Crestview Health & Rehabilitation

on neglect, how to respond if they were aware of neglect, and who to immediately report it to.

The

jeopardy to resident health or to verbalize the need to review residents MOST forms after falls with injury and the need to contact safety 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

06/12/24 was validated.

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Crestview Health & Rehabilitation 752 E Center Avenue Mooresville, NC 28115

was a pillow behind her head for support.

Nurse #2 continued to explain that Resident #1's face was

if he was in a trance.

Nurse #2 reported she then moved Resident #1 away from Resident #2 and

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.

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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.

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Crestview Health & Rehabilitation 752 E Center Avenue Mooresville, NC 28115

Administrator reported he was employed at the facility on 7/8/2023, but was not able to recall

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

if a resident was admitted to the facility after being hospitalized for suicidal ideation, the resident

have been care planned for suicidal ideation.

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they just did not have anyone that could do it.

She explained that the facility was running ads online

that came in one time, but they have not had anyone since then and she could not recall when that

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.

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stated around lunchtime (11:30 am) she noticed Resident #196 had pitting edema (swelling), crackles

jeopardy to resident health or continued to wear oxygen at 3 liters per minute.

Nurse #5 reported she notified the physician, at the safety 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

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.

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 routinely for results and were to notify the on-call provider of any results.

The DON also reported she obtained results from labs and radiology every morning and notified the provider as well.

The DON confirmed 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 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 labs that needed

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screen had not been completed since 03/31/23 the SW stated, I do not know how that fell through the

An interview conducted with the Director of Nursing on 06/07/24 at 10:03 AM revealed the safe

social services or the nursing staff.

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that each indwelling catheter tubing was anchored and if not make the nurse aware so it can be

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.

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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.

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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.

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

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

#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).

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.

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Form Approved OMB

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