Accordius Health At Mooresville

F-F684: Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to perform a comprehensive assessment including vital signs before moving a Level of Harm - Immediate resident off the floor after a fall with injury and failed to seek immediate medical treatment or higher level of jeopardy to resident health or care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded safety to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident Residents Affected - Few #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice was identified for 1 of 3 residents reviewed for change of condition (Resident #40).

F-F697: Based on observations, record review, staff, Physician Assistant (PA), and Medical Director (MD) interviews the facility failed to provide effective pain management for a resident (Resident #40) after a fall, with obvious deformity, or transfer him to the hospital for pain that could not be managed in the facility as outlined by his advanced directive. On 5/27/2024 Resident #40 was found face down on the floor beside his bed and was noted to have internal rotation and shortening of the left hip and leg. Resident #40 was crying, moaning, guarding (protecting/holding) his left leg, grimacing, and unable to be consoled by staff. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of the resident's chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directed that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. Nurse #3 notified the provider on-call and obtained an order for a one-time dose of Ibuprofen (pain medication, decreases inflammation) to be given for pain and a left hip/pelvis x-ray. Nurse #3 administered that medication as well as oxycodone-acetaminophen 5-325 mg (pain medication) that was scheduled (for every 6 hours) at 12:00 am and Resident #40 continued to grimace in pain throughout the remainder of her shift. Nurse #3 administered the 6:00 am oxycodone-acetaminophen. Nurse #10 administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, and documented a pain assessment of 8 out of 10 for Resident #40. An x-ray was performed in the facility on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone) and Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The deficient practice occurred for 1 of 3 residents (Resident #40) reviewed for pain management.

The Administrator was notified of Immediate Jeopardy on 6/5/2024 at 11:35 am.

The facility provided the following credible allegation of immediate jeopardy removal:

o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The facility neglected to thoroughly assess resident #40 on 5/27/24 at 10:40 pm after he fell from his wheelchair to the floor on his left side face down. Resident #40 was discovered by his roommate who Level of Harm - Immediate summoned assistance from staff. Nurse #1, Nurse #2, NA #1, and NA #2 lifted resident #40 under his arms jeopardy to resident health or and held traction to Resident #40's left leg and picked him up from the floor and placed him in the bed. Nurse safety #3 completely assessed Resident #40 and observed that the left leg was internally rotated and shortened. Nurse #1 described left leg as a limp noodle. Residents Affected - Few

The facility neglected to ensure Resident #40 immediately received the necessary care and services from a higher level of care after sustaining an obvious injury status post fall, effective pain management strategies identified through his assessment, and neglecting to implement identified services according to Resident #40's MOST form.

Resident #40 still resides in the facility and continues to participate in his Plan of Care receiving all necessary care and services to include a pending orthopedic follow-up appointment. Awaiting the orthopedics office to review the referral documentation and provide the facility with the appointment date. Resident #40 is currently on an increased frequency of Oxycodone 5/325 mg PO Q4 hours. Resident #40's pain is assessed prior to scheduled routine administration, in addition to his routine pain assessment every shift identifying nonverbal pain including facial grimacing, moaning, and crying.

On 6/7/24, the Chief Nursing Officer and Director of Nursing reviewed Resident #40's medical records documentation revealing he's receiving all necessary care and services.

All current residents have the potential to be affected by this deficient practice.

On 6/7/24, the Chief Nursing Officer and Director of Nursing reviewed risk management events of falls with obvious injuries within the last 30 days, as well as alert and oriented interviewed with pain issues. No residents were identified requiring a higher level of care and/or current ineffective pain management regimens were identified.

o 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Starting 6/7/24, the Chief Nursing Officer educated the Director of Nursing on the process at the time of an event ensuring residents immediately receive a higher level of care for obvious injuries, effective pain Level of Harm - Immediate management strategies implemented and understanding MOST forms in relation to residents' immediate jeopardy to resident health or needs after an event. Education includes when the MOST form indicates comfort measures are to be safety implemented and the facility's unable to manage, the resident should be provided services and care at a higher level. At no time will the DON direct the facility staff to neglect providing the necessary services Residents Affected - Few required from a higher level of care following an obvious injury or ineffective pain management strategies be acceptable standards of practice. The Director of Nursing, along with the clinical team, will review all falls/incidents daily in the clinical meeting to determine if the event required residents to receive a higher level of care and/or the need for additional care and services. The pain assessment conducted with each event will be reviewed during the clinical meeting for immediate interventions implemented and real time effectiveness. The clinical team will also review the MOST forms to ensure facility's compliance with resident/responsible party's wishes. If the post assessment following pain interventions are not effective, the Director of Nursing, along with the clinical team, will notify the clinicians of its ineffectiveness and implement additional and/or alternative measures as indicated.

Starting 6/7/24, The Director of Nursing/Staff Development Coordinator will in-service all facility staff (including contracted agency staff) on Neglect, including failing to provide the necessary care and services from a higher level of care and effective pain management strategies following an event with obvious injuries.

The Director of Nursing/Staff Development Coordinator will educate all new hires during orientation and scheduled contracted agency nurses prior to working their shift. The Administrator and Chief Nursing Officer will ensure all facility staff (including contracted agency staff) are educated.

Effective 6/10/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Alleged Date of IJ Removal: 6/12/24

A validation of immediate jeopardy removal was conducted on 06/13/24. The inital audit of residents records and pain interviews with alert and oriented residents were reviewed with no issues noted. Staff interviews across all departments were able to verbalize that they had recieved the education on neglect, how to respond if they were aware of neglect, and who to immediately report it to. The staff were able to verbalize examples of neglect and ways to identify neglect. Nursing staff were able to verbalize the need to review residents MOST forms after falls with injury and the need to contact the residents responsible party if the resident required a higher level of care. Nursing staff were also able to verbalize the pain assessment protocol and who to report any changes in pain or ineffectiveness of currently scheduled pain medication.

The immediate jeopardy removal date of 06/12/24 was validated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 37280 potential for actual harm Based on record review and staff interviews, the facility failed to implement their abuse policy in the areas of Residents Affected - Few reporting and investigating. When there was an allegation of abuse, an initial report was not submitted to the State Agency, a 5 day investigation was not submitted to the State Agency, law enforcement and Adult Protective Services (APS) were not notified for 1 of 2 residents reviewed for abuse (Resident # 1).

The finding included:

The facility's policy titled, Abuse, Neglect and Exploitation, revised 10/22/23 read in part, It is the policy of

this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include identifying staff responsible for investigation; identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; providing complete and thorough documentation of the investigation. The facility will have written procedures that include: reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable within specified timeframes: a) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse and result in serious bodily injury or b) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; and assuring that reporters are free from retaliation or reprisal.

An interview was conducted with Nurse #1 on 07/22/24 at 9:20 AM who explained that she was on duty

during the day of 06/28/24 and noticed that Resident #1 and Resident #2 were together all during the shift sitting in the hallway together holding hands and thought that was their normal routine. The Nurse explained that the night of 06/28/24 during shift change, she and Nurse #2 were standing at the medication cart giving shift report when she observed Resident #2 reach up with his hand and cover her mouth. Resident #1's eyes began to roll back while she was looking at the two nurses standing close by. Nurse #1 stated Resident #2 then released his grip then pinched Resident #1's nose closed using his thumb and index finger after which Resident #1's face started to turn red, and her head fell backwards. Nurse #1 continued to explain that she alerted Nurse #2 who was closer to the two residents to see what was happening and when she alerted Nurse #2, Resident #2 removed his hand from Resident #1's mouth and started to force his thumb in her mouth and by that time Nurse #2 had reached the two residents. She stated the whole encounter happened

in a matter of about 20 seconds. Nurse #1 continued to explain that Nurse #2 immediately removed Resident #1 from Resident #2 and asked her if she was okay when Resident #2 answered her that Resident #1 was okay. Nurse #1 described the look on Resident #1's face during the incident as fright.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Interviews were conducted with Nurse #2 on 07/18/24 at 4:45 PM and 07/18/24 at 8:40 PM. Nurse #2 explained that during shift change report on the evening of 06/28/24 she was receiving report from Nurse #1 Level of Harm - Minimal harm or while standing by the medication cart in the hallway. The Nurse stated that Nurse #1 told her to turn around potential for actual harm and look at what Resident #2 was doing to Resident #1 who were sitting in their wheelchairs in the hallway directly behind her. Nurse #2 reported that she observed Resident #2's hand over Resident #1's mouth with Residents Affected - Few his thumb and index finger pinching Resident #1's nose and appeared to be pushing Resident #1's head back. Resident #1's head was leaning to the left and there was a pillow behind her head for support. Nurse #2 continued to explain that Resident #1's face was bright red, and her eyes were rolled to the top of her eyelids. The Nurse rushed to the two residents and stated to Resident #2 what are you doing and Resident #2 slowly moved his hand off her face as if he was in a trance. Nurse #2 reported she then moved Resident #1 away from Resident #2 and asked Resident #1 if she was okay and as she moved the Resident, she gave Nurse #2 a look like Resident #1 was in shock. The Nurse stated as she was moving Resident #1 away from Resident #2, Resident #2 stated to Resident #1 to tell them that you are okay twice while being wheeled to her room. The Nurse continued to explain that after Resident #1 was taken to her room and put to bed Nurse #2 assured the Resident that she was safe, and she would not have to have any contact with Resident #2 that night. The Nurse reported Resident #1 never stated Resident #2 was trying to hurt her, but Resident #1 did say that she was afraid of him and did not want to make him mad. Nurse #2 explained that as she was assessing Resident #1's vital signs and performed a skin check she assured Resident #1 again that she was safe, and tears began to roll down the Resident's face. The Nurse stated Resident #1 was okay but that she appeared to be in shock because the Resident seemed just as surprised at what happened as the staff were. Nurse #2 reported she called the Director of Nursing (DON), the Administrator, the on-call provider and Resident #1's representative and informed them of what happened. She stated the Administrator had her repeat the incident twice and instructed her to put Resident #2 on a one-on-one observation until Monday 07/01/24 and for Resident #2 not to have any contact with Resident #1. Nurse #2 revealed Resident #1 and Resident #2 were a couple and in a relationship in that they were with each other all the time like sitting in

the hallway and in rooms together. She stated they were in each other's faces all the time but that she had never seen anything abnormal between the two before the incident on 06/28/24.

An interview was conducted with the Administrator on 07/19/24 at 12:25 PM. The Administrator explained that Nurse #2 called him the night of 06/28/24 and reported that Nurse #1 reported that she observed Resident #2's hand over Resident #1's mouth and they had separated them and took Resident #1 to her room. The Nurse reported that Resident #2 was not happy about Resident #1 being separated from him and wanted to see Resident #1, but the Administrator told the Nurse to put Resident #2 on one-to-one

observation until he had a chance to evaluate the situation. The Administrator stated that the way the incident was described to him by Nurse #2 that he felt the situation was questionable and did not think of it as abuse. The Administrator indicated that in retrospect he should have perceived the incident as abuse and followed the facility's abuse policy and procedures by submitting an initial and 5-day investigation report to

the state agency and he should have notified adult protective services and local law enforcement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 48006

Residents Affected - Few Based on record reviews and staff interviews, the facility failed to submit a 5-Day Investigation Report within

the required timeframe to the State Agency for 1 of 1 resident reviewed for misappropriation of property (Resident # 247).

The findings include:

Review of the facility's Abuse Policy titled Abuse, Neglect, and Exploitation, dated 10/22/2023 revealed in part, all alleged violations involving misappropriation of resident property will be reported immediately to the Administrator who will ensure the initial report and the 5-day investigation report were received as required by the state agency.

A review of the Initial Allegation Report completed by the Director of Nursing (DON) revealed Resident #247 reported his personal bank card was missing and had been used without Resident #247's consent. The Initial Allegation Report was faxed to the State Agency on 12/01/2023 at 11:01 AM.

The 5-day Investigation Report was not received by the State Agency as of 06/06/2024 at 10:47 AM.

On 06/04/2023 at 2:15 PM an interview was conducted with the DON. The DON stated the Social Services Director notified her on 12/01/2023 at 9:00 AM that Resident #247 was missing his credit card. The DON stated that she notified the police department on 12/01/2023 at 10:00 AM. The DON explained that she completed the 24-hour report and faxed the document to the state agency on 12/01/2023 around 11:00 AM.

The DON further explained that an internal investigation was initiated, and a 5-day investigation report was completed. The DON stated that she thought she had faxed the 5-day report to the State Office when she completed the report on 01/08/2024 but she could not locate the 5-day report fax confirmation. The DON further stated she was aware of the requirement to submit the 5-day investigation report to the State Office.

An interview was conducted with the Administrator on 06/04/2023 at 3:00 PM. The Administrator stated that

he had only been in his position since March 2024 and was not in the facility at the time of the incident. The Administrator revealed he was aware of the requirement to submit the 5-day investigation report to the State Office.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50045 Residents Affected - Few Based on record review, and staff and Resident Responsible Party (RP) interviews the facility failed to permit

a resident (Resident #346) who required skill nursing services to return to the facility after being sent to the Emergency Department (ED) for evaluation on 07/08/2023 after he cut himself with a soda can. On 7/11/2023, Hospital Social Worker #1 contacted the Admissions Coordinator at the facility and informed her that Resident #346 had been cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued involuntary commitment (IVC) paperwork had been reversed. The facility did not accept Resident #346 for readmission. The hospital sent Resident #346's skilled nursing referrals to 50 other skilled nursing facilities and was unable to place Resident #346. Resident #346 remained in the Emergency Department until he was discharged home on 7/19/2023 with his elderly parents who were not physically able to care for him. Emergency Department documentation revealed Resident #346 had acquired a deep tissue injury to his left heel at the skilled nursing facility, prior to arrival at

the Emergency Department on 7/8/2023 that required wound care. The deficient practice was identified for 1 of 3 residents reviewed for discharge (Resident #346). Resident #346 was transferred to the Emergency Department on 07/08/23 and was treated and stabilized on 07/11/23. Resident #346 remained in the Emergency Department from 07/11/23 through 07/19/23 while awaiting discharge plans. The reasonable person would be anxious, scared, and fearful of being the Emergency Department for such an extended period of time.

The findings included:

A review of an initial referral dated 6/28/2023 for Resident #346 revealed he had been hospitalized since 6/25/2023 for aggression, depressed mood, and suicidal ideation. Documentation revealed Resident #346 had been stabilized in the Emergency Department and was not a candidate for inpatient psychiatric services due to his acute medical needs and total care needs that required management outside the inpatient psychiatric setting. On the cover sheet of the initial referral was a handwritten note that read; patient had behaviors at arrival due to drug resistant Urinary Tract Infection (UTI), he has gotten on the right antibiotics and has had no behaviors since.

Resident #346 was admitted to the facility on [DATE REDACTED] with diagnoses which included bipolar, anxiety, post-traumatic stress disorder, and major depressive disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 A review of an admission Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #346 was cognitively intact and was coded as feeling down, depressed, and hopeless, had trouble falling asleep, felt tired/little Level of Harm - Actual harm energy, poor appetite, felt bad about self, had trouble concentrating, and had thoughts he would be better off dead. Resident #346 was coded as having physical behavioral symptoms directed towards others (1 to 3 Residents Affected - Few days), verbal behavior symptoms directed towards others (1 to 3 days), and other behavioral symptoms not directed towards others (1 to 3 days). The behaviors were coded as putting Resident #346 at significant risk for physical illness or injury, interfering with Resident #346's care, and interfering with Resident #346's participation in activities and social interactions. Resident #346 was coded as placing others at risk of physical injury. Resident #346 was coded as requiring maximum assistance for toileting (had an indwelling catheter and was always incontinent of bowel), bathing/showering, substantial/maximal assistance with lower body dressing and putting on/taking off footwear, partial/moderate assistance with upper body dressing, supervision/touching assistance with oral hygiene, and was independent for eating. Resident #346 was coded as requiring substantial/maximum assistance with rolling left to right and retuning to lying on back in bed, from lying to sitting and was dependent for chair/bed-to-chair transfers. Resident #346 was coded as using a wheelchair and was not ambulatory. Resident #346 was not coded as having a pressure ulcer or injury.

A review of a care plan dated 7/6/2023 revealed Resident #346 was admitted short term, had verbally aggressive behaviors towards staff, had behaviors which included throwing objects, playing loud music, fabricating stories, physically aggression towards staff, and Resident #346 had not been care planned for a history of suicidal ideation.

A review of a nursing note dated 7/7/2023 at 12:28 pm written by the DON revealed Resident #346 threw his lunch tray in the hall and refused to take his medications. Staff received orders to send Resident #346 to the Emergency Department due to behaviors and refusal to take medications.

A review of a nursing note dated 7/7/2023 at 8:30 pm written by the DON revealed PA #1 was in the facility when Resident #346 struck a staff member in the abdomen. The Social Worker (SW) and nursing staff went to the Magistrate's office where they were denied involuntary commitment (IVC) papers and instructed staff to call law enforcement to report Resident #346 hitting a staff member.

A review of a nursing note dated 7/7/2023 at 8:31 pm revealed Resident #346 was found to be in the courtyard where he had thrown garbage and taken the facility's fire extinguisher and sprayed it all over the ground. Resident #346 had refused to take his medications and yelled at a Nurse Aide (NA).

A review of a nursing note dated 7/8/2023 at 9:29 pm written by Nurse #8 revealed Resident #346 rang his call bell. When the staff arrived at Resident #346's room, he had cut himself with a soda can and cut himself

on the top area of his right leg. Resident #346 then stated, I am suicidal, and I want to go to the hospital.

An interview was conducted on 6/6/2024 at 3:55 pm with Nurse #8. Nurse #8 stated she worked on 7/8/2024

during night shift (7:00 pm to 7:00 am) and was assigned Resident #346. Nurse #8 stated a staff member had come and gotten her to check on Resident #346. Nurse #6 stated when she arrived at Resident #346's room, she observed blood on his upper thigh and had been cutting himself with a soda can. Nurse #8 reported she removed the can from Resident #346's room, had a staff member stay with him and contacted

the Director of Nursing (DON). Nurse #8 stated the DON told her to contact law enforcement and Emergency Medical Services (EMS) to have him sent to the Emergency Department. Nurse #8 reported she given report to EMS, notified Resident #346's RP and transferred him to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 A review of the Emergency Department records revealed the following:

Level of Harm - Actual harm An Emergency Department note dated 7/8/2023 at 11:46 pm revealed Resident #346 was presented to the Emergency Department via EMS for suicidal ideation. Residents Affected - Few

An Emergency Department note dated 7/11/2023 at 10:30 pm revealed Resident #346 had been seen by mental health staff and was started on a mood stabilizer.

An Emergency Department note dated 7/12/2023 at 10:59 am revealed Resident #346 had rested comfortably overnight without any issues. Resident #346 was found to have a Urinary Tract Infection (UTI) and was started on antibiotics. The medical team discussed Resident #346 was not homicidal or suicidal and continued to seek placement in a skilled nursing facility.

A review of the Emergency Department record dated 7/19/2023 at 1:02 pm revealed Resident #346 was discharged home with his RP.

An interview was conducted on 6/7/2024 at 11:49 am with Hospital Social Worker #1. Hospital Social Worker #1 stated she contacted the facility's Admissions Coordinator on 7/11/2023 and was told that the facility would not accept Resident #346 back until he had received in-patient psychiatric services. Hospital Social Worker #1 informed the Admissions Coordinator that Resident #346 was cleared by in-house psychiatric services, no longer required acute care or in-patient psychiatric services, and his hospital-issued IVC had been reversed and the Admissions Coordinator stated the facility would not take Resident #346 back. The Hospital Social Worker stated she had sent referrals to over 50 skilled nursing facilities and was never able to place Resident #346. The Hospital Social Worker stated Resident #346 was sent home to be cared for by his parents on 7/19/2023.

An interview was conducted on 6/6/2024 at 4:54 pm with the Admissions Coordinator. The Admissions Coordinator stated she was employed at the facility on 7/11/2023 and no longer worked at the facility. The Admissions Coordinator stated she remembered Resident #346's RP really wanted him to reside long term at the facility when he was admitted . The Admissions Coordinator stated the facility had sent Resident #346 to the hospital for psychiatric reasons and was told by the DON not to accept Resident #346 back to the facility because he needed to be in a psychiatric facility. The Admissions Coordinator was unable to recall any communication with the hospital after Resident #346 was transferred for evaluation.

A telephone interview was conducted on 6/6/2023 at 11:17 am with Resident #346's RP. The RP stated Resident #346 was sent to the Emergency Department on 07/08/23 because the facility staff had stated he was suicidal. The RP reported that while Resident #346 was being stabilized in the hospital he went to the facility to speak with the DON about Resident #346 returning after discharge and was told by the DON, they would not take him back. The RP stated the hospital never could find Resident #346 anywhere to go, and that he (the RP) would have to take him home. The RP stated he was the primary caregiver for Resident #346 after discharge and struggled to take care of Resident #346 and his elderly spouse who had end-stage Parkinson's disease, while he continued to work fulltime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 An interview was conducted on 6/6/2024 at 9:22 am with facility Social Worker (SW) #1. SW #1 reported she remembered Resident #346 and his transfer to the hospital. SW #1 reported she had not called the hospital, Level of Harm - Actual harm sent a transfer/discharge notice, or bed hold documentation to the family because the hospital was his safe discharge. SW #1 was unable to recall if the DON had informed her, they would not accept Resident #346 Residents Affected - Few back to the facility.

An interview was conducted on 6/6/2024 at 9:28 am with the DON. The DON reported Resident #346 had been sent to the hospital for suicidal ideation on 7/8/2023. The DON stated prior to his transfer to the ED he had been aggressive towards the staff and had hit one of the nurses. The DON reported the facility was not able to manage his behaviors. The DON reported she discharged him to the hospital with the intent of not taking him back to the facility because she was worried about the safety of the residents and staff. The DON stated the Admissions Director was aware that he had a history of behaviors, aggression, and suicidal ideation, but had not informed her until right before he arrived at the facility on 06/29/23. The DON stated she never would have accepted Resident #346 if she had known that prior to his admission. The DON reported

she never followed up with the hospital once he was transferred and stated the RP had come to the facility and asked multiple times for Resident #346 to be taken back and she informed the RP she would not accept him back to the facility.

An interview was conducted on 6/6/2024 at 6:00 pm with the Previous Administrator. The Previous Administrator reported he was employed at the facility on 7/8/2023, but was not able to recall Resident #346, his transfer, or discharge.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50045

Residents Affected - Few Based on record review and staff interviews the facility failed to develop and implement a person-centered care plan for a resident (Resident #346) with a history of suicidal ideation for 1 of 2 residents reviewed for development and implementation of a comprehensive care plan.

The findings included:

Resident #346 was admitted to the facility on [DATE REDACTED] with diagnoses which included bipolar, anxiety, post-traumatic stress disorder, and major depressive disorder.

A review of a facility referral dated 6/28/2023 revealed Resident #346 would be discharged from the hospital

after being admitted with aggression, depressed mood, and suicidal ideation.

A review of an admission MDS dated [DATE REDACTED] revealed Resident #346 was cognitively intact and was coded as feeling down, depressed, and hopeless, had trouble falling asleep, felt tired/little energy, poor appetite, felt bad about self, had trouble concentrating, and had thoughts he would be better off dead. Resident #346 was coded as having physical behavioral symptoms directed towards others (1 to 3 days), verbal behavior symptoms directed towards others (1 to 3 days), and other behavioral symptoms not directed towards others (1 to 3 days). The behaviors were coded as putting Resident #346 at significant risk for physical illness or injury, interfering with Resident #346's care, and interfering with Resident #346's participation in activities and social interactions. Resident #346 was coded as placing others at risk of physical injury.

A review of a care plan dated 7/6/2023 revealed Resident #346 had not been care planned for a history of suicidal ideation.

A review of a nursing note dated 7/8/2023 at 9:29 pm written by Nurse #8 revealed Resident #346 rang his call bell. When the staff arrived at Resident #346's room, he had cut himself with a soda can and cut himself

on the top area of his right leg. Resident #346 then stated, I am suicidal, and I want to go to the hospital. Resident #346 was sent to the hospital for suicidal ideation and had not returned to the facility.

An interview was conducted on 6/6/2024 at 9:00 am with the MDS Nurse. The MDS Nurse reported SW went through hospital documentation on admission and would identify if a resident had a history of suicidal ideation. The MDS Nurse reported that suicidal ideation should be care planned. The MDS Nurse was not sure why Resident #346 had not been care planned for suicidal ideation and agreed that he should have been.

An interview was conducted on 6/6/2024 at 12:09 pm with SW #1. SW #1 stated she reviewed hospital documentation when a resident was admitted . SW #1 reported she had not noticed

Resident #346 had been hospitalized for suicidal ideation. SW #1 verified Resident #346 had not been care planned for suicidal ideation and agreed that he should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 An interview was conducted on 6/7/2024 at 8:45 am with the Director of Nursing (DON). The DON stated if a resident had a history of suicidal ideation, it should be care planned. The DON reported that section of the Level of Harm - Minimal harm or care plan should be completed by the MDS Nurse or SW. The DON was not aware Resident #346 had not potential for actual harm been care planned for suicidal ideation and agreed that he should have been.

Residents Affected - Few An interview was conducted on 6/7/2024 at 3:27 pm with the Administrator. The Administrator stated if a resident was admitted to the facility after being hospitalized for suicidal ideation, the resident should have been care planned for suicidal ideation. The Administrator agreed Resident #346 should have been care planned for suicidal ideation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50045 potential for actual harm Based on observations, record review, and staff interviews the facility failed to provide nail care for a Residents Affected - Few dependent resident (Resident #40) and failed to provide a haircut for a dependent resident (Resident #78) for 2 of 10 dependent residents reviewed for activities of daily living (ADL).

The findings included:

1. Resident #40 was admitted to the facility on [DATE REDACTED]. Resident #40 had diagnoses which include dislocation (ball joint comes out of socket) of the left hip and was documented as deaf and mute.

A quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #40 was severely cognitively impaired. Resident #40 was documented as requiring setup or clean-up assistance for eating and was dependent for personal hygiene.

A review of the care plan dated 5/8/2024 revealed Resident #40 required partial to moderate assistance with hygiene.

An observation was conducted on 6/3/2024 at 11:01 am. Resident #40 was observed with quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath.

An observation was conducted on 6/4/2024 at 8:50 am. Resident #40 was observed with quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath.

An observation was conducted on 6/4/2024 at 1:16 pm. Resident #40 was observed with quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath.

An observation was conducted on 6/5/2024 at 2:26 pm. Resident #40 was observed with quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath.

An interview was conducted on 6/5/2024 at 2:48 pm with Nurse Aide (NA) #6. NA #6 reported she was assigned to care for Resident #40 that day, 6/5/2024. NA #6 reported nail care is performed anytime that a resident is noted to have long or dirty nails. NA #6 had verbalized she had been trained on how to cut and clean nails. NA #6 was asked to observe Resident #40's fingernails and agreed that they were long, dirty, and needed to be cut and cleaned. NA #6 stated she would cut and clean Resident #40's fingernails.

A review of a shower sheet dated 6/6/2024 revealed Resident #40 had his nails cleaned and trimmed by NA #8.

An interview with NA #8 was attempted on 6/6/2024, which was unsuccessful.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 An observation was conducted on 6/6/2024 at 9:15 am. Resident #40 was observed with quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath. Level of Harm - Minimal harm or Resident #40 was observed picking up bread with his left hand and putting the bread in his mouth. potential for actual harm

A follow-up interview with NA #6 was attempted on 6/6/2024, which was unsuccessful. Residents Affected - Few

An interview was conducted on 6/6/2024 at 12:26 pm with the Unit Manager (UM). The UM reported she had educated NA's regarding nail care, which included cutting and cleaning fingernails. The UM stated she made daily rounds on long-term care residents and reminded NAs to complete ADL tasks. The UM reported she monitored nail care and if she noticed long and/or dirty fingernails on a resident, she would bring it to the attention of their NA. The UM had not noticed Resident #40 had long, dirty fingernails.

An interview was conducted on 6/7/2024 at 9:10 am with NA #7. NA #7 reported residents received nail care

on shower days and on an as needed basis. NA #7 reported she has been trained to clean and cut fingernails but had noticed Resident #40's fingernails were long and dirty when she came on to shift, 6/7/2024, at 7:00 am. NA #7 stated she had noticed if she had not cut and cleaned resident's fingernails it was not getting done. NA #7 was asked to observe Resident #40's fingernails are agreed his fingernails were long, dirty, and needed to be cut and cleaned. NA #7 reported she would cut and clean Resident #40's fingernails before she left her shift.

An observation was conducted on 6/7/2024 at 2:41 pm. Resident #40 was observed to have had all 10 fingernails, on both his left and right hands, cut and cleaned.

An interview was conducted on 6/7/2024 at 9:05 am with the Director of Nursing (DON). The DON reported nail care should be completed on shower days and as needed. The DON reported the UM was new and was supposed to monitor nail care. The DON was not aware Resident #40 had long, dirty nails.

An interview was conducted on 6/7/2024 at 3:21 pm with the Administrator. The Administrator reported he would refer to the DON and indicated that there were designated staff to monitor nail care. The Administrator was not aware Resident #40 had long, dirty nails.

35789

2. Resident #78 was admitted to the facility on [DATE REDACTED] with diagnoses that included chronic obstructive pulmonary disease, diabetes, chronic pain, and others.

The quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed that Resident #78 was cognitively intact and required set up or clean up assistance with personal hygiene. No behaviors or rejection of care were noted.

Review of a care plan revised on 05/16/24 read, Resident #78 had an activity of daily living self-care performance deficit related to decrease mobility, rheumatoid arthritis, and weakness. The interventions included: the resident requires up to extensive assistance of 1-2 person with personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 An interview and observation were made with Resident #78 on 06/03/24 at 1:38 PM. Resident #78 was sitting beside her bed in her wheelchair, she was dressed in jeans and T-shirt and was well groomed. Her Level of Harm - Minimal harm or hair appeared clean, was not oily or greasy, but was long, shaggy and fell into her eyes anytime Resident potential for actual harm #78 moved her head. Resident #78 was observed throughout the interview to push her hair out of her eyes. Resident #78 had a picture of herself from approximately six months ago and her hair was cut short and Residents Affected - Few neatly styled. She stated that she had not had her hair cut since December 2023 and I am in need of a cut. Resident #78 explained that in November 2023 a friend of hers that used to work in the activities department cut her hair, but she no longer worked at the facility and in December 2023 the facility had volunteer that came in and trimmed her hair, but she had not had a haircut or trim since then. Resident #78 stated that she had told the Nurse Supervisor, Human Resources, and the Administrator that she was in need a haircut.

An observation of Resident #78 was made on 06/04/24 at 3:24 PM. Resident #78 was up in her wheelchair at bedside and was reading a book. Her hair remained long and shaggy and would fall into her eyes while reading and she would have to sweep it to one side so she could see the book she was reading.

An interview was conducted with Social Worker (SW) #1 on 06/04/24 at 2:01 PM. She stated the facility had not had a beautician since at least August 2023. She explained that they had someone who briefly volunteered to come and cut hair but that was short lived, and she could not recall when that was. SW #1 was not sure how the facility would handle if a resident needed or requested a haircut. She added she was unaware that Resident #78 wanted a haircut.

An observation of Resident #78 was made on 06/05/24 at 2:17 PM. Resident #78 was in the main dining room playing Bingo. Her hair remained long and shaggy and kept falling into her eyes while looking down at her bingo card. She was observed to keep sweeping her hair out of her eyes so she could see her Bingo card.

An interview was conducted with Medication Aide (MA) #3 and Nurse #14 on 06/06/24 at 10:48 AM, both stated that the facility did not have anyone to cut hair at this time. Both stated that they used to have someone who came around and cut hair but that was a while ago, but they could not recall how long ago.

Nurse #11 was interviewed on 06/06/24 at 10:50 AM. Nurse #11 stated she was not aware who would cut a resident's hair if they needed it or requested it. She added she did not think the facility had anyone that could cut hair at this time.

An interview was conducted with the Nurse Supervisor on 06/06/24 at 12:22 PM who stated that she had worked at the facility since April 2024 and before becoming the Nurse Supervisor she was a floor nurse. The Nurse Supervisor stated that when she was temporarily setting up her office in the beauty salon while the facility was under construction, she stated that Resident #78 had inquired if she was the beautician because

she needed their services. She added that the facility currently had no one to cut hair but management was interviewing for the position. The Nurse Supervisor stated, I have not been shared the information on what to do if someone needs a haircut. She stated from time to time a family member would come in and cut their loved one's hair and of course if a resident had an appointment to get their haircut they would transport them to the appointment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 An interview was conducted with Human Resources on 06/06/24 at 2:22 PM. She stated that Resident #78 had not mentioned to her that she needed a haircut that she could recall and was unaware what the plan Level of Harm - Minimal harm or was if a resident needed a haircut, she would have to ask the Director of Nursing (DON). potential for actual harm

The DON was interviewed on 06/06/24 at 11:11 AM. The DON stated that the facility currently did not have a Residents Affected - Few beautician, however some families would come in and cut their loved one's hair. The DON stated there had been lots of residents over the last year and half that had requested a haircut, but they just did not have anyone that could do it. She explained that the facility was running ads online to hire someone that could cut hair at the facility but added they had not had anyone since January 2023 when she came to the facility. The DON added that the activities department had a volunteer that came in one time, but they have not had anyone since then and she could not recall when that was. The DON stated, Resident #78 was mobile so

they could get her on the facility van and get her a haircut that would be no problem.

The Administrator was interviewed on 06/06/24 at 4:10 PM who stated Resident #78 had not mentioned to him that she needed a haircut, and she had no problem expressing herself. He stated, we can get her a haircut no problem. The Administrator stated he had been at the facility for a few months and had been trying to hire someone, but it was difficult with the amount that they get for a haircut from Medicare/Medicaid. He stated that he had reached out to his corporation about possibly supplementing the rate. In addition, Human Resources had been in contact with the beautician from another facility that was familiar with the Medicare/Medicaid rate, and we were going to assist with buying her supplies, so he was hopeful that would work out.

An observation and interview were conducted with Resident #78 on 06/07/24 at 3:05 PM. She was ambulating up the hallway with her walker, she kept sweeping her hair out of her eyes. She explained that

the staff had come to take her to get a haircut and she asked how it was going to be paid for and no one could answer her. She stated that her insurance paid for a haircut every month so it should come out of her benefit money and since she had not used the benefit since last November, she wanted to make sure that

the haircut would be paid for. She added she did not have the money to pay out of pocket but was waiting on someone to verify that her insurance benefit would cover it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50045 jeopardy to resident health or safety Based on record review, and Resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews

the facility failed to perform a comprehensive assessment including vital signs before moving a resident off Residents Affected - Few the floor after a fall with injury and failed to seek immediate medical treatment or higher level of care. On 5/27/2024 at 10:40 pm Nurse #1, Nurse #2, Nurse #3, Nurse Aide (NA) #1, and NA #2 responded to Resident #40's room after they heard Resident #44 yell that Resident #40 was on the floor. Resident #40 was found face down on the floor. Nurse #1 and Nurse #2 rolled Resident #40 over, transferred Resident #40 by picking him up under his arms while NA #1 held traction to Resident #40's left leg. When Resident #40 was placed back in bed, Nurse #3 assessed Resident #40 and obtained vital signs at which time she noticed Resident #40's left leg was internally rotated and shorter than the right leg. Nurse #3 immediately summoned Emergency Medical Services (EMS) but after review of his chart and speaking to the Director of Nursing (DON), she was instructed to cancel EMS because Resident #40 had an advance directive that indicated Do Not Hospitalize unless his comfort needs could not be met at the facility. An x-ray was performed on 5/28/2024 which revealed Resident #40 had sustained an acute fracture of the proximal left femur (thigh bone). Resident #40 was transferred to the hospital on 5/28/2024 where he was admitted for further evaluation and pain management. The facility also failed to follow up with a provider about an abnormal radiology report, failed to obtain ordered laboratory testing, failed to ensure the necessary diagnostics were completed for a resident (Resident #196) that had confusion reported by the RP on 12/24/2023, and failed to immediately initiate Emergency Medical Services (EMS) when Resident #196 was only responsive to painful stimuli. Resident #196 was transferred to the hospital on 12/26/2023 at 2:04 pm and was admitted for respiratory failure and placed on Bilevel Positive Airway Pressure (BiPAP, non-invasive ventilator). The deficient practice occurred for 2 of 3 residents reviewed for change of condition (Resident #40 and Resident #196).

Immediate jeopardy began on 5/27/2024 when nursing staff failed to assess or obtain vital signs prior to moving Resident #40 after finding him face down on the floor and failed to follow through with emergency medical services for a resident with obvious signs of injury. Immediate jeopardy was removed on 6/12/2024 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 G (actual harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective.

Example #2 is being cited at a lower scope and severity of a G.

The findings included:

Resident #40 was admitted to the facility on [DATE REDACTED]. His recent diagnosis as of January 2024 included dislocation of the internal left hip and was deaf and mute.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of a Medical Order for Scope of Treatment dated 7/13/2023 completed by PA #1 revealed Resident #40 did not want to be resuscitated if he had no pulse and was not breathing. The MOST form stated Level of Harm - Immediate Resident #40 wanted comfort measures to include keep clean, warm dry. Use medication by any route, jeopardy to resident health or positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual safety treatment of airway obstruction as needed for comfort. Resident #40 was not to be transferred to the hospital unless comfort needs could not be met in the facility. Residents Affected - Few

A quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #40 was severely cognitively impaired. Resident #40 was coded as no impairment of his upper extremities, impairment on one side of his lower extremities. Resident #40 was coded as maximum assist for chair/bed to chair transfers. Resident #40 was coded as requiring substantial/maximal assistance with bed mobility, sitting to standing, lying to sitting, was not ambulatory, and used a wheelchair.

A review of the care plan dated 5/8/2024 revealed Resident #40 required partial to moderate assistance with transfers.

An interview was conducted on 6/3/2024 at 10:59 with Resident #44. Resident #44 reported Resident #40 had fallen approximately one week ago. Resident #44 reported he had returned to his room at night after going outside and found Resident #44 lying face down on the floor. Resident #44 stated he yelled for help and multiple staff members arrived. Resident #44 stated he told nursing staff in the room not to move Resident #40 until EMS could assess him because he was afraid Resident #40's leg was broken. Resident #44 stated Resident #40 was sent to the Emergency Department the next day and was found to have a broken leg.

An interview was conducted on 6/4/2024 at 4:51 pm with Nurse #1. Nurse #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 on 400 hall and was passing medications when she heard Resident #44 yell that Resident #40 was on the floor. Nurse #1 stated she, NA #1, and NA #2 ran into Resident #40's room. Nurse #1 stated Resident #40 was found lying on his left side in a fetal position and appeared to have his left hand under his left hip. Nurse #1 reported that Nurse #2 arrived in the room, and they all rolled Resident #40 over. Nurse #1 reported she thought that something was wrong with his left hip. Nurse #1 reported she thought Resident #40 had recently had hip surgery and wanted to get him off the hard floor, which is why she had not assessed him and obtained vital signs prior to transferring Resident #40 into bed. Nurse #1 reported that she, in addition to Nurse #2, NA #1, and NA #2 picked Resident #40 off the floor and placed him in bed and recalled his left leg as looking like a limp noodle.

An attempt to speak to Nurse #2 was made on 6/4/2024 and was unsuccessful.

An interview was conducted on 6/4/2024 at 7:26 pm with NA #2. NA #2 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned to the 400-hall. NA #2 reported she heard Resident #44 yell that Resident #40 was on the floor. NA #2 reported when she arrived in the room, Resident #40 was lying next to the wheelchair and appeared to have his right leg under the wheelchair. She reported Resident #40 was on his left side in a fetal position. NA #2 reported Resident #40's leg was moved when they rolled him onto his back. NA #2 stated that she had assisted Nurse #1, Nurse #2, and NA #1 as they transferred Resident #40 to the bed by helping lift under his arms. NA #2 stated she was not able to recall Nurse #1, Nurse #2, or Nurse #3 assessing Resident #40 until Resident #40 was in the bed. NA #2 stated she observed Resident #40's leg to not look right and appeared to be disfigured. NA #2 reported someone obtained vital signs after Resident #40 was placed back in the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 An interview was conducted on 6/4/2024 at 7:57 pm with NA #1. NA #1 reported she worked night shift (7:00 pm to 7:00 am) on 5/27/2024 and was assigned 200 and 400 halls. NA #1 reported she was in the hall when Level of Harm - Immediate she heard Resident #44 yell that Resident #40 was on the floor. NA #1 stated when she arrived at the room, jeopardy to resident health or Resident #40 was laying on his left side and appeared to have his right leg tangled in the wheelchair. NA #1 safety reported Resident #40's leg was moved from under the wheelchair when they rolled him over in the floor. NA #1 stated Nurse #1 thought Resident #40's leg was broken, and stated Resident #40 needed to be placed in Residents Affected - Few the bed. NA #1 reported she held traction to Resident #40's left leg and kept it straight while the Nurse #1, Nurse #2, and NA #2 picked Resident #40 up using his arms. NA #1 reported traction was the pull and hold

the leg in a neutral position. NA #1 reported she had been an Emergency Medical Technician (EMT) in the past, but that she did not function as one at the facility.

A review of an incident report dated 5/27/2024 at 10:40 pm completed by Nurse #3 revealed Resident #40 was found lying face down on the floor beside the bed. An assessment revealed Resident #40 had internal rotation and shortening of the left leg, a small head laceration to the top of the scalp, and a small laceration to the left outer ankle.

An interview was conducted on 6/4/2024 at 12:38 pm with Nurse #3. Nurse #3 reported she was passing medications on 300-hall when NA #1 and NA #2 came to tell her that Resident #40 was lying on the floor by

the bed. Nurse #3 reported that when she arrived in Resident #40's room, Nurse #1, Nurse #2, NA #1, and NA #2 were transferring Resident #40 into bed. Nurse #3 stated after Resident #40 was in the bed she performed an assessment by asking him if he was okay and got his vital signs. Nurse #3 reported she observed his left leg internally rotated and shorter than his right leg. Nurse #3 stated she instructed another staff member to call 911 and began to print out his paperwork at which time she noticed Resident #40 had a Do not hospitalize order in his Electronic Medical Record (EMR). Nurse #3 reported she immediately called

the Director of Nursing (DON) and was instructed by the DON to cancel Emergency Medical Services (EMS) and contact the on-call provider because the family would not want Resident #40 to be sent to the hospital. Nurse #3 stated she cancelled EMS and contacted the on-call provider, PA #2, that Resident #40 had internal rotation and shortening of his left leg, at which time PA #2 ordered Ibuprofen 600 milligrams (mg) one time for pain and was instructed to perform neurological checks every four hours. Nurse #3 stated if she had gotten to the room prior to Nurse #1, Nurse #2, NA #1, and NA #2 transferring Resident #40 to bed, she would have instructed them not to move him until she had assessed him and obtained vital signs.

A physician's order dated 5/27/2024 at 10:54 pm for Resident #40 revealed an order for an x-ray of the left hip and pelvis written by the MD. The order was entered by Nurse #3 after she called to report Resident #40's left leg was internally rotated and shorter than his right leg.

The pain documentation, on the MAR, from 5/27/2024 through 5/28/2024 revealed Resident #40 experienced pain 6 out of 10 during day shift on 5/28/2024 with no time noted and 8 out of 10 on 5/28/2024 at 12:19 pm prior to being transferred to the hospital.

A radiology report dated 5/28/2024 at 9:37 am revealed Resident #40 had a dislocation of a left hip arthroplasty (a surgery to restore the hip joint) and an acute fracture of the proximal (close to the hip) left femur noted as new since 1/12/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:00 pm, as scheduled (6:00 am, 12:00 pm, 6:00 pm, 12:00 am), and documented a pain assessment of 8 Level of Harm - Immediate out of 10 for Resident #40. jeopardy to resident health or safety The physician's orders dated 5/28/2024 at 12:15 pm written by PA #1 revealed Resident #40 was to give another dose oxycodone-acetaminophen 5-325 mg tablet, one time only, for increased pain. Residents Affected - Few Nurse #10 documented that she administered oxycodone-acetaminophen 5-325 mg tablet on 5/28/2024 at 12:19 pm, one time, and documented a pain assessment of 8 out of 10 for Resident #40.

A review of a PA #1's progress noted dated 5/28/2024 revealed Resident #40 was seen after he fell from bed

during the night (5/27/2024). Resident #40 had complained of pain. An x-ray was obtained that revealed a fracture of the left femur with lateral displacement. The PA spoke with the Resident Representative (RR) who agreed to have Resident #40 sent to the hospital for evaluation and possible reduction.

On 5/28/2024 at 1:15 pm, PA #1 ordered Resident #40 to be transferred to the hospital.

An interview was conducted on 6/4/2024 at 3:19 pm with PA #1. PA #1 reported she was made aware of Resident #40's fall the following day, 5/28/2024 when she arrived at the facility. PA #1 stated she was very familiar with Resident #40 and could tell on 5/28/2024 he was in a lot of pain and was grimacing. PA #1 reported she ordered an additional pain pill to be administered, and ultimately sent him to the hospital for further evaluation. The PA stated Resident #40's leg did not appear to be in the neutral position it should be in. The PA stated she ordered an x-ray on 5/28/2024 which revealed an old dislocation and a new fracture.

The PA reported she was not aware staff had transferred Resident #40 back to bed prior to assessing him and obtaining vital signs. The PA stated that if Resident #40's leg was stabilized she could not see a problem with moving him prior to performing an assessment and obtaining vital signs. The PA reported that the facility staff always do things the way they are supposed to and follow protocol. The PA was unsure of what the facility's protocol was for assessing a resident after a fall. The PA reported after she received the x-ray results, she contacted the family, and sent Resident #40 to the Emergency Department for further evaluation. PA #1 verified she had received the x-ray results on 5/28/2024 at 9:37 am but had difficulty reaching Resident #40's RR to get permission to transfer him to the hospital, which caused a delay in his transfer to

the hospital. PA #1 reported she was not an expert in orthopedics and was not familiar with traction.

The Emergency Medical Services (EMS) report dated 5/28/2024 at 1:43 pm revealed Resident #40 had pointed to his left leg, and made a grimacing face as if to say that it hurt and there was obvious deformity noted in the left hip with inward rotation.

Review of ED department evaluation on 5/28/24 Resident #40 presented to the Emergency department after

he fell to the ground while transferring from his bed on 5/27/2024. Documentation revealed Resident #40 was complaining of pain and appeared to be less ambulatory. Resident #40 had an x-ray of his left hip and pelvis that demonstrated left hip arthroplasty with an associated fracture dislocation. Resident #40 was admitted to the facility for further evaluation and pain management medications were adjusted (he was administered hydrocodone-acetaminophen 5-325 mg every 6 hours) and his oxycodone was continued. Resident #40 was recommended nonsurgical interventions, he was not a surgical candidate, and was to follow up in two weeks with outpatient orthopedics. Resident #40 was discharged back to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A review of the June 2024 MAR revealed Resident #40 had received oxycodone-acetaminophen 5-325 mg

on 6/4/2024 at 12:00 pm, as scheduled. Level of Harm - Immediate jeopardy to resident health or An observation and interview were conducted on 6/4/2024 at 1:16 pm. Resident #40 was lying in bed turned safety on his right size and pointed to his left upper outer thigh area, made a grimacing face and a squeezing motion with his hands. Resident #40 nodded yes that he had pain and mouthed the pain medication only Residents Affected - Few helped a little.

An interview was conducted on 6/5/2024 at 8:41 am with the Director of Nursing (DON). The DON reported

she was aware of Resident #40's fall on 5/27/2024. The DON reported she was not aware Nurse #1, Nurse #2, and Nurse #3 failed to assess Resident #40 and obtain vital signs prior to transferring him to bed. The DON stated she expected staff to assess the resident for physical injury/deformity, pain, mental status changes, and obtain vital signs prior to moving a resident after a fall. The DON acknowledged staff could have caused additional harm to the resident if they were not assessed prior to being moved after a fall. The DON stated a Nurse should have assessed Resident #40 prior to transferring him back to bed. She further stated the facility had not investigated the incident because they knew he had fallen. The DON stated Nurse #3 should have contacted the family about Resident #40's condition and to get permission to send Resident #40 to the hospital on the night of the fall, 5/27/2024. The DON reported there was confusion because his advanced directives said to Do Not Hospitalize, so she advised staff to get RP permission. Nurse #3 was sending the resident out and the DON stopped her.

An interview was conducted on 6/5/2024 at 3:09 pm with the MD. The MD reported she had been made aware on 5/28/2024 of Resident #40's fall on 5/27/2024 by PA #1. The MD stated PA #1 had Resident #40 sent to the hospital for evaluation because she was concerned how his leg looked. The MD was not aware Resident #40 had been transferred to the bed prior to being assessed or having vital signs obtained. The MD stated the Nurse should have performed a quick assessment to ensure Resident #40 was breathing and had no obvious deformity prior to moving him. The MD stated if there was obvious deformity staff could cause additional harm to the resident.

An interview was conducted on 6/7/2024 at 3:23 pm with the Administrator. The Administrator reported he knew Resident #40 fell on [DATE REDACTED] but had not been made aware Resident #40 had not been assessed prior to transfer back to his bed. The Administrator agreed Resident #40 should have been assessed prior to moving him from the floor to the bed.

The Administrator was made aware of Immediate Jeopardy on 6/5/2024 at 11:35 am.

The facility provided the following credible allegation of immediate jeopardy removal:

o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The facility failed to thoroughly assess resident #40 on 5/27/24 at 10:40 pm after he fell from his wheelchair to the floor on his left side face down. Resident #40 was discovered by his roommate who summoned Level of Harm - Immediate assistance from staff. Nurse #1, Nurse #2, NA #1, and NA #2 lifted resident #40 under his arms and held jeopardy to resident health or traction to Resident #40's left leg and picked him up from the floor and placed him in the bed. Nurse #3 safety completely assessed Resident #40 and observed that the left leg was internally rotated and shortened. Nurse #1 described left leg as a limp noodle. Nurse #3 immediately summoned Emergency Medical Services Residents Affected - Few (EMS) but after speaking to the Director of Nursing (DON) Nurse #3 cancelled EMS even though Resident #40 had obvious deformity that warranted a higher level of care to manage the resident's comfort needs which could not be met in the facility. On 5/28/24, Resident #40 was further assessed by the provider and sent to the emergency room .

The facility failed to identify the resident's obvious injury status post fall requiring a higher level of care.

Starting 6/6/24, the Director of Nursing (DON) will review falls within the last 30 days to ensure residents were assessed by licensed nurses identifying obvious injuries prior to being moved to determine if the resident required a higher level of care.

All the current residents with falls are at risk as a result of this deficient practice.

o 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 6/10/24, the Chief Nursing Officer will educate the DON on directing the staff that call regarding falls with injury to the MOST forms and when to notify family and/or EMS.

Starting 6/5/24, the Director of Nursing will educate licensed nurses on assessing resident status post falls, to include vital signs, neuro checks, range of motion, skin assessment and pain assessment, prior to being moved. Residents assessed with obvious injuries will be transferred to a higher level of care warranted by their MOST form. The Director of Nursing and clinical team will review falls daily, in clinical meetings, to ensure assessments were completed and if indicated, resident receive a higher level of care. The MOST forms will be reviewed/updated weekly and/or changes in condition by the Social Workers and kept in a binder at both nursing stations. Residents without a MOST form, Staff will notify Resident/Resident's responsible party, along with the provider, on assessment findings and guidance to determine if a higher level of care and services are warranted.

Starting 6/5/24, the Director of Nursing and the SDC will educate the licensed nurses to review resident MOST forms before calling Emergency Medical Services and if obvious deformity to include indications of fracture are observed residents should be immediately transferred to a higher level of care because resident's comfort needs cannot be met at the facility.

Starting 6/5/24, the Director of Nursing and the Staff Development Coordinator will educate all staff to include

the certified nursing assistants (CNA), certified medication assistants (CMA), licensed nurses, therapy staff, housekeeping/ laundry staff, dietary staff, social services, administrative staff, weekend staff, agency and prn staff on ensuring that residents that experience falls are not moved prior to an assessment by a licensed nurse and reporting any changes from baseline immediately to the nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Starting 6/5/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides Level of Harm - Immediate (CMA), dietary staff, social services, housekeeping/laundry staff, therapy staff, maintenance staff, jeopardy to resident health or administrative staff, weekend staff, agency staff and prn staff receive the education. Staff including new hires safety and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the education is completed. Residents Affected - Few Effective 6/5/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Alleged Date of IJ Removal: 6/12/24

A validation of immediate jeopardy removal was conducted on 06/13/24. The inital audit of falls within the last 30 days was reviewed with no issues noted and no residents that required a higher level of care identified. Nursing staff were able verbalize that they had recieved the education that after a fall, no resident was to be moved until assessed for injury by the licensed nurse. Licensed nurses were able to verbalize the steps to assessment including range of motion, vital signs, and neurological checks. They verbalized that if there was obvious injury that would be indicative of a fracture they were to check the MOST from, consult with the residents medial provider, as well as the residents responsible party for direction and the potential need to transfer to the acute care setting. The nursing staff were aware that the MOST forms were kept in a binder at each nursing station. Non nursing staff were able to verbalize that they had recieved education on not moving or touching a resident that had fallen but to immediately alert the licensed nurse. The education was verified to be a part of the new hire orientation packet. The immediate jeopardy removal date of 06/12/24 was validated.

2. Resident #196 was admitted to the facility on [DATE REDACTED] with a diagnosis of respiratory failure (condition that makes it difficult to breath independently).

A review of a care plan dated 12/18/2023 which revealed Resident #196 had an altered respiratory status and difficulty breathing related to respiratory failure with interventions which included monitoring for signs and symptoms of respiratory distress, increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy (lack of energy), confusion, hemoptysis (bloody sputum), cough, pleuritic pain (chest wall pain), accessory muscle usage, and skin color changes.

A review of the 5-day Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #196 was severely cognitively impaired with no behaviors.

Review of a physician order dated 12/25/2023 read; Obtain chest-ray related to increased confusion per family members observation.

A review of a radiology report for a 2-view (from the front and from the side of the body) chest x-ray dated 12/25/2024 at 2:16 pm revealed Resident #196 had left lower airspace disease related to either pneumonia or atelectasis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A review of the December 2023 progress notes revealed no progress note indicating a provider was made aware of the abnormal chest x-ray. Level of Harm - Immediate jeopardy to resident health or Review of a physician order dated 12/25/23 read; Complete Blood Count (CBC) and Basic Metabolic Panel safety (BMP) related to increased confusion per family members observation.

Residents Affected - Few A review of the December 2023 progress notes revealed no progress note indicating a provider was made aware of laboratory results or the inability to obtain laboratory results.

A review of the Resident #196's December 2023 Medication Administration Record (MAR) indicated Nurse #6 had collected a CBC and BMP on 12/25/2023 at 1:24 am.

A review of Resident #196's vital signs collected on 12/26/2023 at 10:15 am revealed a blood pressure of 147/96, heart rate of 98, a respiration rate of 16 breaths per minute, an oxygen saturation of 92%, and a temperature of 97.6 degrees Fahrenheit.

A review of a nursing assessment dated [DATE REDACTED] at 11:23 am revealed Resident #196 was confused, had crackles/rales (wet sounds), and pitting edema (swelling).

A review of Resident #196's vital signs collected on 12/26/2023 at 1:24 pm revealed a blood pressure of 168/89, heart rate of 102, a respiration rate of 16 breaths per minute, no oxygen saturation was obtained, and a temperature of 98.8 degrees Fahrenheit.

A review of a nursing note dated 12/26/2023 at 1:47 pm written by Nurse #5 which revealed the MD had been contacted regarding a change in Resident #196's condition and was advised to transfer Resident #196 to the hospital.

A review of a nursing note dated 12/26/2023 at 2:03 pm written by Nurse #5 revealed Resident #40 had been transferred to the hospital with Emergency Medical Services.

A review of the EMS record dated 12/26/2023 at 2:09 pm revealed Resident #196 was diagnosed with pneumonia via a chest s-ray and staff reported Resident #196 had been lethargic and not acting normally. Nursing staff reported the facility physician requested Resident #196 to be sent to the hospital. EMS documented vital signs which read; heart rate of 104, blood pressure 123/77, and an oxygen saturation of 93% on 3 liters of oxygen per minute.

A review of the Emergency Department documentation dated 12/26/2023 revealed Resident #196 had presented with altered mental status and shortness of breath. Resident #196 was admitted to the intensive care unit with acute hypoxemic respiratory failure (decreased oxygen saturation without increased carbon dioxide) and sepsis (severe infection). Resident #196 had an oxygen saturation of 83% on 6 liters of oxygen per minute on arrival to the Emergency Department and was placed on the BiPAP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #6. Nurse #6 reported she worked on 12/24/2023 during the night shift (7:00 pm to 7:00 am) and was assigned Resident #196. Nurse #6 stated Level of Harm - Immediate after she had started her shift, Resident #196's Representative (RR) reported Resident #196 had acted more jeopardy to resident health or confused. Nurse #6 stated she called the provider on-call and was given orders to obtain laboratory testing safety and a chest x-ray. Nurse #6 reported she had not obtained laboratory testing that night because she never drew blood at night and was not able to draw blood. Nurse #6 was not able to recall documenting that she Residents Affected - Few had collected Resident #196's labs, and was not sure why it was documented that she had on the MAR.

An interview was conducted on 6/4/2024 at 4:07 pm with PA #2. PA #2 reported she was notified by Nurse #6 on 12/24/2023 that Resident #196 was confused and had a cough. PA #2 reported she ordered laboratory testing and a chest x-ray. PA #2 stated she was never called about the results of the laboratory testing or chest x-ray. PA #2 reported she was not on-call 12/25/2024, and that the on-call provider that day should have been notified.

An interview was conducted on 6/4/2024 at 10:23 am with Nurse #5. Nurse #5 stated she worked 12/26/2024 and was assigned Resident #196. Nurse #5 stated she recalled Resident #196 had a chest x-ray performed that day, but she had not seen the results. Nurse #5 stated radiology reports would come over the fax machine and a Nurse or the Director of Nursing (DON) would contact the provider on call. Nurse #5 stated

she had not notified the on-call provider because she had not received the radiology report and indicated if

she had received it, she would have called the provider on call. Nurse #5 reported she had not called to check the results of the chest x-ray. Nurse #5 reported she had not collected laboratory testing on Resident #196 because she was not prompted to do so on the computer system used in the facility. Nurse #5 stated

she thought the labs had been completed since Nurse #6 had checked the collection off on the MAR. Nurse #5 stated when she arrived on shift 12/26/2023, she had given medications to Resident #196 and noticed he was confused but was responsive and answering questions. Nurse #5 reported she had checked on him hourly. Nurse #5 stated around lunchtime (11:30 am) she noticed Resident #196 had pitting edema (swelling), crackles (wet lung sounds), and was only responsive to painful stimuli. Nurse #5 stated Resident #196 continued to wear oxygen at 3 liters per minute. Nurse #5 reported she notified the physician, at the time documented in the Electronic Health Record (EHR), 1:47 pm and received an order to send Resident #196 to the Emergency Department. Nurse #5 was unsure why there was an approximately 2-hour delay in her notification to the MD and she obtained one set of vital signs prior to transfer and was unable to recall if

she obtained an oxygen saturation or not. Nurse #5 reported she transferred Resident #196 to the Emergency Department via Emergency Medical Services (EMS) at 2:04 pm.

An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #7. Nurse #7 stated she worked on 12/25/2024 on night shift (7:00 pm to 7:00 am). Nurse #7 was assigned Resident #196 and was not able to recall receiving chest x-ray results during her shift and had not called to check on them. Nurse #7 stated if

she received it she would called the on call provider with the results. Nurse #7 stated she would assume dayshift had notified the provider since it had resulted during dayshift. Nurse #7 reported she drew blood at night if it was ordered but was not able to recall Resident #196.

An interview was conducted on 6/5/2024 at 3:32 pm with the MD. The MD reported she had been contacted by Nurse #5 on 12/26/2023 at 1:47 pm that Resident #196 had a change in condition and was less responsive. The MD stated Nurse #5 had not informed her Resident #196 was only responsive to painful stimuli at 11:23 am on 12/26/2023. The MD stated she would expect Nurses to notify the MD as soon as possible with mental status changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 An interview was conducted on 6/7/2024 at 8:37 am with the Director of Nursing (DON). The DON stated abnormal radiology results were faxed to the facility. The DON stated Nurses checked the fax machine Level of Harm - Immediate routinely for results and were to notify the on-call provider of any results. The DON also reported she jeopardy to resident health or obtained results from labs and radiology every morning and notified the provider as well. The DON confirmed safety there was no indication in Resident #196's medical record that the on-call provider had been notified of the x-ray or that nursing staff had called to check on the results of the chest x-ray. The DON stated she assumed Residents Affected - Few it was because the report was not marked as alert which would usually indicated to staff the provider should be contacted. The DON reported laboratory tests were to be drawn and sent out. She stated the facility utilized an outside phlebotomist, but that Nurses could draw labs and use the courier until a certain time. The DON stated after the courier hours were over, if the resident had l [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50045

Residents Affected - Few Based on record reviews and staff and Resident interviews, the facility failed to ensure physical therapy had established a safe means for nursing to transfer a resident prior to a resident (Resident #346) falling. The facility also failed to complete quarterly safe smoking assessments on a resident (Resident #62) for 2 of 7 reviewed for accidents.

The findings included:

1. Resident #346 was admitted to the facility on [DATE REDACTED] with diagnoses which included anxiety, post-traumatic stress disorder, and major depressive disorder.

Review of a physical therapy (PT) evaluation dated 6/30/2023 written by PT #1 revealed Resident #346 was dependent for chair/bed-to chair transfers.

Review of a PT treatment noted dated 7/6/2023 written by PT #2 revealed Resident #346 had been assisted by PT with a transfer from the wheelchair to the shower chair using the slide board, at which time he required maximum assistance with set-up and transfer.

A review of an admission Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #346 was cognitively intact. Documentation revealed Resident #346 was coded as having physical behavioral symptoms directed towards others, verbal behavior symptoms directed towards others, and other behavioral symptoms not directed towards others. The behaviors were coded as putting Resident #346 at significant risk for physical illness or injury, interfering with Resident #346's care, and interfering with Resident #346's participation in activities and social interactions. Resident #346 was coded as placing others at risk of physical injury. Resident #346 was coded as dependent for toileting, bathing/showering, substantial/maximal assistance with lower body dressing and putting on/taking off footwear.

Review of a care plan dated 7/6/2023 revealed Resident #346 required extensive assistance of 1 to 2 people for transfers, and Resident #346 had not been care planned for the use of a slide board.

Review of an incident report dated 7/6/2023 at 12:45 pm written by Nurse #13 revealed Resident #346 had fallen off the slide board during a transfer from the bed to the wheelchair while being assisted by NA #9. A head-to-toe assessment was completed, Resident #346 had no complaints of pain and was assisted back to

the wheelchair. PA #1 was notified, and an x-ray was ordered. Therapy was notified to educate resident on foot/body positioning when transferring using a slide board.

Review of a PT treatment note dated 7/7/2023 written by the PT Director revealed Resident #346 had been educated on safe sequencing by having both feet placed flat on the floor.

An interview was conducted on 6/6/2024 at 11:01 am with Nurse #13. Nurse #13 reported she was unable to remember Resident #346, his fall on 7/6/2023, or completing an incident report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An interview was conducted on 6/6/24 at 12:37 am with NA #9. NA #9 reported she had worked on 7/6/2023 and was assigned Resident #346. NA #9 reported she was only able to remember transferring him with a Level of Harm - Minimal harm or slide board and recalled him sliding off the slide board. NA #9 reported Resident #346's feet were not placed potential for actual harm flat on the ground, and she had attempted to que him to flatten his feet but reported Resident #346 kept moving and slid onto the floor. NA #9 reported she had not been trained on how to use a slide board Residents Affected - Few specifically with Resident #346, but had found the slide board in his room, and had been told by an NA in report that Resident #346 used a slide board with transfers.

An interview was conducted on 6/6/2024 at 10:30 am with the PT Director. The PT director was able to recall working with Resident #346. He reported nursing staff were required to be trained on how to use a slide board with each resident specifically prior to using it. The PT Director confirmed nursing staff had not been educated about how to transfer Resident #346 using a slide board because PT staff had not felt like nursing staff could safely transfer him using one because of his impulsive behavior. The PT Director was not sure why a slide board was left at the bedside since the nursing staff had not been cleared to use it with Resident #346. The PT Director felt that nursing should have used a mechanical lift until Resident #346 was proven safe with a slide board.

An interview with PT #1 was attempted on 6/6/2024 and was unsuccessful.

An interview with PT #2 was attempted on 6/6/2024 and was unsuccessful.

An interview was conducted on 6/7/2024 at 8:44 am with the Director of Nursing (DON). The DON reported therapy was required to educate nursing staff and clear a resident to use a slide board prior to nursing staff utilizing one. The DON reported each resident required different techniques for transferring with a slide board and therapy educated nursing staff on how to use one for each resident. The DON was not aware NA #9 had not been educated regarding using a slide board with Resident #346 and reported she should have had education by PT prior to using one.

An interview was conducted on 6/7/2024 at 3:25 pm with the Administrator. The Administrator reported he was not employed at the facility at the time of the incident but was surprised a slide board was left in the room if nursing staff had not been cleared to use it with the resident. The Administrator expected staff to be trained on the use of a slide board.

37280

2. Resident #62 was admitted to the facility on [DATE REDACTED] with diagnoses that included cerebral vascular accident (CVA), hemiplegia and dementia.

A review of Resident #62's medical record revealed the last safe smoking screening dated 03/31/23 revealed

the Resident was able to smoke independently. The screen was completed by SW #1.

A review of Resident #62's annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the Resident's cognition was moderately impaired and he used tobacco.

An interview was conducted with Resident #62 on 06/04/24 at 9:12 AM. The Resident indicated that he smoked independently when he chose to smoke and kept his smoking materials in his locker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During interviews with Social Worker (SW) #1 on 06/04/24 at 4:24 PM and 06/07/24 at 9:11 AM, the SW explained that the safe smoking screenings were completed on admission and quarterly and as changes Level of Harm - Minimal harm or indicated by social services or nursing. The screens automatically popped up under the assessments to be potential for actual harm done. She continued to explain that she assessed the residents while they demonstrated smoking and completed the questionnaire to determine if they were a safe smoker and Resident #62 was determined to Residents Affected - Few be a safe smoker. The SW acknowledged that Resident #62's safe smoking screen was last completed on 03/31/23 by herself and when asked why a safe smoking screen had not been completed since 03/31/23 the SW stated, I do not know how that fell through the cracks.

An interview conducted with the Director of Nursing on 06/07/24 at 10:03 AM revealed the safe smoking screening should be done quarterly along with the MDS assessments and as needed by social services or

the nursing staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35789

Residents Affected - Few Based on observations, record review, resident, and staff interview the facility failed to secure an indwelling catheter to prevent displacement and/or tension for 1 of 1 resident reviewed with a catheter (Resident #39).

The findings included:

Resident #39 was admitted to the facility on [DATE REDACTED] and most recently readmitted on [DATE REDACTED]. Resident #39's diagnosis included retention of urine.

A care plan revised on 01/14/24 read, Resident #39 has an indwelling catheter related to urinary retention and wound. The interventions included: monitor and document intake as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, monitor/document pain/discomfort due to catheter, monitor and report to Medical Doctor for signs and symptoms or urinary tract infection, and provide catheter care every shift.

A quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed that Resident #39 was cognitively intact and had an indwelling catheter during the assessment reference period.

An observation of Resident #39 was made on 06/03/24 at 11:58 AM. Resident #39 was resting in bed. She was noted to have an indwelling catheter and the tubing was not anchored and was resting on the bed under her leg. There was a collection bag hanging from the side of the bed with approximately 200 milliliters (ml) of clear yellow fluid in the bag which was covered with a privacy cover.

An observation of Resident #39 was made on 06/04/24 at 3:21 PM. Resident #39 was resting in bed on her right side. Her indwelling catheter tubing was resting on her left thigh but was not anchored or secured, the collection bag was hanging from the side of the bed and contained a privacy cover.

An observation of Resident #39 was made on 06/05/24 at 2:54 PM. Resident #39 was resting in bed and again her indwelling catheter was not anchored or secured to either leg.

An observation and interview were conducted with Resident #39 on 06/07/24 at 11:32 PM. Resident #39 was resting in bed and her indwelling catheter was not anchored or secured to eighter leg. Her collection bag was hanging from the side of the bed with a privacy cover in place. Resident #39 stated that the facility staff did not normally anchor or secure the tubing to her leg and that sometimes it pulled and tugged and cause her some discomfort. And added if they did come to anchor it or secure it they are going to put it on top of her leg because it hurts when it was placed under her leg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Nurse Aide (NA) #11 was interviewed on 06/07/24 at 11:34 Am. NA #11 confirmed that she was caring for Resident #39 and stated that had not yet provided care to her. She stated that Resident #39 rang her call Level of Harm - Minimal harm or light when she was ready to get cleaned up for the day. NA #11 stated that she cleaned her catheter and potential for actual harm emptied her catheter bag several times throughout her shift. She added that the nurses were responsible for putting the anchor on the residents but if she saw that it was not there would let the nurse know and she Residents Affected - Few would ensure the anchor got put in place. NA #11 was requested to check Resident #39's indwelling catheter and confirmed that it was not anchored to her upper leg and that she would alert the nurse because she had not so yet.

Nurse #17 was interviewed on 06/07/24 at 11:39 AM. She stated that the NAs should be monitoring that each indwelling catheter tubing was anchored and if not make the nurse aware so it can be replaced or put into place. Nurse #17 stated that no one had reported to her that Resident #39 did not have an anchor for her indwelling catheter but stated she would take care of it promptly.

Medication Aide (MA) #1 was interviewed on 06/07/24 at 12:08 PM. MA #1 confirmed that she had been on

the medication cart on Resident #39's unit on 06/03/24, 06/04/24, and 06/07/24 and no one had reported to her that Resident #39 did not have an indwelling catheter anchor. She stated she did nothing with the anchors the nurses would take care of that, however if one of the NAs reported to her that a resident needed one, she would report that information to the nurse.

The Director of Nursing (DON) was interviewed on 06/07/24 at 12:34 PM. She stated that the NAs should clean the catheter twice a day and each indwelling catheter should be anchored or secured to the resident's leg to prevent tension and displacement. The placement of the anchor should be checked every shift by the nursing staff and replaced as needed or if soiled or missing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37280 potential for actual harm Based on observations, record reviews and staff interviews, the facility failed to maintain a medication error Residents Affected - Few rate of less than 5% as evidenced by having 3 medication errors out of 27 opportunities, resulting in a medication error rate of 11.11%. This affected 2 of 7 residents reviewed for medication pass (Resident #99 and Resident #51).

The findings included:

1. Resident #99 was admitted to the facility on [DATE REDACTED] with diagnoses that included exacerbation of chronic obstructive pulmonary disease (COPD) and allergies.

A review of Resident #99's physician orders revealed an order with the start date of 06/02/24 for Prednisone (a steroid) 10 milligrams (mg) give 3 tablets by mouth once a day for 3 days for pneumonia and Tiotropium bromide (a bronchodilator) 2.5 MCG/ACT aerosol inhalation solution inhale 2 puffs orally once a day for exacerbation of COPD.

On 06/04/24 at 9:44 AM Medication Aide (MA) #2 was observed as she prepared to medicate Resident #99.

The MA administered 7 medications to the Resident which included one Prednisone 10 mg tablet and did not include the Tiotropium bromide inhaler.

An interview was conducted with MA #2 on 06/04/24 at 2:35 PM. The MA explained that she thought she gave Resident #99 three Prednisone tablets and the reason she did not give her the inhaler was because

she thought the Resident had the inhaler at her bedside and could medicate herself. There was no Tiotropium bromide inhaler in the Resident's room.

2. Resident #51 was admitted to the facility on [DATE REDACTED] with diagnoses that included gastrointestinal reflux disease (GERD).

A review of Resident #51's physician orders revealed an order for famotidine 20 mg by mouth two times a day for GERD with a start date of 01/30/24.

On 06/04/24 at 10:20 AM Medication Aide #1 was observed as she prepared to medicate Resident #51. The MA administered 14 medications to the Resident which included one famotidine 10 mg tablet.

An interview with MA #1 on 06/04/24 at 2:30 PM. The MA was asked to show the bottle of famotidine that

she used to medicate Resident #51 earlier that morning and the MA obtained a bottle of famotidine from the medication cart that indicated famotidine 10 mg tablets. The MA read the order and the contents of the label and confirmed she did not give the Resident 2 tablets of the famotidine. She stated she needed to pay closer attention to the label.

During an interview with the Director of Nursing (DON) on 06/07/24 at 9:34 AM the DON was informed of the 11.11% medication error rate made by the two Medication Aides. She indicated both would be further educated on medication pass procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 345179 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345179 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Accordius Health at Mooresville 752 E Center Avenue Mooresville, NC 28115

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50045

Residents Affected - Few Based on record review, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to ensure accurate medical records when a resident's labs were incorrectly documented as collected for 1 of 1 resident (Resident #196) reviewed for medical record accuracy.

The findings included:

Review of a physician order dated 12/25/23 read; Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) related to increased confusion per family members observation.

A review of Resident #196's December 2023 Medication Administration Record indicated Nurse #6 had collected a CBC and BMP on 12/25/2023 at 1:24 am.

An interview was conducted on 6/4/2024 at 8:36 pm with Nurse #6. Nurse #6 reported she worked on 12/24/2023 during the night shift (7:00 pm to 7:00 am) and was assigned Resident #196. Nurse #6 stated

after she had started her shift, Resident #196's Representative (RR) reported Resident #196 had acted more confused. Nurse #6 reported she had not obtained laboratory testing that night because she never drew blood at night and was not able to draw blood. Nurse #6 was not able to recall documenting that she had collected Resident #196's labs, and was not sure why it was documented that she had on the MAR.

An interview was conducted on 6/7/2024 at 8:35 am with the DON. The DON verified Nurse #6 had documented she had collected Resident #196's labs on 12/25/2023 at 1:24 am. The DON stated since she had documented it, she would have expected labs to have been obtained at that time. The DON was not aware Resident #196 never had his labs collected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 345179