Crestview Health & Rehabilitation

During an interview with the Director of Nursing (DON) on 06/07/24 at 10:03 AM the DON reported the PA addressed the residents' advanced directives when they were admitted to the facility and the paperwork was placed in the code status notebook at the nursing desk.

The DON stated she was not aware that Resident #72's advanced directive forms had not been placed in the code status notebook and remarked that the Resident had been in the facility long enough for the paperwork to be completed.

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

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resident was prescribed apixaban then use of anticoagulants should be coded.

The MDS Nurse

sure why it was not coded correctly.

An interview was conducted on 6/7/2024 at 8:27 am with the Director of Nursing (DON).

The DON stated the MDS Nurse was responsible for accurately completing the MDS assessments.

The DON stated she was not familiar enough with MDS to know if anticoagulants were required to be coded and would have to refer to the MDS Nurse.

The DON agreed that apixaban was classified as an anticoagulant.

An interview was conducted on 6/7/2024 at 3:19 pm with the Administrator and indicated they expected the MDS to be coded correctly.

• Resident #346 was admitted to the facility on [DATE] with diagnoses which included bipolar,

anxiety, post-traumatic stress disorder, and major depressive disorder.

A review of an admission MDS dated [DATE] revealed Resident #346 was cognitively intact with no behaviors and was not coded as having a Level II Pre-admission Screening and Resident Review (PASRR).

A review of a care plan dated 7/6/2023 revealed Resident #346 did not have a Level II PASRR determination.

A review of the PASRR confirmation documentation revealed Resident #346 had a Level II PASRR with an expiration date of 9/5/2023.

A review of the medical record demographic section revealed Resident #346 had a Level I PASRR determination.

An interview was conducted on 6/6/2024 at 9:00 am with the MDS Nurse.

The MDS Nurse reported when a resident was admitted to the facility, Admissions and the Social Worker (SW) would verify if the resident had a Level II PASRR.

The MDS Nurse stated Resident #346 had a Level II PASRR determination.

The MDS Nurse stated in the demographics, Resident #346 was indicated as having a Level I PASRR.

The MDS Nurse stated she had not completed that assessment and assumed the Nurse who completed the assessment probably referred to the demographics and had not looked at the PASRR documentation that was scanned into the chart.

The MDS Nurse reported Resident #346 should have been coded with a Level II PASRR and that it was an error.

An interview was conducted on 6/7/2024 at 8:27 am with the Director of Nursing (DON).

The DON stated the MDS Nurse was responsible for accurately completing the MDS assessments.

The DON stated she was not familiar enough with MDS to know if a Level II PASRR was required to be coded and would have to refer to the MDS Nurse.

An interview was conducted on 6/7/2024 at 3:19 pm with the Administrator and indicated they expected the MDS to be coded correctly.

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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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During an interview with Social Worker (SW) #1 on 06/07/24 at 9:11 AM, the SW explained that she was the one responsible for writing Resident #62's smoking care plan and that the Resident was a safe smoker who could smoke unsupervised.

The SW was asked to review Resident #62's smoking care plan that stated the Resident was both a supervised and unsupervised smoker and the SW acknowledged the discrepancy in the care plan and stated she had made a mistake.

The SW stated Resident #62 was able to smoke unsupervised.

An interview was conducted with the Director of Nursing (DON) on 06/07/24 at 10:03 AM.

The DON explained that social services wrote the smoking care plans and she expected the care plan to accurately reflect the Resident's ability to smoke unsupervised.

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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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certified in CPR was located in a binder at each nursing station. In addition, those staff that were

jeopardy to resident health or carts were located in the building, one at each nursing station, the logbook was on each cart and had safety been checked each night since [DATE]. A mock code blue had been conducted on each shift and staff responded accordingly.

Interviews with the scheduling coordinator revealed that she ensured staff

had been educated on where the crash carts were located, their role in emergency response, and how to identify which staff were certified in CRP.

They were also able to verbalize that only staff certified in CPR should participate in CPR.

The IJ removal date of [DATE] was validated.

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

During an interview with the Director of Nursing (DON) on 06/07/24 at 9:46 AM the DON explained the oxygen concentrator filters should be cleaned once a week on Wednesday third shift and as needed in case they need cleaning more than weekly.

She stated the admitting nurse should place the oxygen in use sign on the residents' door when they were admitted .

The DON stated Resident #34 had changed rooms recently and the nurses must have missed moving the oxygen sign to her new room.

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jeopardy to resident health or responsible for ensuring licensed nurses, weekend nursing staff, CNAs, and CMAs receive the safety education to include identifying sign and symptoms of pain, and pain management and prevention to include follow up with the provider if pain management interventions are not effective.

Staff including

education.

The education will be ongoing to include new hires and prn staff.

The SDC will be responsible for ensuring the education is completed.

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: 6/10/24 A validation of immediate jeopardy removal was conducted on 06/13/24.

The initial pain assessments and interviews were reviewed with no issues noted.

Licensed nurses were able to verbalize that they had the education reguarding pain and that pain was assessed after a fall, with change in condition, before and after pain medication administration and would documented in the medical record.

Non licensed staff were able to vervalize that if a resident complained of pain or indicated thier pain medication was not effective who to report that information too.

The licensed nurses were able to verbalize the need to communicate to the medical provider and involve the responsibel party if the residents pain could not be managed in the facility and needed a higher level of care.

The immediate jeopardy removal date of 06/10/24 was validated.

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Review of the emergency checklist revealed that the staff had been ensuring the emergency equipment was stocked and ready for use each night since [DATE].

The immediate jeopardy removal date of [DATE] was validated.

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During an interview with the Director of Nursing (DON) on 06/07/24 at 9:54 AM the DON explained that the facility monitored for the side effects of the psychotropic medications by putting the monitoring tools on the MAR under the specific medication.

When the DON reviewed Resident #32's MARs since her admission in November 2023 she acknowledged the Resident did not have any monitoring tools set up for the psychotropic medications.

The DON stated the Pharmacist must have missed that during her monthly reviews of her chart.

An interview conducted with the Physician Assistant (PA) on 06/07/24 at 2:49 PM.

The PA explained that she has had to change and adjust Resident #32's psychotropic medications multiple times due to her behaviors and diagnoses.

When asked how she monitored the side effects of the psychotropic medications she indicated she monitored for the side effects of the psychotropic medications herself because was in the facility all the time.

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

During an interview with the Director of Nursing (DON) on 06/07/24 at 9:38 AM and 4:57 PM and a follow-up interview on 06/13/24 at 5:25 PM the DON explained that she had posted pharmacy medication storage sheets on the medication carts for the nurses to use as a guide to assist them in knowing how and where the medications should be stored.

The DON stated the medication rooms and refrigerators were checked weekly by the day shift nurses and should have found the out-of-date medications and disposed of them.

She indicated the controlled substances should always be behind double lock and key.

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policies and coordination of medical care in the facility.

record review, staff, and Medical Director (MD) interviews the facility failed to ensure the MD was

Response.

This deficient practice had the potential to affect all current residents in the facility.

The findings included: A review of the Medial Director service agreement signed by the facility's Medical Director (MD) on [DATE] included the following under duties and obligations of Medical Director: Medical Director shall be responsible for implementation of resident care policies, coordination of medical care in the facility and shall perform such other duties and responsibilities customary for a medical director in a facility of comparable size to the facility.

The Medical Director (MD) was interviewed on [DATE] at 2:55 PM.

The MD stated she was not familiar with the protocol for CPR or Emergency Response in the building, but she had always told the facility to call EMS before calling her.

The Administrator was interviewed on [DATE] at 4:46 PM.

The Administrator stated the MD was a contracted employee and evaluated residents as outlined by the regulation and as needed.

The MD visited the facility each week and played a part in every major medical decision made, had input on policies, attended the Quality Assurance meeting and made recommendations as needed.

The Administrator stated the MD had access to all the facility policies and then staff would supplement that with any education needed. He stated, it is very important for her to be informed of the policies of this building and anything to do with the residents in our building.

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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.

During a resident council meeting held on 06/05/24 at 10:00 AM, the council reported seeing flies for the last week or so especially around the exit door and they had mentioned it to the Administrator.

The Maintenance Director was interviewed on 06/05/24 at 4:24 PM who stated that resident and staff started complaining of flies, so 2 to 3 months ago he put an air curtain up at the smoking exit door because the flies were not supposed to be able to fly through it.

The Maintenance Director explained the smoking exit door had an interior door to the facility that could be closed but the residents were not able to open it, so it stayed propped open.

Then the exit door to the smoking area had a handicapped door which was equipped with a delay to allow wheelchairs to pass through the door before it closed. He added that if staff said something about flies in a particular resident room, he would spray that room with a chemical that the pest control company gave him that could be used in resident rooms safely. He confirmed that he had treated rooms on 100 and 300, that included room [ROOM NUMBER] and also called for an extra visit from the Pest Control company on 06/05/24.

The Maintenance Director stated that they had fly lights but only in the service hall but not on any resident hall or commons areas in the facility.

An interview with the Pest Control Technician was conducted on 06/06/24 at 10:04 AM. He explained the facility had reached out to him yesterday to come and treat for flies but he was unable to get to the facility yesterday (06/05/24).

The technician stated that there was evidence of flies in several rooms including 308 and 311. He believed that the flies in room [ROOM NUMBER] (Resident #10's room) was directly related to the open food containers and urinal that had yellow fluid in it which both attracted flies.

The technician stated that both resident rooms were empty at the time, and he was able to treat the entire room but they have to eliminate the source referring to the facility staff. He continued to say that the other rooms he treated had residents in them and he was only able to treat low level areas of their rooms.

The Technician stated that during his observations he noted several flies on beds and pillows which indicated that the mattress and pillow may have excrement embedded in them and that was attracting flies and recommended replacing both if the facility was able to do so.

He added that he had treated the smoking exit door and despite the air curtain flies could get still through it.

The Technician recommend adding some external fly bait stations that the Maintenance Director approved.

The Director of Nursing (DON) was interviewed on 06/06/24 at 10:54 AM.

The DON's office was located diagonally across from the smoking exit door.

There were flies noted in her office flying and she stated she had noticed them and put a work order in for Maintenance to treat them.

The Administrator was interviewed on 06/07/24 at 3:06 PM. He stated that the Maintenance Director had spoken to him this week about flies, but 'we had not identified the issue at the level identified by the surveyor. He stated that they had recently replaced all the screens in the resident room windows.

The Administrator stated he had spoken to the residents in room [ROOM NUMBER] and asked them about the flies and they thought the flies were present because of the temperature in the room and he offered to turn the air conditioning up and they declined. He stated that he asked them to move rooms temporarily so the room could be deep cleaned, and they consented.

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During CPR Nurse #4 and the Staff Development Coordinator observed NA #3's compression were not effective or deep enough to create recoil and had to instruct NA #3 that his compressions were not deep enough before switching NA #3 out with another staff member that could assist. NA #3 and NA #4 were not certified in CPR for Healthcare Providers.

Emergency Medical Services (EMS) arrived and placed a backboard under Resident #70 and continued CPR. Resident #70 expired.

A review of a document provided by the facility titled, Orientation Overview with no date noted, indicated that on day 1 and day 2 of orientation new staff would watch a video on emergency preparedness.

The required paperwork was listed as CPR card (required for Nurses only, but good to have for other staff), facility codes and security access, and included a facility tour.

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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

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).

During an interview with Social Worker (SW) #1 on 06/07/24 at 9:11 AM, the SW explained that she was the one responsible for writing Resident #62's smoking care plan and that the Resident was a safe smoker who could smoke unsupervised.

The SW was asked to review Resident #62's smoking care plan that stated the Resident was both a supervised and unsupervised smoker and the SW acknowledged the discrepancy in the care plan and stated she had made a mistake.

The SW stated Resident #62 was able to smoke unsupervised.

An interview was conducted with the Director of Nursing (DON) on 06/07/24 at 10:03 AM.

The DON explained that social services wrote the smoking care plans and she expected the care plan to accurately reflect the Resident's ability to smoke unsupervised.

345179

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