DON revealed she expected for nursing staff to intervene and stop any abuse and to report immediately to upper management.
An interview conducted with the Administrator on 9/14/22 at 5:55 PM revealed she thought she had 24 hours to send the initial investigation report once the incident had happened. The Administrator further revealed the DON had contacted law enforcement the next day after speaking to their corporate, but an official police report was not made. The Administrator indicated a report was not made to APS because she was not aware the facility needed too. The Administrator expected for staff to intervene and stop any kind of abuse, but felt like NA #1 was upset and scared of retaliation from NA #2.
The Administrator was notified of immediate jeopardy on 9/15/22 at 9:00 AM. The facility provided the following credible allegation of immediate jeopardy removal.
The corrective action plan was as followed:
On 6/13/22, the Director of Nursing and Administrative Nurse initiated a skin sweep on 100% of all in house residents assessing for any signs of abuse, as all residents have the potential to be affected. This sweep was completed on 6/14/22, approximately at 3:00am. No additional concerns were identified.
On 6/14/22, the Social Worker and Administrator interviewed all in-house alert and oriented residents with a BIMS of 10 or higher, to ensure no allegations of abuse were reported. No residents verbalized concerns.
Nurse #1 began abuse in-servicing to Nurse Aide #1 immediately after notifying the Director of Nursing and Administrator of the alleged event with Nurse Aide #2 to reeducate on the abuse policy, prevention, protecting and reporting, and dealing with residents with aggressive behaviors in long term care. Nurse #1 then in-serviced all other staff in the facility on the abuse policy, prevention, protecting and reporting, and providing care for residents with aggressive behaviors in long term care. This education included what to do if witness to abuse and when to report. All staff were trained in empathy, prevention, and de-escalation. The Director of Nursing and the Administrator arrived at the facility at approximately 11pm to continue with the investigation of abuse. Education on the abuse policy, prevention, protecting and reporting, and dealing with residents with aggressive behaviors in long term care to all staff was completed on 6/15/22. Any staff not educated by 6/15/22 will not be allowed to work until education is completed. On 9-15-22, all facility staff were interviewed on the education provided on What is abuse, who reports abuse, what to do if you witness an abuse, and when to report abuse. No issues were identified.
The Regional Operations Manager educated the Administrator and the Director of Nursing on 6-21-22 on the abuse policy, prevention of abuse, protecting residents, staff & visitors, and reporting abuse to include reporting to The Healthcare Personnel Registry and Police Department within 2 hours of an abuse allegation.
As of 6-21-22, the Regional Operations Manager and/or the Regional Clinical Manager will review all reportable allegations to ensure timely reporting to the State Agency and other officials as required by the regulation, and to ensure that there is no failure for timely reporting an allegation to a nurse, supervisor, or Administrator. Any issues identified during this monitoring process will addressed promptly. On 9-17-22, Department of Health and Human Services educated the Administrator on the requirement for reporting to APS. The Administrator educated the Director of Nursing on 9-17-22 regarding reporting to APS.
On 9-15-22, all facility staff, to include those not in the facility on 9-15-22, were interviewed by the Director of Nursing and Nurse Administration on the re-education that was provided on 6/13/22-6/15/22 by Administrator or designee validating what is abuse, who reports abuse, what to do if you witness an abuse, and when to report abuse. No issues were identified.
Education on the abuse policy, preventing, protecting, and reporting, and caring for residents with aggressive behaviors in long term care will be provided in the monthly All-Staff meeting starting July 7/13/22 by the Administrator or Director of Nursing to staff x 6 months.
Date of Immediate Jeopardy Removal: 9-18-22
On 9/20/22, the facility's credible allegation for immediate jeopardy removal effective 9/18/22 was validated by the following: Staff interviews revealed they had received education on resident abuse and how to care for aggressive and combative residents. Skin assessments were conducted on all residents and identified, and alert and oriented residents were interviewed with no concerns identified. The regional operational manager educated the Administrator and DON on abuse policy, prevention of abuse, protecting residents, staff and visitors, and reporting abuse Education was received regarding reporting in a timely manner to agencies. All reportables would be reviewed to ensure that that they are reported timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of the discharge date for 1 of 1 sampled resident reviewed for discharge (Resident #35).
Findings included:
Resident #35 was admitted to the facility on [DATE].
A Social Worker progress note dated 08/02/22 at 8:00 AM noted Resident #35 was sent out to the hospital on [DATE] and was admitted .
Review of Resident #35's medical record revealed the last completed MDS assessment was a quarterly dated 07/26/22. There was no discharge assessment completed or transmitted.
During an interview on 09/14/22 at 10:54 AM, the MDS Coordinator explained typically MDS assessments showed up on their computer dashboard to indicate when an MDS assessment was due and/or had not been transmitted but for some reason Resident #35's discharge MDS assessment wasn't. The MDS Coordinator stated it was an oversight and should have been completed within the regulatory time frame.
During an interview on 09/15/22 at 7:36 PM, the Administrator stated she would expect for MDS assessments to be completed and transmitted within the regulatory timeframes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #44 was admitted on [DATE] with diagnoses which included osteomyelitis (infection of the bone), muscle wasting and atrophy and muscle weakness.
The resident was confined to his wheelchair due to paraplegia.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 had walked in his room once with minimal assistance from staff.
An interview with the MDS Coordinator on 09/15/22 at 2:38 PM revealed Resident #44 was paraplegic and was not able to walk on his own or with assistance and this had been an error in coding the MDS. She explained some of the information on the assessment automatically populated from documentation by the Nurse Aides (NAs) but said the MDS nurses should have caught the error. The MDS Coordinator stated the assessment would be modified and corrected.
An interview with the Director of Nursing (DON) on 09/15/22 at 6:29 PM revealed the information on the Activities of Daily Living on the MDS assessment automatically populated from documentation of the NAs but said the MDS nurses should verify the information as correct prior to signing off on the assessment.
An interview with the Administrator on 09/15/22 at 7:40 PM revealed some of the information on the MDS assessment automatically populated from the NAs documentation. She stated they were no longer going to auto-populate that section from documentation but rather were going to code it according to the resident at the time of the assessment to ensure the MDS was accurate.
5. Resident #153 was admitted on [DATE] with diagnoses which included osteomyelitis of right ankle, arterial ulcers, diabetes mellitus and diabetic foot ulcer on the left foot.
Review of Resident #153 ' s physician orders dated 09/01/22 revealed he was non-weight bearing to bilateral lower extremities.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #153 had walked in his room independently and had walked in the corridor at least once with minimal assistance from staff. The MDS further indicated Resident #153 had impairment on both sides of his lower extremities.
An interview with the MDS Coordinator on 09/15/22 at 2:38 PM revealed Resident #153 was non-weight bearing and was not able to walk on his own or with assistance and this had been an error in coding the MDS. She explained some of the information on the assessment automatically populated from documentation by the Nurse Aides (NAs) but said the MDS nurses should have caught the error. The MDS Coordinator stated the assessment would be modified and corrected.
An interview with the Director of Nursing (DON) on 09/15/22 at 6:29 PM revealed the information on the Activities of Daily Living on the MDS assessment automatically populated from documentation of the NAs but said the MDS nurses should verify the information as correct prior to signing off on the assessment.
An interview with the Administrator on 09/15/22 at 7:40 PM revealed some of the information on the MDS assessment automatically populated from the NAs documentation. She stated they were no longer going to auto-populate that section from documentation but rather were going to code it according to the resident at the time of the assessment to ensure the MDS was accurate.
6. Resident #65 was admitted on [DATE] with diagnoses which included displaced fracture of the humerus and ulnar with routine healing and displaced fracture of right femur with routine healing.
The resident was able to feed herself with set up of her meals.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #65 required supervision from 2 or more staff physical assistance with eating.
An interview with the MDS Coordinator on 09/15/22 at 2:38 PM revealed Resident #65 was independent with eating after being set up and this had been an error in coding the MDS. She explained some of the information on the assessment automatically populated from documentation by the Nurse Aides (NAs) but said the MDS nurses should have caught the error. The MDS Coordinator stated the assessment would be modified and corrected.
An interview with the Director of Nursing (DON) on 09/15/22 at 6:29 PM revealed the information on the Activities of Daily Living on the MDS assessment automatically populated from documentation of the NAs but said the MDS nurses should verify the information as correct prior to signing off on the assessment.
An interview with the Administrator on 09/15/22 at 7:40 PM revealed some of the information on the MDS assessment automatically populated from the NAs documentation. She stated they were no longer going to auto-populate that section from documentation but rather were going to code it according to the resident at the time of the assessment to ensure the MDS was accurate.
Based on record review and staff interviews, the facility failed to accurately code the Prospective Payment System (PPS) and Minimum Data Set (MDS) assessments in the areas of dialysis, hospice, Preadmission Screening and Resident Review (PASRR), and activities of daily living for 6 of 30 sampled residents (Residents #79, #309, #45 #44, #153, and #65) reviewed for MDS accuracy.
Findings included:
1. Resident #79 was admitted to the facility on [DATE]. His diagnoses included diabetes, chronic kidney disease, and dependence on renal dialysis.
A staff progress note dated 07/09/22 written by the Social Worker revealed Resident #79 was scheduled to go to dialysis on Tuesday, Thursday, and Saturdays.
Review of Resident #79's comprehensive care plans, last reviewed/revised 07/18/22, revealed he had the potential for complications related to hemodialysis. Interventions included hemodialysis three times a week as ordered on Tuesday, Thursday, and Saturday.
The 5-day PPS assessment dated [DATE] revealed Resident #79 was not coded as having received dialysis services.
During an interview on 09/14/22 at 10:32 AM, the MDS Coordinator confirmed Resident #79 received dialysis and stated it was a coding error that dialysis was not indicated as received on the 5-day PPS assessment dated [DATE].
During an interview on 07/01/22 at 7:40 PM, the Administrator stated she would expect for PPS assessments to be coded appropriately and accurately reflect a resident's status at the time of the assessment.
2. Resident #309 was admitted to the facility 08/05/21. His diagnoses included dementia, heart failure, and diabetes.
The Hospice Recertification for the period 06/06/22 through 07/30/22 revealed Resident #309 was admitted under hospice care on 12/03/21 related to a primary diagnosis of Alzheimer's disease, had a limited life expectancy of 6 months or less, and was certified as eligible for hospice care.
The annual MDS assessment dated [DATE] revealed Resident #309 was not coded as having a prognosis that might result in a life expectancy of less than 6 months and receiving hospice care.
During an interview on 09/14/22 at 10:32 AM, the MDS Coordinator confirmed Resident #309 received hospice services. The MDS Coordinator revealed she did not code hospice services or prognosis of life expectancy of less than 6 months on the MDS assessment because he was currently listed as private pay. She explained Resident #309 admitted to the facility with a Medicare replacement as his payor source then went to private pay due to having to spend down before he qualified for Medicaid. She added, once he became eligible for Medicaid hospice would become the payor source.
During an interview on 07/01/22 at 7:40 PM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's status at the time of the assessment.
3. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety, depression, unspecified mood disorder, and dementia with behavioral disturbance.
A Preadmission Screening and Resident Review (PASRR) Level II Determination Letter dated 05/23/19 indicated Resident #45 had a Level II PASSR that ended in a C with no expiration date.
Review of the North Carolina Skilled Nursing Facility PASRR authorization codes document revealed a PASRR ending in C indicated Level II: no end date, no limitation unless change in condition, specialized services required.
The annual MDS dated [DATE] revealed Resident #45 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability.
During interviews on 09/14/22 at 10:32 AM and 11:57 AM, the MDS Coordinator explained when they reviewed Resident #45's PASRR information via the North Carolina Medicaid Uniform Screening Tool (NC MUST) website, it was noted as no under the column sent to Level II. The MDS Coordinator stated based on what she was instructed, Resident #45's PASRR did not meet the criteria and did not need to be coded as a Level II PASRR on the MDS assessment dated [DATE].
During an interview on 07/01/22 at 7:40 PM, the Administrator stated she would expect for MDS assessments to be coded appropriately and accurately reflect a resident's status at the time of the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to discard an expired medication available for use in 1 of 5 medication carts (F hall medication cart).
The findings included:
An observation of the F hall medication cart on [DATE] at 6:38 AM with Medication Aide (MA) #1 revealed a large, opened bottle of Thera-tabs which was about ¾ full of oblong-shaped reddish-brown tablets. (Thera-tabs is a multivitamin and iron product used to treat or prevent vitamin deficiency.) The bottle was marked with a best by date of 11/21. (Best by date is the date at which the manufacturer can still guarantee the full potency and safety of the drug.)
An interview with MA #1 on [DATE] at 6:40 AM revealed she was not sure if any of the residents on her hall took Thera-tabs, but she didn't give it to any of her residents on her shift. MA #1 stated the staff just used the bottle of Thera-tabs to prop up the narcotic cards in the narcotic drawer. MA #1 also stated that the bottle did not need to be left inside the medication cart and that it needed to be disposed of.
An interview with the Director of Nursing (DON) on [DATE] at 6:51 PM revealed she had just been made aware of an expired bottle of Thera-tabs being used to hold up the narcotic cards in the F hall medication cart. The DON stated all nurses and medication aides who worked on the medication carts were responsible for checking the dates on the medications and discarding any that were expired. She also stated that the expired bottle of Thera-tabs should not be stored in the medication cart and should have been discarded when it went out of date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place on after COVID-19 Focused Infection Control and complaint investigation survey completed on [DATE] and the recertification survey completed on [DATE]. This was for two repeated deficiencies in the areas of labeling and storage of drugs and biologicals and freedom from abuse and neglect. These areas were cited again on the current recertification survey with an exit date of [DATE]. The continued failure of the facility during the three federal surveys shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.
The findings included:
This tag was cross referenced to:
F-761: Based on observation and staff interviews, the facility failed to discard an expired medication available for use in 1 of 5 medication carts (F hall medication cart).
During the recertification survey of [DATE] the facility failed to discard an undated opened multi-dose vial of influenza vaccine in 1 of 1 medication room, discard an opened single-dose vial of an injectable medication, undated and opened insulin pens, and loose pills in 5 of 5 medication carts (A hall, B hall, C hall, D hall and F hall). They also failed to store undated and unopened vials of insulin per manufacturer instructions and failed to secure a narcotics drawer in 1 of 5 medication carts.
F- 600: Based on record review and staff interviews the facility failed to protect a resident from verbal and physical abuse when Nurse Aide (NA) #2 proceeded to provide care to a resident (Resident #257) while he was agitated and combative. NA #2 taunted, aggressively pushed, aggressively turned, slapped the resident on the hip, and grabbed his arms and held them on his neck resulting in the resident asking, are you trying to choke me, and leaving a bruise on his right hand and redness to his chest for 1 of 3 residents reviewed for abuse (Resident #257).
During the COVID-19 Focused Infection Control Survey and complaint investigation survey completed on [DATE], the facility failed to transfer a resident with the required level of staff assistance. As a result, the resident was unable to support her weight during the transfer and fell. The fall was not reported to the assigned nurse, the next shift nurse or administration; the resident was not thoroughly assessed after the fall and the fall was not documented in the medical record. A day after the fall the resident complained of pain and an x-ray revealed a fracture of the outer layer of the femur just above the knee joint on the right leg. This was for 1 of 3 sampled residents for provide supervision to prevent accidents.
An interview was conducted on [DATE] at 7:35 PM with the Administrator who also headed the QAA committee. The Administrator stated the facility had completed medicine cart audits by the Administrator, nurses, and pharmacist after the last recertification, discussed medicine storage frequently at quarterly QAA meetings, and had staff complete in-service and education on medicine storage. The Administrator further revealed she could did not know why medicine storage had been an issue again but indicated one on one training would be completed with staff.