Every finding on record at Belmont Health & Rehabilitation, The

Based on record review and interview, the facility failed to document meal consumption values for 8 of 10 residents reviewed for nutrition. (Residents E, F, G, H, J, B, K, and L)Finding include:1. The clinical record for Resident E was reviewed on 09/29/2025 at 10:35 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 08/21/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, stroke, and Chronic Obstructive Pulmonary Disease (COPD). The August and September 2025 Meal Consumption Record lacked documented meal intake values for the following dates: - 08/27/2025 at dinner, - 08/28/2025 at dinner, - 08/29/2025 at breakfast, lunch, and dinner, - 08/30/2025 at dinner, - 08/31/2025 at breakfast and lunch, - 09/05/2025 at dinner, - 09/06/2025 at dinner, - 09/07/2025 at breakfast, lunch, and dinner, - 09/08/2025 at dinner, and - 09/09/2025 at breakfast, lunch, and dinner. 2. The clinical record for Resident F was reviewed on 09/29/2025 at 4:19 P.M. A Quarterly MDS assessment, dated 07/21/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, bipolar disease, heart failure, hypertension, diabetes, dementia, anxiety, and depression. The August and September 2025 Meal Consumption Record lacked documented meal intake values for the following dates: - 08/23/2025 at breakfast, lunch, and dinner, - 08/24/2025 at dinner, - 08/25/2025 at dinner, - 08/27/2025 at dinner, - 08/28/2025 at dinner, - 09/02/2025 at dinner - 09/07/2025 at breakfast, lunch, and dinner, - 09/12/2025 at lunch, and - 09/13/2025 at breakfast, and lunch. 3. The clinical record for Resident G was reviewed on 09/29/2025 at 10:45 A.M. An admission MDS assessment, dated 06/21/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, anxiety, and depression. The August and September 2025 Meal Consumption Record lacked documented meal intake values for the following dates: - 08/01/2025 at dinner, - 08/04/2025 at dinner, - 08/05/2025 at breakfast and lunch, - 08/14/2025 at lunch and dinner, - 08/15/2025 at breakfast and lunch, - 08/23/2025 at breakfast, lunch, and dinner, - 08/24/2025 at dinner, - 08/25/2025 at dinner, - 08/27/2025 at dinner, - 08/28/2025 at dinner, - 08/29/2025 at dinner, - 09/02/2025 at dinner, and - 09/07/2025 at breakfast, lunch, and dinner. 4. The clinical record for Resident H was reviewed on 09/25/2025 at 3:58 P.M. A Quarterly MDS assessment, dated 06/17/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included but, were not limited to, malnutrition, hypertension, diabetes, depression, and anxiety. The August and September 2025 Meal Consumption Record lacked documented meal intake values for the following dates: - 08/01/2025 at dinner, - 08/04/2025 at dinner, - 08/05/2025 at lunch and dinner, - 08/09/2025 at breakfast, lunch, and dinner, - 08/10/2025 at breakfast and lunch, - 08/16/2025 at dinner, - 08/22/2025 at dinner, - 08/23/2025 at breakfast, lunch, and dinner, - 08/24/2025 at breakfast, lunch, and dinner, - 08/27/2025 at dinner, - 08/28/2025 at dinner, - 08/30/2025 at dinner, - 08/31/2025 at dinner, - 09/03/2025 at dinner, - 09/05/2025 at dinner, - 09/06/2025 at breakfast and lunch, and - 09/07/2025 at dinner. 5. During an interview, on 09/26/2025 at 1:57 P.M., Resident J indicated he always ate breakfast, lunch, and dinner in the facility. He had not left the facility and eaten somewhere else. He always ate his meals in his room. The resident's clinical record was reviewed on 09/29/2025 at 1:30 P.M. An admission MDS assessment, dated 09/05/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, diabetes, and coronary artery disease. The September 2025 Meal Consumption Records lacked documented meal consumptions for the following dates: -09/07/2025 at breakfast, and lunch, -09/09/2025 at breakfast, and lunch, -09/15/2025 at dinner, -09/17/2025 at dinner, -09/19/2025 at dinner, -09/21/2025 at dinner, -09/22/2025 at dinner, -09/24/2025 at dinner, and -09/25/2025 at dinner. 6. The clinical record for Resident B was reviewed on 09/26/2025 at 1:41 P.M. A Quarterly MDS assessment, dated 08/19/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, heart failure, wound infection, and diabetes. The August and September 2025 Meal Consumption Records lacked documented meal consumptions for the following dates: -08/01/2025 at breakfast, lunch, and dinner, -08/04/2025 at dinner, -08/05/2025 at breakfast and lunch, -08/14/2025 at lunch and dinner, -08/15/2025 at breakfast and lunch, -08/23/2025 at breakfast, lunch, and dinner, -08/24/2025 at dinner, -08/25/2025 at dinner, -08/27/2025 at dinner, -08/28/2025 at dinner, -08/29/2025 at dinner, -09/02/2025 at dinner, -09/05/2025 at dinner, -09/06/2025 at dinner -09/07/2025 at dinner, and-09/21/2025 at dinner. 7. The clinical record for Resident K was reviewed on 09/26/2025 at 11:25 A.M. A Quarterly MDS assessment, dated 09/04/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anxiety, depression, and psychotic disorder. The August and September 2025 Meal Consumption Records lacked documented meals for the following dates: -08/01/2025 at dinner, -08/02/2025 at dinner,-08/08/2025 at breakfast, lunch, and dinner, -08/09/2025 at breakfast and lunch, -08/14/2025 at dinner, -08/21/2025 at dinner, -08/25/2025 at dinner, -08/26/2025 at dinner, -09/08/2025 breakfast and lunch,-09/17/2025 dinner, -09/20/2025 breakfast and lunch, and-09/26/2025 breakfast and lunch. 8. The clinical record for Resident L was reviewed on 09/26/2025 at 10:08 A.M. An Annual MDS assessment, dated 07/09/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, dementia, anemia, heart failure, obstructive uropathy, and diabetes. The August and September 2025 Meal Consumption record lacked documented meals for the following dates: -08/01/2025 at dinner, -08/04/2025 at dinner, -08/05/2025 at breakfast and lunch, -08/06/2025 at breakfast and lunch, -08/14/25 at lunch and dinner, -08/15/2025 at breakfast and lunch, -08/23/2025 at breakfast, lunch, and dinner, -08/27/2025 at dinner,-08/28/2025 at dinner,-08/29/2025 at dinner, -09/02/2025 at dinner, -09/07/2025 at dinner, and-09/21/2025 at dinner. During an interview, on 09/29/2025 at 10:19 A.M, QMA (Qualified Medication Aide) 5 indicated all resident meals, that included breakfast, lunch, and dinner were documented in the resident's clinical record on the computer. If the residents refused a meal or were out of the facility during the meal they were able to document, it also. The current facility policy titled, Meal Consumption Record was provided by the Assistant Director of Nursing on 09/29/25 4:35 P.M. The policy indicated, .To provide means to monitor the resident's daily intakes.Percentage of meals consumed daily will be recorded on the document designated by the facility. This citation relates to Intake 2617395. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to store medications appropriately and ensure a resident was assessed to self-administer medications for 1 of 25 residents reviewed for medications. (Resident 55)Findings include:Resident 55 was observed in her room sitting in her chair on 09/24/2025 at 11:41 A.M. A medication cup with three Tums (an antacid medication) tablets was observed on the overbed table near the resident. The resident indicated she had the medication because she had heartburn.The resident's clinical record was reviewed on 09/28/2025 at 12:05 P.M. A Comprehensive Minimum Data Set (MDS) assessment, dated 07/02/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, cerebrovascular accident, coronary artery disease, and gastroesophageal reflux disease (GERD).The resident's record lacked a physician's order for the Tums medication and lacked a physician's order to self-administer medications.The resident was observed in her room sitting in her chair on 09/24/2025 at 12:16 P.M. The medication cup with the Tums tablets was still on the overbed table. The resident indicated a nurse gave her the Tums the day before.The resident was observed with Licensed Practical Nurse (LPN) 3 on 09/24/2025 at 12:24 P.M. LPN 3 indicated it looked like Tums tablets in the medication cup. She was the nurse caring for the resident and she did not leave the Tums. She thought maybe a Qualified Medication Aide left the medication.The resident's Electronic Health Record was reviewed with LPN 3 on 09/24/2025 at 12:28 P.M. LPN 3 indicated the resident didn't have a physician's order for Tums. She was not sure where the Tums came from. She looked in the medication cart and the resident did not have Tums in the cart. The resident did not have a physician's order to self-administer medications either. The medication should not have been left on the resident's overbed table.The current facility policy, titled MEDICATIONS, SELF-ADMINISTRATION, dated 09/17, was provided by the Regional Director of Operations on 09/30/2025 at 10:28 A.M. The policy indicated, .the interdisciplinary team shall evaluate the resident for the.ability to accomplish this task.if the evaluation reveals the resident capable of participation in self-administration, a physician's order reflecting the same shall be obtained.3.1-11(a)

Based on observation, record review, and interview, the facility failed to identify and treat pressure ulcers before they progressed to Stage III (full thickness skin loss that may extend into the subcutaneous tissue) pressure ulcers for 2 of 4 residents reviewed for pressure ulcers. (Residents C and B)Findings include:1. Resident C's coccyx wound was observed on 09/26/2025 at 2:58 P.M. The wound was pea-sized, with a dark pink wound bed and lighter pink skin around the wound. There was no drainage or signs of infection. The resident's clinical record was reviewed on 09/26/2025 at 11:11 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/04/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart disease, cancer, peripheral vascular disease, and malnutrition. The resident was receiving hospice services. Both of the resident's lower extremities were impaired and the resident depended on nursing staff for all Activities of Daily Living (ADLs). The resident was at risk for developing pressure ulcers and had a Stage 3 pressure ulcer that was not present on admission. A Wound Management Detail Report, dated 06/27/2025, indicated the wound on the resident's coccyx was identified on 06/26/2025 as a Stage 3 pressure ulcer that measured 2.5 centimeters (cm) X (by) 1 cm, with a depth of 1 cm. There was a moderate amount of serosanguineous (pale red to pink, thin and watery) drainage. The wound bed was covered with 100% granulation (new, pink/red moist) tissue. There was 0.5 cm of undermining (a separation of the wound edge from the surrounding healthy tissue) present. The resident's shower sheets and hospice aide visit notes lacked any indication the resident had any wounds when staff provided care on 06/06/2025, 06/10/2025, 06/13/2025, 06/17/2025, or 06/24/2025. During an interview, on 09/30/2025 at 10:17 A.M., the Facility Wound Nurse indicated the wound should have been identified before it was a Stage 3 with undermining. 2. The clinical record for Resident B was reviewed on 09/26/2025 at 1:41 P.M. A Quarterly MDS assessment, dated 08/19/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, heart failure, wound infection, and diabetes. The resident had pressure ulcers at the time of the assessment. A Wound Clinic Note, dated 02/14/2025, indicated the resident had a new wound to the right lateral ankle. The wound was a Stage 3 pressure ulcer that was acquired on 02/11/2025. The wound measured 1.5 cm X 2 cm X 0.1 cm. There was fat layer exposed, with a medium amount of necrotic tissue within the wound bed including slough. A Facility Wound Management Report, indicated the resident had a Stage 3 pressure ulcer to the right lateral ankle that was identified on 02/11/2025. The Wound Management Report was created on 02/14/2025. The wound measured 1.5 cm X 2 cm X 0.1 cm. The resident had the following orders in place at the time the wound was identified: -A physician's order, dated 06/05/2024 through 03/06/2025, to perform a weekly skin inspection on Fridays. If any new areas were identified, a new skin impairment event was to be opened, and -A physician's order, dated 02/12/2025 through 04/09/2025, to cleanse the right lateral ankle with normal saline, pat dry, apply skin prep to the peri-wound, apply moistened Prisma to base of the wound, cover with a 4 x 4 gauze, wrap with conforming rolled gauze, and secure with tape. The Event Reports lacked an assessment for the resident's right lateral ankle. The resident's shower sheets lacked any indication the resident had any wounds on 02/03/2025, 02/06/2025, or 02/10/2025. The resident's clinical record lacked documentation of the resident's wound until 02/14/2025, when it was a Stage 3 pressure ulcer. The February 2025 EMAR/ETAR lacked documentation that the right ankle treatment was completed prior to 02/14/2025. During an interview, on 09/29/2025 at 10:25 A.M., Licensed Practical Nurse (LPN) 9 indicated the nurses assessed the residents' skin weekly and it was documented in the EMAR/ETAR. The Certified Nurse Aides (CNAs) would check the residents' skin daily and would let the nurse know of any new skin impairments. The CNAs also completed shower sheets and would document the new skin impairments and let the nurse know. Once a new skin impairment was identified the nurse would measure the wound, document it in wound management and in a nurse's note, let the wound nurse know, and get a new treatment order. During an interview, on 09/29/2025 at 2:25 P.M., the Facility Wound Nurse indicated the resident's right ankle wound developed in February 2025. The wound was a Stage 3 when it was first identified. The nurses assessed residents' skin weekly in the EMAR/ETAR. If a new wound was identified, then it should be documented in a skin event and a progress note. The CNAs would document skin impairments on the shower sheets and would notify the nurse. The resident's ankle wound should have been identified before it was a Stage 3. The current facility policy, titled SKIN MANAGEMENT PROGRAM, most recently revised in 2025, was provided by the Regional Director of Operations on 09/30/2025 at 3:48 P.M. The policy indicated, .The facility will assess/identify the presence of risk factors that may contribute to the development of pressure ulcers.in an effort to prevent skin breakdown and/or further deterioration.Residents who receive assistance with bathing and/or pericare will be observed daily by nursing staff and any observance of red areas, open areas .will be reported to the licensed nurse for further assessment . This citation relates to intake 2617395. 3.1-49(a)(2)

Based on observation and interview, the facility failed to store medications appropriately for 1 of 4 medication carts observed (300 Hall Medication Cart).Findings include:The 300 Hall Medication Cart was observed with RN 2 on 09/30/2025 at 9:35 A.M. The following were observed in the top drawer:- A half full insulin glargine pen belonging to Resident 77 with an opened date of 09/01/2025, and - A three-fourths full insulin Aspart pen belonging to Resident 108 with an opened date of 09/01/2025. During an interview, on 09/30/2025 at 9:39 A.M., RN 2 indicated insulin pens should be dated when placed in the medication cart and once opened were good for 30 days at room temperature. The manufacture's package insert for Insulin Glargine was provided on 09/30/2025 at 10:00 A.M., by the Regional Director of Operations (RDO). The insert indicated, .Throw away the pen you are using after 28 days, even if it still has insulin left in it.The manufacture's package insert for Insulin Aspart was provided on 09/30/2025 at 10:00 A.M., by the RDO. The insert indicated, .Unused Insulin Aspart FlexPen stored at room temperature should be thrown away after 28 days. The current facility policy titled, MEDICATION EXPIRATION, was provided by the RDO on 09/30/2025 at 9:52 A.M. The policy indicated, .If a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . 3.1-25(j)3.1-25(o)

Based on interview and record review, the facility failed to ensure residents were adequately assessed after a change in condition for 1 of 4 residents reviewed for Quality of Care. (Resident B).Findings include: During an interview, on 7/31/2025 at 2:39 P.M., LPN 3 indicated she was taking care of Resident B on the morning of 6/26/2025. She indicated Resident B was not feeling well, and LPN 3 recorded a very low blood pressure reading. LPN 3 contacted the on-call Nurse Practitioner (NP). The NP prescribed a medication to raise Resident B's blood pressure and staff were to start some continuous intravenous fluids to help raise the residents blood pressure. During an interview, on 7/31/2025 at 4:08 P.M., LPN 2 indicated that he was the nurse caring for Resident B on 6/26/2025 from 2:00 P.M. until 10:00 P.M. He never received anything significant in report about Resident B. He recalled Resident B was restless and was hollering out. The CNA reported to LPN 2 that Resident B was hollering out. LPN 2 checked on the resident and believed he took vitals due to Resident B being in distress. The LPN recalled the resident being very restless and that wasn't her norm. The LPN never called the physician or family and he could not recall if he gave Resident B any medications that night.During an interview, on 7/31/2025 at 3:55 P.M., Certified Nursing Aide (CNA) 9 indicated that she was caring for Resident B on the evening of 6/26/2025. She was told in report that Resident B was not feeling well. The resident was complaining of stomach pain and was very anxious. Resident B had requested to go to the hospital around 6:00 P.M. and again at 8:30 P.M. to CNA 9. Both times the CNA informed LPN 2 of the resident's request. The resident was never sent to the hospital. She recalled Resident B was moaning, groaning, yelling, and praying off and on.During an interview, on 7/31/2025 at 3:28 P.M., Confidential Staff 8 indicated she was in the facility on the evening of 6/26/2025 and overheard CNA 5 report to LPN 2 that Resident B wasn't feeling right and wanted to go to the hospital.On 6/26/2025 at 11:45 p.m., Resident B was found unresponsive by Licensed Practical Nurse (LPN) 10 with no pulse or breaths lying in bed.The clinical record for Resident B was reviewed on 8/1/2025 9:55 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 6/19/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, asthma, anemia, and heart failure. Resident B was admitted to the facility for rehabilitation following hospitalization for cellulitis. The Vitals report, dated 6/26/2025 at 6:40 p.m., indicated LPN 2 assessed the resident's temperature at 98 degrees Fahrenheit and her oxygen saturation of 97 % (percent). No other vital signs were documented.The Vitals report, dated 6/26/2025 at 4:03 p.m., indicated LPN 2 assessed the resident's pain scale. The resident's pain level was 0 out of 10, with 10 being the worst. No other vital signs were documented.The Vitals report, dated 6/26/2025 at 2:47 p.m., indicated LPN 2 assessed the resident's temperature of 97.9 degrees Fahrenheit. No other vital signs were documented.The Vitals report, dated 6/26/2025 at 8:54 a.m., indicated LPN 3 assessed the resident's respirations of 16 per minute and her temperature was 97.7 degrees Fahrenheit.The Vitals report, dated 6/26/2025 at 8:35 a.m., indicated RN 4 assessed the resident's oxygen saturation of 96 percent.The Vitals report, dated 6/26/2025 at 8:20 a.m., indicated LPN 3 assessed the resident's pulse of 101 per minute and the resident's blood pressure was 80/53 mmHG (millimeters of mercury). The resident's record lacked a reassessment of her blood pressure or pulse rate after the abnormally low blood pressure reading on 6/26/2025 at 8:20 a.m.The Vitals report from the day before, dated 6/25/2025 at 7:04 a.m., indicated LPN 3 assessed the resident's blood pressure to be 107/66 mmHg and her pulse was 93 per minute.The on admission Vitals report, dated 6/12/2025 at 6:47 p.m., indicated the resident's blood pressure was 134/72 mmHg and her pulse rate was 67 per minute.During an interview, on 8/1/2025 at 11:38 a.m., MD 5 indicated he assessed Resident B on 6/26/2025 between 10:00 a.m. and 11:00 a.m., the resident was alert and orientated with no symptoms related to low blood pressure. Her skin was pink, warm, and dry. He would expect a resident's pulse to be in the upper 130's related to sepsis. Since the resident's pulse was only 101, he did not feel the resident was septic. During an interview, on 8/1/25 at 2:21p.m., Qualified Medication Aide (QMA) 12 indicated when a resident had a lower than normal blood pressure, she would rechecked the resident's blood pressure, sometimes every 30 minutes.During an interview, on 8/1/25 at 2:26 p.m., QMA 13 indicated normally an out-of-range vital sign would be re-checked and documented to indicate if treatments were effective. During an interview, on 8/1/25 at 2:31 p.m., LPN 14 indicated she would document the residents' vitals and re-checked vitals in the resident's chart. At least the reassessment would be documented. The current facility policy titled, Change in Resident Condition/ Emergency Transfer to Acute Care Hospital with a revision date of 11/2016, was provided by the DON on 8/1/2025 at 2:50 P.M. The policy Indicated, . At the time of a critical condition change, the decision to transfer for emergency treatment may be made by the Director of Nursing, or designee (i.e. practitioner other than a physician). Attempts would then be made to contact the resident's physician making him/her aware of resident status and necessary transfer.The current facility policy titled, Notification of Change dated 10/2014, was provided by the DON on 8/1/2025 at 3:00 P.M. The policy indicated, .Each nurse must enter on the 24-hour report any information that must be passed to the oncoming shift relative to notification of change .This citation relates to Complaint 2576363.3.1-37

Based on interview and record review, the facility failed follow the physician's orders related to administration parameters for cardiac medications and complete neurological assessments after a fall for 2 of 5 residents reviewed for quality of care. (Residents C and E) Findings include: 1. The clinical record for Resident C was reviewed on 05/15/25 at 11:00 A.M. An Admission Minimum Data Set (MDS) assessment, dated 04/16/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, and coronary artery disease. The physician's orders included, but were not limited to, an order with a start date of 04/14/25 that was discontinued on 04/28/25, indicated staff were to administer the resident's midodrine (a medication for low blood pressure) 7.5 milligrams (mg) three times a day for hypotension. The medication was to be administered if the resident's systolic (the top number) blood pressure was below 90. The resident's Electronic Medication Administration Record (EMAR) for April 2025 indicated the resident received the midodrine medication the systolic blood pressure was above 90 on the following dates and times: - The medication was administered on 04/19/25 at 3:30 P.M., when the resident's blood pressure was 116/62. - The medication was administered on 04/19/25 at 7:30 P.M., when the resident's blood pressure was 100/65. - The medication was administered on 04/22/25 at 7:30 A.M., when the resident's blood pressure was 101/71. - The medication was administered on 04/22/25 at 3:30 P.M., when the resident's blood pressure was 113/73. - The medication was administered on 04/22/25 at 7:30 A.M., when the resident's blood pressure was 101/71. - The medication was administered on 04/22/25 at 3:30 P.M., when the resident's blood pressure was 113/73. - The medication was administered on 04/22/25 at 7:30 P.M., when the resident's blood pressure was 116/70. - The medication was administered on 04/24/25 at 7:30 A.M., when the resident's blood pressure was 94/65. During an interview, on 05/15/25 at 12:05 P.M., RN 3 indicated she was familiar with the resident. She took medications for high blood pressure and for low blood pressure. When a resident had medication orders with hold parameters, she would obtain the resident's blood pressure before administering the medication. If the blood pressure was out of range (too high or too low) she would not administer the medication per the physician's order. The current facility policy titled MEDICATION ADMINISTRATION, dated 04/2017, was provided by the Regional Director on 05/15/25 at 1:11 P.M. The policy indicated, .safely administer medications as per physician's orders .qualified personnel shall be responsible to follow accepted practices of medication administration as per physician's orders . 38769 2. The clinical record for Resident E was reviewed on 05/15/25 at 12:16 P.M. A Quarterly MDS assessment, dated 03/10/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, seizure disorder, malnutrition, anxiety, and depression. A Progress Note, dated 04/05/25 at 2:11 A.M., indicated the nurse was called to the room after the resident had a fall. The nurse found the resident lying on the bathroom floor on her back. The resident stated she was trying to go to the toilet by herself when she fell . The resident complained of right hip pain but refused to go to the hospital and was attempting to get up off the floor by herself. The resident's neurological assessment was within normal limits at the time of the fall. The Accident and Incident Report and Investigation sheet, dated 04/05/25 at 1:20 A.M., indicated the resident fell when she was up going to the bathroom. The If it is known or suspected that resident hit head or face, have neurochecks been initiated? was marked yes. The Fall Assessment and Neurological Check Flowsheet, dated 04/05/25 at 1:30 A.M., indicated the resident was found on the floor in their bathroom. The neurological checks lacked the following information: - at 1:30 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities, - at 1:45 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities, - at 2:00 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities, - at 2:15 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities, - at 3:15 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities, - at 4:15 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities, and - at 5:15 A.M., pupil size, level of consciousness, level of orientation, complaints of pain, and extremities. During an interview, on 05/15/25 at 12:46 P.M., the Assistant Director of Nursing (ADON) indicated if a resident had an unwitnessed fall the nurse would complete an assessment on the resident and either send the resident to the hospital or keep them in the facility. If the resident remained in the facility then neurological assessments would be completed. They were completed per the assessment form and would include the resident's vital signs, pupil response, level of consciousness, level of orientation, complaints of pain, and extremities. The neurological assessment for Resident E should have been completed. The current facility policy titled, Fall Prevention Program, dated 10/2014, was provided by the Corporate Clinical Nurse on 05/15/25 at 1:30 P.M. The policy indicated, .To identify resident's who are at risk for falls and subsequently implement appropriate individualized fall prevention interventions . The current facility policy titled, Neurological Assessment, with a revision date of 03/2019, was provided by the Regional Director on 05/15/25 at 1:11 P.M. The policy indicated, .To determine the level of neurological function of a resident .Neurological assessment, is to be completed .Assess level of consciousness .Assess level of verbal communication .Assess resident response to stimuli .Assess pupils; size, reaction to light .Assess ability to move .Observe for nausea, vomiting and/or increased lethargy .Document assessment findings in appropriate location on clinical record . This citation related to Complaint IN00458274. 3.1-37(a)

Based on record review and interview, the facility failed to transcribe resident records for 1 of 3 residents' records reviewed. (Resident B) Findings include: The clinical record for Resident B was reviewed on 05/15/25 at 10:20 A.M. The resident was admitted to the facility on [DATE]. The resident's diagnosis included, but was not limited to, Displaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing. An After Visit Summary, dated 04/21/25, indicated the instructions for wound care included, but were not limited to, the following: - Icing Protocol: Use 10 to 14 hours per day until the follow-up appointment or use ice packs for 20 minutes per hour while awake. Do not put the ice pad directly against your skin (use a thin towel/clothing). The resident's clinical record lacked an order for the resident to have ice on her wound until 04/28/25. During an interview, on 05/15/25 at 11:57 A.M., Licensed Practical Nurse (LPN) 2 indicated when a resident was a new admission from the hospital the Unit Managers would get the resident's orders and transcribe them into the computer. There should have been a second nurse that verified the orders. During an interview, on 05/15/25 at 12:46 P.M., the Assistant Director of Nursing (ADON) indicated they were alerted by the resident's family member that the resident was to have ice on her shoulder, and it had not been getting applied. The nurse that he talked to reviewed the After-Visit Summary from admission and called the physician and implemented the order. The facility determined there was a transcription error and started a plan of correction. The nurse that made the error was educated immediately along with other nurses, and she started audits of all new resident admissions. The current facility policy titled, Physician Orders, dated 10/2014, was provided by the ADON on 05/15/25 at 1:58 P.M. The policy indicated, .Physician's orders are administered upon the clear, complete and signed order of an individual lawfully authorized to prescribe .Facility nursing personnel will ensure clear, accurate and complete physician's orders .New orders shall be transcribed . The deficient practice was corrected on 04/28/25 after the facility educated staff and implemented a process to monitor new admissions. This citation relates to Complaint IN00458427. 3.1-50(a)(2)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for medications for 5 of 24 residents reviewed for Quality of Care. (Residents 76, 4, 65, 98, and 38) Finding include: 1. The clinical record for Resident 76 was reviewed on 09/23/24 at 9:21 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/28/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, heart failure, and hypertension. An open-ended physician's order, with a start date of 01/23/24, indicated the resident was to take Humalog (an insulin) 10 units before meals. The staff were to hold the Humalog if the blood sugar was less than 120. The August and September 2024 EMAR (Electronic Medication Administration Record) indicated the resident received the medication on the following dates and times when the blood sugar was less than 120: - 08/20/24 at 7:30 A.M., when the blood sugar was 101, - 09/01/24 at 7:30 A.M., when the blood sugar was 105, - 09/07/24 at 7:30 A.M., when the blood sugar was 100, and - 09/ 13/24 at 7:30 A.M., when the blood sugar was 101. 2. The clinical record for Resident 4 was reviewed on 09/24/24 at 1:37 P.M. An Annual MDS assessment, dated 07/11/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hypertension, and atrial fibrillation. An open-ended physician's order, with a start date of 08/05/24, indicated the resident was to be given metoprolol 12.5 mg (milligrams) at bedtime for hypertension. The staff were to hold (not give) the medication if the residents pulse was less than 60 or the systolic blood pressure (top number) was less than 120. The August and September 2024 EMAR indicated the resident received the medication when his systolic blood pressure was less than 120 on the following dates and times: - 08/30/24, when the blood pressure was 106/67, - 09/07/24, when the blood pressure was 112/69, - 09/08/24, when the blood pressure was 112/69, and - 09/14/24, when the blood pressure was 107/53. 33613 3a. The clinical record for Resident 98 was reviewed on 09/19/24 at 10:24 A.M. A Quarterly MDS assessment, dated 07/01/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, a stroke, hypertension, diabetes, heart failure, Parkinson's disease, and depression. An open-ended physician's order, with a start date of 07/19/24, indicated the resident was to take aspart niacinamide (an insulin) 5 units before meals. The staff were to hold the insulin if the blood sugar was less than 120. The August and September 2024 EMAR indicated the resident received the medication on the following dates and times when the blood sugar was less than 120: - 08/06/24 at 11:00 A.M., when the blood sugar was 109, - 08/11/24 at 7:30 A.M., when the blood sugar was 112, - 08/12/24 at 4:00 P.M., when the blood sugar was 116, - 08/22/24 at 7:30 A.M., when the blood sugar was 112, - 09/12/24 at 4:00 P.M., when the blood sugar was 107, - 09/17/24 at 7:30 A.M., when the blood sugar was 97, - 09/17/24 at 4:00 P.M., when the blood sugar was 114, - 09/20/24 at 7:30 A.M., when the blood sugar was 117, - 09/21/24 at 7:30 A.M., when the blood sugar was 118, and - 09/23/24 at 7:30 A.M., when the blood sugar was 119. 3b. An open-ended physician's order, with a start date of 07/26/24, indicated the resident was to be given hydralazine 10 mg, three times a day for hypertension. The staff were to hold the medication if the resident's pulse was less than 60. The August and September 2024 EMAR indicated the resident received the medication when his pulse was less than 60 on the following dates and times: - 08/01/24, when the pulse was 59 at 3:30 P.M., - 08/09/24, when the pulse was 57 at 3:30 P.M., - 08/14/24, when the pulse was 58 at 7:30 A.M., - 08/14/24, when the pulse was 58 at 3:30 P.M., - 08/15/24, when the pulse was 58 at 7:30 A.M., - 09/07/24, when the pulse was 57 at 3:30 P.M., and - 09/11/24, when the pulse was 59 at 11:30 P.M. 3c. An open-ended physician's order, with a start date of 03/26/24, indicated the resident was to be given metoprolol tartrate 50 mg, every 12 hours for hypertension. The staff were to hold the medication if the resident's pulse was less than 60. The August 2024 EMAR indicated the resident received the medication when his pulse was less than 60 on the following dates and times: - 08/14/24, when the pulse was 58 at 8:00 A.M., - 08/14/24, when the pulse was 58 at 8:00 P.M., and - 08/15/24, when the pulse was 58 at 8:00 A.M. During an interview on 09/24/24 at 9:05 A.M., RN 3 indicated for medications with hold parameters, staff should hold the medication and mark due to condition on the EMAR, then notify the physician. 34232 4. The clinical record for Resident 65 was reviewed on 09/19/24 at 11:04 A.M. A Significant Change MDS assessment, dated 07/09/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, stroke, dementia, hypertension, and depression. The EMAR for August and September 2024 was provided by the ADON (Assistant Director of Nursing) on 09/24/24 at 3:52 P.M., and included the following current physician's order: - Midodrine 5 mg twice a day for a diagnosis of hypotension (low blood pressure), with a start date of 04/01/24. The medication was to be held (not given) if the systolic blood pressure was over 130. The medication was to be given on Day Shift, between 6:30 A.M. and 10:30 A.M., and on Evening Shift between 6:30 P.M. and 10:30 P.M. The record indicated the medication was administered when the resident's blood pressure was out of the prescribed range on the following dates and times: - 08/03/24, Evening Shift, the blood pressure was 138/76, - 08/08/24, Evening Shift, the blood pressure was 132/74, - 08/09/24, Day Shift, the blood pressure was 134/78, - 08/11/24, Evening Shift, the blood pressure was 142/82, - 08/12/24, Evening Shift, the blood pressure was 138/76, - 08/18/24, Evening Shift, the blood pressure was 134/86, - 08/19/24, Day Shift, the blood pressure was 132/88, - 08/19/24, Evening Shift, the blood pressure was 132/88, - 08/21/24, Evening Shift, the blood pressure was 132/78, - 08/25/24, Evening Shift, the blood pressure was 138/86, - 08/26/24, Day Shift, the blood pressure was 132/76, - 08/29/24, Day Shift, the blood pressure was 132/78, - 08/29/24, Evening Shift, the blood pressure was 132/78, - 09/01/24, Evening Shift, the blood pressure was 138/82, - 09/02/24, Day Shift, the blood pressure was 132/74, - 09/05/24, Evening Shift, the blood pressure was 150/88, - 09/06/24, Evening Shift, the blood pressure was 137/81, - 09/07/24, Day Shift, the blood pressure was 132/76, - 09/07/24, Evening Shift, the blood pressure was 139/56, and - 09/12/24, Day Shift, the blood pressure was 136/70. The current Care Plan for orthostatic hypotension was provided by the ADON on 09/24/24 at 3:29 P.M. The interventions included, but were not limited to, administer medications as ordered. During an interview on 09/23/24 at 3:21 P.M., RN 3 indicated for medications with hold parameters, staff should hold the medication and mark due to condition on the EMAR, then notify the physician. If there was a parameter, staff should take the vital sign right before giving the medication. On the EMAR there would be a notification if a resident required vital signs to be taken prior to medication administration. The special instructions on each medication will say which vital sign was required. The computer did not read the vital sign documented and tell you to hold the medication. The parameter would be stated on the physician's order. 38239 5. The clinical record for Resident 38 was reviewed on 09/23/24 at 10:48 A.M. A Quarterly MDS assessment, dated 08/29/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, coronary artery disease, and renal insufficiency An open-ended physician's order, with a start date of 02/16/24, indicated the resident was to be given losartan (a cardiac medication) 25 mg tablet. Give a half tablet (12.5 mg) once a day. The medication was to be held if the resident's systolic blood pressure was below 130. The June, July, August, and September 2024 EMAR indicated the resident received the medication when her systolic blood pressure was below 130 on the following dates: - 06/01/24, when the blood pressure was 129/75, - 06/03/24, when the blood pressure was 126/80, - 06/04/24, when the blood pressure was 128/74, - 06/08/24, when the blood pressure was 128/78, - 06/15/24, when the blood pressure was 122/80, - 06/16/24, when the blood pressure was 118/74, - 06/23/24, when the blood pressure was 118/80, - 06/25/24, when the blood pressure was 127/86, - 07/06/24, when the blood pressure was 128/70, - 07/13/24, when the blood pressure was 128/74, - 07/14/24, when the blood pressure was 128/74, - 07/27/24, when the blood pressure was 122/75, - 08/07/24, when the blood pressure was 122/80, - 08/17/24, when the blood pressure was 122/76, - 08/25/24, when the blood pressure was 123/74, - 09/12/24, when the blood pressure was 128/72, and - 09/15/24, when the blood pressure was 128/74. During an interview on 09/24/24 at 10:51 A.M., LPN 11 indicated if there were hold parameters for medications, she would assess the resident's vital signs as required and not administer the medication if the vitals were outside the ordered parameters. The current facility policy, titled PHYSICIAN ORDERS, dated 10/2014, was provided by the Regional Director on 09/24/24 at 3:00 P.M. The policy indicated, .Physician's orders are administered upon the clear, complete, and signed order of an individual lawfully authorized to prescribe .Facility nursing personnel will ensure clear, accurate, and complete physician's orders . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure pressure ulcers were accurately assessed, monitored, and treated for 1 of 8 residents reviewed for pressure ulcers. (Resident 40) Findings include: Resident 40 was observed in his room on 09/19/24 at 1:37 P.M. The resident was sitting up on the side of his bed with his overbed table in front of him. The resident was wearing thin, mid-calf length socks that covered his ankles. A pressure ulcer dressing was not visible. The resident indicated he had a wound on his left outer ankle and lowered his sock to expose the wound dressing. The dressing was clean, dry, and intact, and dated for that day. The resident's wound was observed with RN 9 on 09/20/24 at 11:50 A.M. The RN removed the resident's sock and dressing on his left outer ankle. The wound was nickel-sized, with a red wound bed and a small amount of slough (moist, non-viable tissue) present. There were no signs of infection. RN 9 indicated the resident had been laying in bed on his left side a lot when the wound was identified. They determined the wound was a pressure ulcer. The resident's clinical record was reviewed on 09/23/24 at 1:52 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 03/07/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, heart failure, peripheral vascular disease, and diabetes. The resident had no pressure ulcers but was at risk for pressure ulcers. An INITIAL PRESSURE ULCER ASSESSMENT, dated 04/16/24, indicated a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) was identified on 04/16/24. The wound measured 0.5 cm (centimeters) X (by) 0.7 cm. There was purulent (containing pus), serous (clear/yellow), and bloody exudate (drainage/fluid). There was granulation (new) tissue in the wound bed. The assessment indicated the wound location was the right ankle, but that was crossed out and the left lateral ankle was listed as the location. The April and May 2024 EMAR (Electronic Medication Administration Record) included the following physician's orders: - An order with a start date of 04/17/24 and an end date of 05/02/24, indicated Wound Location: RIGHT LATERAL ANKLE. Monitor wound/peri wound for redness, swelling, change in drainage quantity/characteristics every shift. Notify medical provider of complications. The EMAR documentation indicated the wound was not monitored on the following date: - On 04/29/24 the evening shift nurse indicated they did not monitor the wound. They couldn't find the wound. - An order with a start date of 04/17/24 and an end date of 05/02/24, indicated Wound Location: RIGHT LATERAL ANKLE. Once a day, cleanse open area with normal saline and pat dry. Apply skin protectant to peri wound. Apply calcium alginate to wound bed. Cover with border gauze dressing. The documentation indicated the treatment was not administered as ordered on the following dates: - On 04/25/24 the treatment was documented as not administered. A comment indicated na, - On 04/28/24 the treatment was documented as not administered. A comment indicated other, and - On 04/29/24 the treatment was documented as not administered. A comment indicated Could not find an open area. The ONGOING ASSESSMENT OF PRESSURE ULCER documentation indicated the following: - On 04/8/24, the wound measured 0.5 cm x 0.7 cm, with a depth of 0.1 cm. There was light serous exudate, and the wound bed was 100% granulation tissue. The wound was a Stage II pressure ulcer. - On 04/25/24, the wound measured 1.5 cm x 1.3 cm, with a depth of 0.1 cm. There was light serous exudate, and the wound bed was 100% granulation tissue. The wound was a Stage II pressure ulcer. - On 05/02/24, the wound measured 0.9 cm x 1.0 cm, with a depth of 0.2 cm. There was moderate serous exudate. The wound bed was 30% slough and 70% granulation tissue. The wound was now a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss). The Wound Clinic Doctor was in to see the resident on 05/02/24. They debrided the wound (removed non-viable tissue) at that time and changed the wound treatment order to apply calcium alginate with silver to the wound once a day. A Nurses' Note, dated 05/02/24, indicated the facility was notified by the Wound Doctor that the order in the computer should be for the left ankle instead of the right ankle. The order was corrected. The current facility policy, titled PRESSURE ULCER PREVENTION, dated 10/2014, was provided by the Regional Director on 09/24/24 at 2:38 P.M. The policy indicated, .To prevent pressure ulcers and promote healing . The current facility policy, titled PHYSICIAN ORDERS, dated 10/2014, was provided by the Regional Director on 09/24/24 at 3:00 P.M. The policy indicated, .Facility nursing personnel will ensure clear, accurate, and complete physician's orders .Transcribe new order onto MAR or TAR, as indicated . 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to provide a safe environment related to a resident's bed position for 1 of 6 residents reviewed for accidents. (Resident 15) Findings include: Incontinence care for Resident 15 was observed on 09/19/24 at 1:30 P.M., with providers CNA (Certified Nurse Aide) 6 and CNA 7. The CNAs washed their hands, prepared a basin of water, had clean linens at the bedside, and raised the resident's bed to the high position to perform the task. During the process, CNA 6 left the bedside and went into the resident's adjoining bathroom. After putting a bag in a trash can, CNA 7, left the bedside as well, walked around the edge of the bed and pulled privacy curtain, and was standing approximately three feet from the foot of the bed while the bed was in the high position. CNA 7 spoke to CNA 6, who was in the bathroom, for about a minute, then both CNAs returned to the bedside and continued with care. During an observation on 09/23/24 at 10:22 A.M., the resident was in their room in bed. The bed was in the high position, chest height. No staff were observed in the room or in the immediate area in the hallway. On 09/23/24 at 10:36 A.M., CNA 5 was observed entering the resident's room and lowering the bed. The CNA then walked across the hall into another resident's room, shutting the door. During an interview on 09/23/24 at 10:43 A.M., CNA 5 indicated Resident 15's bed probably should not have been left in the high position. During an interview on 09/23/24 at 3:19 P.M., RN 3 indicated the resident had a history of seizures. During an interview on 09/24/24 at 9:46 A.M., LPN (Licensed Practical Nurse) 4 indicated the resident was non-verbal, non-responsive, and unable to use their call light. The resident's hands were contracted. During an interview on 09/24/24 at 2:18 P.M., RN 3 indicated the resident was physically unable to adjust the height of their bed. Residents' beds should not be left in the high position when a resident was in the bed. Staff should not leave the bedside when a resident was in the bed and the bed was in the high position. The clinical record for Resident 15 was reviewed on 09/23/24 at 11:31 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/29/24, indicated the resident was rarely/never understood. The Resident's diagnoses included, but were not limited to, cancer, dementia, and seizure disorder. The resident's current Care Plans were provided by the Regional Director on 09/24/24 at 2:38 P.M., and included, but were not limited to, the following: - A Care Plan for Seizure Activity indicating the resident was at risk for injury, with interventions that included, but were not limited to, administering the medications of Lacosamide and Valporic Acid per the physician's orders, and - A Care Plan for Bed Mobility indicating the resident needed the assistance of two staff members due to cognitive loss, chronic pain syndrome, neoplasm of the brain, debility, and Alzheimer's disease. 3.1-45(a)(2)

Based on observation and interview, the facility failed to provide dining services in a sanitary manner related to clothing protectors and food service for 7 of 19 residents observed in the Main Dining Room, for 2 of 2 dining observations. (Residents 38, 106, 31, 137, 85, 86, and 109) Findings include: 1. Meal service was observed in the Main Dining Room on 09/17/24 at 12:03 P.M. AA (Activities Assistant) 2 held a clean stack of clothing protectors up against their chest touching their clothes, purse strap, and a coiled wrist band that was holding their keys. AA 2 assisted Resident 38, Resident 106, and Resident 31 with applying clothing protectors. At 12:06 P.M., AA 2 touched the front of their face mask, touched the remaining clothing protectors in their arms, then delivered a cup of fluid to Resident 31. AA 2 continued to hold the clothing protectors against their left chest, touching the coiled wrist band holding keys. AA 2 touched the front of their face mask again, took a cup from Resident 137, went to a drink station, touched the ice tongs, poured a drink from a common pitcher on counter into the cup, and returned the cup to Resident 137. AA 2 touched the front of their facemask, used hand sanitizer, and continued to hold clothing protectors to their chest. AA 2 put the clothing protectors down on an empty table and exited the Main Dining Room. 2. Meal service was observed in the Main Dining Room on 09/24/24 at 11:40 A.M. AA 2 used hand sanitizer, touched the front of their face mask, fixed a cup of cocoa at a common drink station, then served the cocoa to Resident 85. At 11:56 A.M., they fixed two cups of coffee and served them to Resident 86 and Resident 109. During an interview on 09/24/24 at 12:20 P.M., Administrator indicated staff members should not hold clean linens against their person and protective face masks should cover around the nose and mouth. The current LINEN, HANDLING policy, dated 12/2015, was provided by the Administrator on 09/24/24 at 12:28 P.M. The policy indicated, .The facility shall handle linen in a manner to prevent spread of infection .Linen will not be carried against the body . The current Glove Use & Meal Service policy, dated 05/2018, was provided by the Regional Director on 09/24/24 at 2:49 P.M. The policy indicated, .All objects (ie. watches) that could potentially contaminate food should be removed .If an employee .touches any area of their body - they MUST immediate [sic] wash their hands . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to transmission-based precautions for COVID-19 and wound care for 1 of 3 residents reviewed for COVID-19 and 1 of 6 residents observed for wound care. (Residents 20 and 69) Findings include: 1. During an observation on 09/18/24 at 10:39 A.M., Physical Therapist 8 was sitting in a chair in Resident 20's room with a gown, gloves, and a surgical mask on. After a few minutes he disposed of his gown, gloves, and surgical mask at the door and exited. Upon exiting the room he retrieved an N95 mask, out of a three-drawer cart outside the room and donned the mask. He then walked down the hallway to another resident's room that was not on and transmission-based precautions. The cart outside Resident 20's room contained N95 masks, gowns, gloves, and face shields. A sign on the door indicated the room was a red zone, transmission-based precautions and contact isolation. PPE (Personnel Protective Equipment) was required to enter the room. An N95 mask, face shield or goggles, gown, and gloves. During an observation on 09/24/24 9:59 A.M., Resident 20 was in her room with her call light on. There was a sign on the door that indicated the resident was in a red zone. A three-drawer cart outside the resident's room contained N95 masks, gowns, gloves, and face shields. During an observation on 09/24/24 at 10:08 A.M., LPN (Licensed Practical Nurse) 10 entered the resident's room wearing only a surgical mask. The LPN had a brief conversation with the resident and turned off the resident's call light. During an interview on 09/24/24 at 10:10 A.M., LPN 10 indicated he believed the resident had COVID. When entering a COVID room, staff should wear an N95 mask and a gown. He should have worn an N95 mask and a blue gown when he had entered the resident's room. During an interview on 09/24/24 at 3:10 P.M., the ADON (Assistant Director of Nursing) indicated the resident was COVID positive on 09/14/24 and would be able to come out of isolation on 09/25/24. Staff were to wear an N95 face mask, face shield, a gown, and gloves when entering the residents room. The clinical record for the resident was reviewed on 09/23/24 at 10:18 A.M. An Admission MDS (Minimum Data Set) assessment, dated 08/19/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, pulmonary embolism, anemia, anxiety, depression, and respiratory failure. The LTC (Long Term Care) Respiratory Surveillance Line List indicated Resident 20 had a positive nasal swab on 09/14/24. The current facility policy titled, ISOLATION (TRANSMISSION BASED PRECAUTIONS) GUIDELINES dated 10/2015 was provided by the ADON on 09/24/24 at 3:29 P.M. The policy indicated, .Isolation procedures (i.e., Transmission-Based Precautions) are designed to protect other residents, personnel and visitors from the spread of confirmed or suspected infection or contagious disease .The health care team and visitors should be instructed on the importance and necessity of maintaining precautions before entering the resident's room . 38239 2. On 09/20/24 at 11:34 A.M., RN 9 was observed as she provided wound care for Resident 69. The RN gathered supplies from her cart, entered the resident's room, and donned a gown and gloves. With her gloved hands she used the bed controller to raise the base of the bed, lower the head of the bed, and move the overbed table. She then closed the resident's door, adjusted the window blinds, and pulled the string to adjust the lighting above the bed. She opened a trash bag and placed it on the end of the bed and opened the wound dressing supplies. She sprayed cleanser on the gauze that was inside one package and labeled the dressing that was in the other package. The resident rolled to her side and the RN pulled the resident's blankets down and opened the resident's brief for access to the wound. There was no dressing on the wound. The wound was about 2 centimeters in diameter with a red wound bed, there were no signs of infection. The RN used a gauze pad and cleansed the wound. She then removed her gloves and washed her hands. During an interview on 09/20/24 at 2:35 P.M., RN 9 indicated she normally would not have had gloves on when she adjusted the resident's bed and blinds. She would normally do all of that stuff and then wash her hands and don gloves before cleansing the wound. The resident's clinical record was reviewed on 09/23/24 at 3:48 P.M. A Significant Change MDS assessment, dated 07/01/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cancer, atrial fibrillation, and hypertension. The resident had an Unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [non-viable tissue] or eschar [dead tissue] that was present on admission. The current facility policy, titled STEPS, INITIAL AND FINAL - PROVISION OF CARE, dated 10/2014, was provided by the ADON on 09/24/24 at 2:05 P.M. The policy indicated, .Gather supplies .close curtains, drapes, and doors .wash hands . The current facility policy, titled DRESSING - CLEAN TECHNIQUE, dated 10/2014, was provided by the ADON on 09/24/24 at 2:05 P.M. The policy indicated, .Perform necessary initial steps .remove gloves, wash hands, and put on a pair of clean gloves .cleanse wound . 3.1-18(b) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to provide prescribed medications for 1 of 5 residents reviewed for pharmacy services. (Resident F) Findings include: During an observation and interview on 05/02/24 at 1:48 P.M., Resident F was sitting in their room in a recliner. The resident indicated there were times when they had not been getting their medications like they were supposed to. The clinical record was reviewed on 05/02/24 at 11:25 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/17/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, and renal insufficiency. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for January 2024 was provided by the DON on 05/03/24 at 11:08 A.M. The resident had a physician's order for Furosemide tablet (water pill), 40 milligrams, twice a day, for hypertension, with a start date of 01/27/23 and a discontinued date of 01/31/24. The resident's record indicated the medication was not administered on the following dates and times: - On 01/03/24, 12:30 P.M. - 1:00 P.M., with the Reason/Comments listed as, Other and days, the charting on the EMAR was completed at 5:44 P.M., - On 01/06/24, 6:30 A.M. - 10:30 A.M., with the Reason/Comments listed as, Other and detained, the charting on the EMAR was completed at 2:15 P.M., - On 01/08/24, 6:30 A.M. - 10:30 A.M., with the Reason/Comments listed as, Other and detained, the charting on the EMAR was completed at 2:06 P.M., - On 01/11/24, 6:30 A.M. - 10:30 A.M., with the Reason/Comments listed as, Resident Unavailable, the charting on the EMAR was completed at 11:21 A.M., - On 01/16/24, 6:30 A.M. - 10:30 A.M., with the Reason/Comments listed as, Other and detained, the charting on the EMAR was completed at 1:18 P.M., - On 01/19/24, 12:30 P.M. - 1:00 P.M., with the Reason/Comments listed as, Other and days, the charting on the EMAR was completed at 2:40 P.M., and - On 01/27/24, 12:30 P.M. - 1:00 P.M., with the Reason/Comments listed as, Other and days, the charting on the EMAR was completed at 2:21 P.M. The complete Care Plan was provided by the DON on 5/03/24 at 2:08 P.M. The resident's plan of care for hypertension, with a reviewed date of 03/01/24, included, but was not limited to, an intervention to administer, furosemide per MD order. During an interview on 05/03/24 at 10:35 A.M., the DON indicated the staff should follow the physician's orders. No explanation was provided related to the Reasons/Comments on the EMAR. The current PHYSICIAN ORDERS policy, dated 10/2014, was provided by the DON on 05/03/24 at 1:50 P.M. The policy indicated, .Physician's order are administered upon the clear, complete and signed order of an individual lawfully authorized to prescribe .Facility nursing personnel will ensure clear, accurate and complete physician's orders .When an order is received, if there is any question regarding the .right dose .right frequency .the licensed nurse will attempt to contact the prescribing physician to obtain clarification of any order in question . This citation relates to Complaint IN00433659. 3.1-25(e)(3) 3.1-37(a)

Based on interview and record review, the facility failed to collect a urine sample in a timely manner, and notify the physician or attempt interventions for a resident's refusal of antibiotic administration related to a Urinary Tract Infection for 1 of 3 residents reviewed for Urinary Tract Infections. (Resident B) Findings include: The clinical record for Resident B was reviewed on 05/02/24 at 9:48 A.M. An Admission MDS assessment, dated 01/17/24, indicated the resident was severely cognitively impaired, occasionally incontinent of bladder and frequently incontinent of bowel. The diagnoses included, but were not limited to, stroke, dementia, Alzheimer's disease, seizure disorder, chronic pain, and anxiety. The EMAR/ETAR for February and March 2024, related to the resident's UTIs were provided by the DON on 05/03/24 at 1:50 P.M., and included, but were not limited to, the following physician's orders for specimen collection and antibiotics: The physician's order, with a start date of 02/02/24, on day shift with a discontinued dated of 02/06/24, indicated staff were to collect the specimen as soon as possible. The specimen was not collected until 02/05/24 on night shift. The resident was prescribed Macrobid 100 mg twice a day from 02/08/24 to 02/14/24. The record indicated the resident's medication of Macrbid was not administered on the following dates and times: - On 02/10/24, 6:30 A.M. - 2:30 P.M., with the Reason/Comments listed as, Refused, the charting on the EMAR was completed at 2:39 P.M., - On 02/12/24, 6:30 A.M. - 2:30 P.M., with the Reason/Comments listed as, Due to Condition, the charting on the EMAR was completed at 11:14 A.M., - On 02/12/24, 2:30 P.M. - 10:30 P.M., with the Reason/Comments listed as, Due to Condition, the charting on the EMAR was completed at 4:22 P.M., - On 02/13/24, 6:30 A.M. - 2:30 P.M., with the Reason/Comments listed as, Due to Condition, the charting on the EMAR was completed at 12:54 P.M., - On 02/14/24, 6:30 A.M. - 2:30 P.M., with the Reason/Comments listed as, Due to Condition, the charting on the EMAR was completed at 10:33 A.M., and - On 02/14/24, 2:30 P.M. - 10:30 P.M., with the Reason/Comments listed as, Refused, the charting on the EMAR was completed at 10:47 P.M. The physician's order, with a start date of 02/19/24 and a discontinued date of 02/19/24, indicated the specimen was to be collected as soon as possible. The special instructions indicated the order could be discontinued when the specimen was collected. The resident was prescribed Ciprofloxacin (antibiotic) 250 mg twice a day from 02/22/24 to 02/28/24. The clinical record indicated the resident's medication (Ciprofloxacin) was not administered on the following dates and times: - On 02/22/24, 2:30 P.M. - 10:30 P.M., with the Reason/Comments listed as, Refused, the charting on the EMAR was completed at 6:54 P.M., - On 02/26/24, 6:30 A.M. - 2:30 P.M., with the Reason/Comments listed as, Due to Condition, the charting on the EMAR was completed at 2:12 P.M., and - On 02/26/24, 2:30 P.M. - 10:30 P.M., with the Reason/Comments listed as, Other and 3rd, the charting on the EMAR was completed on 02/27/24 at 11:42 A.M. The physician's order, with a start date of 03/22/24 and a discontinued date of 03/23/24, indicated staff were to dip the resident's urine and if the urine dip test was positive they were to send the resident's urine for a Urinalysis with C&S as soon as possible. The special instructions indicated the order could be discontinued when the specimen was collected. The resident was prescribed Bactrim 800-160 mg twice a day from 03/24/24 to 03/30/24. The record indicated the medication was not administered on the following dates and times: - On 03/28/24, 6:30 A.M. - 10:30 A.M., with the Reason/Comments listed as, Refused, the charting on the EMAR was completed at 7:15 A.M., and - On 03/29/24, 6:30 A.M. - 10:30 A.M., with the Reason/Comments listed as, Refused, the charting on the EMAR was completed at 7:29 A.M. The resident's Mood and Behavior record lacked documentation of a specific time or interventions attempted for the resident's refusal of antibiotic administration, and there were no documented physician notification of the resident's refusals on the following dates: 02/10/24, 02/12/24, 02/13/24, 02/14/24, 02/22/24, 02/26/24, and 03/28/24. During an interview on 05/03/24 at 12:25 P.M., LPN (Licensed Practical Nurse) 2 indicated when getting a UA, she would hope the specimen would be collected within 24 hours of receiving the order. If a resident needed to be straight cathed it would be part of the physician's order. During an interview on 05/03/24 at 1:50 P.M., the DON indicated they did not have a policy on collecting urine specimens. This citation relates to Complaints IN00433423 and IN00433659. 3.1-41(a)(2)

Based on record review and interview, the facility failed to follow the physician's orders related to hold parameters for hypertension medications for 3 of 7 residents reviewed for unnecessary medications. (Residents 43, 18, and 24) Findings include: 1. The clinical record for Resident 43 was reviewed on 07/10/23 at 10:17 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/06/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, vertigo, hypertension, epistaxis (nose bleed), anxiety, and diabetes. The June and July 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration) indicated the resident had the following physician's orders: An open-ended physician's order, with a start date of 06/28/23, for Losartan 50 mg (milligrams) at bedtime, for hypertension, hold (do not give) for SBP (Systolic Blood Pressure, the top number) less than 130. The record indicated the resident received the medication when the blood pressure was too low per the physician's order on the following dates: - On 07/10/23 the resident's blood pressure was 117/72, - On 07/09/23 the resident's blood pressure was 124/61, - On 07/08/23 the resident's blood pressure was 123/60, and on - On 06/29/23 the resident's blood pressure was 99/64. A physician's order, with a start date of 03/01/23 and a discontinued date of 06/28/23, indicated the resident received Losartan 50. The staff were to hold the resident's medication for a SBP less than 130. The record indicated the resident received the medication when the blood pressure was too low per the physician's order on the following dates: - On 06/25/23 the resident's blood pressure was 124/61, - On 06/23/23 the resident's blood pressure was 108/77, - On 06/10/23 the resident's blood pressure was 124/59, - On 06/08/23 the resident's blood pressure was 129/72, - On 06/06/23 the resident's blood pressure was 102/63, and - On 06/04/23 the resident's blood pressure was 122/64. The Nurse's Notes for June and July 2023 lacked documentation the medication was held per the physician's orders. The resident's current Care Plan for hypertension was provided by the Regional Director on 07/12/23 at 1:25 P.M. Interventions included, but were not limited to, .Monitor blood pressure routinely and notify physician and resident representative per call order parameters . During an interview on 07/12/23 at 10:06 A.M., the ADON (Assistant Director of Nursing) indicated when a resident had a hold parameter it would be placed in the order for the specific medication. The medication should have been held per the physician's orders. If staff held a medication the EMAR would prompt them to choose a reason and that reason will be posted on the EMAR. 38769 2. The clinical record for Resident 18 was reviewed on 07/10/23 at 2:04 P.M. A Quarterly MDS assessment, dated 05/30/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, heart failure, anemia, hypertension, Alzheimer's dementia, malnutrition, anxiety, depression, and respiratory failure. An open-ended physician's order, with a start date of 05/23/23, indicated the resident was to receive metoprolol 50 mg, every 12 hours for hypertension. The medication was to be held if the systolic blood pressure was less than 120 or the heart rate was less than 60. The June and July 2023 EMAR/ETAR indicated the medication was administered to the resident on the following dates and times when the systolic blood pressure was less than 120: - On 06/02/23 at 7:00 A.M. when the resident's blood pressure was 100/61 and at 7:00 P.M. when the resident's blood pressure was 118/63, - On 06/03/23 at 7:00 P.M. when the resident's blood pressure was 112/67, - On 06/04/23 at 7:00 P.M. when the resident's blood pressure was 118/72, - On 06/05/23 at 7:00 A.M. when the resident's blood pressure was 110/74 and at 7:00 P.M. when the resident's blood pressure was 118/68, - On 06/07/23 at 7:00 A.M. when the resident's blood pressure was 118/68, - On 06/08/23 at 7:00 A.M. when the resident's blood pressure was 107/46, - On 06/09/23 at 7:00 P.M. when the resident's blood pressure was 112/74, - On 06/10/23 at 7:00 A.M. when the resident's blood pressure was 113/72, - On 06/11/23 at 7:00 P.M. when the resident's blood pressure was 116/67, - On 06/13/23 at 7:00 A.M. when the resident's blood pressure was 112/76 and at 7:00 P.M. when the resident's blood pressure was 112/76, - On 06/14/23 at 7:00 A.M. when the resident's blood pressure was 118/74, - On 06/20/23 at 7:00 A.M. when the resident's blood pressure was 112/78, - On 06/21/23 at 7:00 A.M. when the resident's blood pressure was 93/42, - On 06/23/23 at 7:00 A.M. when the resident's blood pressure was 112/72, - On 06/28/23 at 7:00 P.M. when the resident's blood pressure was 118/71, - On 06/29/23 at 7:00 A.M. when the resident's blood pressure was 118/71, and at 7:00 P.M. when the resident's blood pressure was 112/69, - On 07/05/23 at 7:00 A.M. when the resident's blood pressure was 119/68, - On 07/06/23 at 7:00 A.M. when the resident's blood pressure was 112/70 and at 7:00 P.M. when the resident's blood pressure was 116/78, - On 07/07/23 at 7:00 A.M. when the resident's blood pressure was 118/74, and - On 07/10/23 at 7:00 A.M. when the resident's blood pressure was 85/42. The nurse notes were reviewed and lacked documentation the medication was held on the above dates and times. 3. The clinical record for Resident 24 was reviewed on 07/10/23 at 1:37 P.M. A Quarterly MDS assessment, dated 04/26/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, cancer, anemia, heart failure, hypertension, anxiety, depression, and respiratory failure. A physician's order, dated 06/07/23 through 07/10/23, indicated the staff were to administer the resident's metoprolol 25 mg once a day for hypertension. The medication was to be held if the systolic blood pressure was less than 120 or the pulse was less than 60. The June and July 2023 EMAR/ETAR indicated the medication was administered to the resident on the following dates when the systolic blood pressure was less than 120: - On 06/09/23 when the resident's blood pressure was 117/98, - On 06/10/23 when the resident's blood pressure was 107/58, - On 06/13/23 when the resident's blood pressure was 114/74, - On 06/19/23 when the resident's blood pressure was 98/65, - On 06/20/23 when the resident's blood pressure was 83/49, - On 06/25/23 when the resident's blood pressure was 100/54, - On 06/28/23 when the resident's blood pressure was 107/65, - On 06/29/23 when the resident's blood pressure was 92/54, - On 07/05/23 when the resident's blood pressure was 95/87, and - On 07/08/23 when the resident's blood pressure was 92/60. The nurse notes were reviewed and lacked documentation the medication was held on the above dates. An open-ended physician's order, with a start date of 04/27/23, indicated the staff were to administer the resident's midodrine 10 mg, three times a day, for hypotention. The medication was to be held if the systolic blood pressure was greater than 130. The June EMAR/ETAR indicated the medication was administered to the resident on the following dates and times when the systolic blood pressure was greater than 130: - On 06/02/23 at 7:30 P.M., when the resident's blood pressure was 131/68, - On 06/16/23 at 7:30 A.M., when the resident's blood pressure was 147/62, - On 06/21/23 at 3:30 P.M., when the resident's blood pressure was 136/62, - On 06/22/23 at 7:30 P.M., when the resident's blood pressure was 149/45, - On 06/23/23 at 3:30 P.M., when the resident's blood pressure was 140/60, - On 06/26/23 at 7:30 P.M., when the resident's blood pressure was 134/63, - On 06/27/23 at 7:30 P.M., when the resident's blood pressure was 143/61, and - On 06/29/23 at 7:30 P.M., when the resident's blood pressure was 146/69. The nurse notes were reviewed and lacked documentation the medication was held on the above dates. The current facility policy titled, Medication Administration with a revision date of 4/2017 and was provided by the Regional Director on 07/12/23 at 2:07 P.M. The policy indicated, .To safely administer medications as per physicians' orders .Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs. Notify the physician if the vital signs are not within the acceptable range . 3.1-48(a)(3)

Based on record review, interview, and observation, the facility failed to follow physician's orders related to medication administration parameters for cardiac medications for 1 of 7 residents reviewed for medications (Resident 12), complete neurological assessments after a fall for 1 of 4 residents reviewed for accidents (Resident 8) and follow manufacturer's guidelines related to insulin pen usage for 3 of 3 insulin medication administrations. (Residents 51, 15, and 3) Findings include: 1. Resident 12's clinical record was reviewed on 07/11/23 at 9:30 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/27/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure and hypertension. The resident's current MD orders included an open-ended order, with a start date of 01/27/23, for metoprolol succinate (a cardiac medication), 50 mg (milligrams) extended-release tablet once a day. The medication was to be held if the resident's pulse was less than 60 and their SBP (systolic blood pressure) was less than 90. During an interview on 07/11/23 at 10:24 A.M., LPN (Licensed Practical Nurse) 9 indicated the resident did have a medication that had hold parameters, she thought it was the resident's pulse that needed to be assessed prior to medication administration. Nursing staff were to obtain the vital sign required by the MD before administering the medication. If the resident's pulse was outside of the administration parameters, she would not administer the medication and would notify the MD or Nurse Practitioner. The resident's May, June, and July 2023 EMAR (Electronic Medication Administration Record) indicated the metoprolol medication had been administered every day. The resident's pulse was assessed and documented on the EMAR. The EMAR lacked documentation of assessment of the resident's blood pressure before the medication was administered. During an interview on 07/13/23 at 10:05 A.M., LPN 9 indicated the resident's pulse was assessed before administering the medication, but the resident's blood pressure was not assessed. The MD order indicated the resident's pulse and blood pressure was to be assessed, but there was no space on the EMAR to document the blood pressure reading. The resident's blood pressure should have been assessed prior to administering the medication. The resident's Care Plans were reviewed on 07/12/23 at 1:52 P.M., and included a hypertension care plan, dated 01/30/23 with a revision date of 05/01/23. The interventions included, but were not limited to, administer medications as ordered, administer metoprolol as ordered. The current facility policy titled, Medication Administration with a revision date of 4/2017 and was provided by the Regional Director on 07/12/23 at 2:07 P.M. The policy indicated, .To safely administer medications as per physicians' orders .Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs. Notify the physician if the vital signs are not within the acceptable range . 2. Resident 8 was observed in his room in bed on 07/06/23 at 1:28 P.M. The resident indicated he had fallen a few times a while ago. He had some bumps and bruises from the falls and injured his shoulder. He hadn't had any recent falls. The resident's clinical record was reviewed on 07/12/23 at 1:39 P.M. A Significant Change MDS assessment, dated 05/10/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, anxiety, and diabetes. The resident required limited staff assistance with transfers and personal hygiene, extensive staff assistance with toileting, and supervision for walking. The resident had one fall without injury since the last assessment. A packet, titled ACCIDENT & INCIDENT REPORT AND INVESTIGATION, was provided by the DON on 07/12/23 at 11:39 A.M. The documents indicated the resident experienced a fall on 05/21/23 at 4:30 A.M. The description indicated the resident was found sitting on the floor by the bathroom door in his room with his head against wall. The wall was noted to have blood on it. The resident was noted to have abrasion on the back of his head from rubbing his head against the wall. There were no other injuries noted. The resident was able to move his extremities normally except for the arm with the dislocated shoulder (fall records indicated the resident fell on [DATE] and dislocated his right shoulder). Neuro (Neurological) checks were initiated. The neurologic check flow sheet in the packet indicated the assessment frequency for the neuro checks. The resident was to be assessed as follows: - an initial check, - every 15 minutes x (times) 3, - every hour x 3, and - every 4 hours x 17, for a total of 72 hours of neuro checks. The resident's neurological check flowsheet lacked documentation of neuro checks after the first four assessments. During an interview on 07/11/23 at 10:55 A.M., LPN 9 indicated nursing staff were to initiate and complete neuro checks for any unwitnessed fall or fall with a head injury. During an interview on 07/12/23 at 11:21 A.M., the DON indicated it looked like the neurochecks for the fall on 05/21/23 at 4:30 A.M. were not complete. The current facility policy, titled NEUROLOGICAL ASSESSMENT, with a most recent revision date of 03/19, was provided by the Regional Director on 07/13/23 at 11:45 A.M. The policy indicated, .Neurological assessment, is to be completed in all cases of head injury to the resident (when suspected or known) at the following frequency: every 15 min x 1 hour; every hour x 3 hours; every 4 hours to complete 72 hours . 33613 3.a. During an observation on 07/07/23 at 11:45 A.M., LPN (Licensed Practical Nurse) 3 entered Resident 51's room to administer a sliding scale dose of insulin. The LPN primed two units on the Novolog insulin pen, with the cap on the needle she pointed the pen downward and dispensed the two units. LPN 3 then dialed the sliding scale dose of six units on the Novolog insulin pen and injected the insulin into the resident. b. During an observation on 07/10/23 at 11:50 A.M., LPN 4 entered Resident 15's room to administer a sliding scale dose of insulin. The LPN primed the Novolog insulin pen with two units, with the needle exposed she pointed the pen downward toward the trash can and dispensed the two units. LPN 4 then dialed the sliding scale dose of four units on the Novolog insulin pen and injected the insulin into the resident's left arm. c. During an observation on 07/11/23 at 11:45 A.M., RN 5 removed Resident 3's Humalog insulin pen from the medication cart, removed the pen cap, cleaned the tip of the pen, applied a new needle, removed the needle cap, primed the pen with two units of insulin, pointed the pen downward and dispensed the two units. RN 5 then dialed the sliding scale dose of three units and injected the Humalog insulin into the resident's left arm. During an interview on 07/11/23 at 11:55 A.M., RN 5 indicated she should have held the insulin pen upright when priming the pen with the two units. The current Novolog Package Insert, with a revised date of 09/11/2015, was provided by the DON on 07/11/23 at 12:24 P.M. The insert indicated, .Before each injection .Wipe the Rubber Seal with an alcohol swab. To avoid injecting air and to ensure proper dosing .Turn the dose selector to select 2 units. Hold your Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the bottom all the way in .A drop of insulin should appear at the needle tip . The current Humalog Package Insert, with a revised date of November 2015, was provided by the DON on 07/11/23 at 12:24 P.M. The insert indicated, .To prime your Pen, turn the Dose Knob to select 2 units, Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with the Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window . The current Insulin Injections policy, with a revised date of 07/2019, was provided by the DON (Director of Nursing) on 07/11/23 at 12:24 P.M. The policy lacked instructions for insulin pens. 3.1-37(a) 3.1-47(a)(1)

Based on interview, observation, and record review, the facility failed to identify pressure ulcers and follow interventions for pressure ulcers for 2 of 8 residents reviewed for pressure ulcers. (Residents 36 and 18) Findings include: 1. During an interview on 07/07/23 at 10:06 A.M., Resident 36 indicated she had little sores on her toes. During an observation on 07/10/23 at 1:24 P.M., Resident 36 was lying in her bed on her back with her feet curled up. During an observation on 07/11/23 at 10:08 A.M., Resident 36 was lying in her bed on her back with her feet curled up. During an observation on 07/12/23 at 9:59 A.M., Resident 36 was lying in her bed on her back with her feet curled up. During an interview on 07/12/23 at 10:04 A.M., LPN (Licensed Practical Nurse) 9 indicated the resident was pleasantly confused and required assistance of one staff member for activities of daily living. The resident had no sores at the time. During an observation and interview on 07/12/23 at 11:35 A.M., the ADON (Assistant Director of Nursing) had obtained permission from the resident to assess her feet. She propelled the resident to her room. The resident indicated her right toe was sore and her left foot was hurting also. The ADON applied gloves and removed the resident's right sock, and the following was observed: - The resident's right great toe had an area that measured 0.3 cm (centimeters) x (by) 0.3 cm. The area was pinkish in color. - The resident's right second toe had an area that covered the joints of the toe that measured 1 cm x 1.2 cm with a dark black center. The toe was bright red where it connected to the foot. The ADON indicated the wound had necrotic tissue. She removed the sock on the resident's left foot and the resident had an area to the inner heel that measured 2 cm x 2.2 cm. The wound had a necrotic center and white area around the outer side. The resident indicated the toe and heel were tender. The ADON indicated it was a deep tissue injury. She was unaware of the resident having any skin concerns. When the staff found a skin concern, they were to fill out a skin sheet and submit it to her. During an interview on 07/12/23 at 11:49 A.M., CNA (Certified Nurse Aide) 16 indicated she worked with Resident 36 frequently and she was unaware that the resident had any skin concerns until the ADON had just mentioned them to her. She had assisted the resident with getting dressed that morning. She always checked the residents' bottoms and under their breasts for skin concerns but had never thought to look at their feet. She would alert the nurse of new concerns. The clinical record for the resident was reviewed on 07/10/23 at 2:20 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 04/11/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, left femur fracture, anemia, Alzheimer's disease, anxiety, and depression. She was always incontinent of bowel and bladder and required total assistance of two or more staff with bed mobility, toileting, and transfers. She required extensive assist of one staff member for dressing and personal hygiene. The resident was at risk for development of pressure ulcer. The weekly skin assessment, nurse notes, and shower sheets lacked documentation the resident had any skin concerns. 2. During an observation and interview on 07/06/23 at 1:07 P.M., Resident 18 had soft foam boots sitting in her recliner and her feet were resting on the bed. She indicated the boots had been in her chair all day. During an observation on 07/11/23 at 2:21 P.M., the resident was lying in bed with her soft boots on. The ADON obtained permission to remove the boots and look at her heels. The boots were removed. The left heel skin was intact with no redness present. The right heel skin was intact with minimal redness. During an interview on 07/11/23 at 2:36 P.M., RN 14 indicated the resident wore soft boots for pressure ulcer prevention. During an interview on 07/12/23 at 11:30 A.M., the ADON indicated the resident had boggy heels that started in June. During an interview on 07/13/23 at 1:52 P.M., CNA 13 indicated the resident had soft boots she was supposed to wear while she was in bed. She started wearing the boots within the last couple of months. The clinical record for Resident 18 was reviewed on 07/10/23 at 2:04 P.M. A Quarterly MDS assessment, dated 05/30/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, heart failure, anemia, hypertension, Alzheimer's dementia, malnutrition, anxiety, depression, and respiratory failure. The resident was at risk for development of pressure ulcers. An Initial Pressure Ulcer Assessment, dated 06/01/23, indicated the resident had a Stage 1 pressure ulcer to the left heel that measured 0.2 cm X 0.2 cm. The wound was intact with a pink wound bed. The area resolved on 07/04/23. An Initial Pressure Ulcer Assessment, dated 06/01/23, indicated the resident had a Stage 1 pressure ulcer to the right heel that measured 0.2 cm X 0.2 cm. The wound was intact with a pink wound bed. The area was resolved on 07/04/23 with a new skin assessment completed for boggy bilateral heels. An Initial Pressure Ulcer Assessment, dated 07/04/23, indicated the resident had boggy bilateral heels. The wound bed was pink blanching skin with pink wound edges. An open-ended physician's order, with a start date of 06/23/23, indicated to apply skin prep to the left heel at night and apply boot to foot. An open-ended physician's order, with a start date of 06/23/23, indicated to apply skin prep to the right heel at night and apply boot to foot. The July 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked documentation that the resident had refused to wear the boots on 07/06/23. The current facility policy, titled Pressure Ulcers dated 10/2014 was provided by the Regional Director on 07/13/23 at 11:55 A.M. The policy indicated, .To assure that residents with pressure ulcers will receive necessary care and treatment to promote healing, prevent new ulcers from developing and prevent infection. The current facility policy, titled Pressure Ulcer Prevention dated 10/2014 was provided by the Regional Director on 07/13/23 at 11:55 A.M. The policy indicated, .To prevent pressure ulcers and promote healing .heel boots .Inspect skin for redness/open areas during provision of daily care . 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident with limited mobility received restorative nursing services for 1 of 3 residents reviewed for restorative services. (Resident 8) Findings include: Resident 8 was observed in his room in bed on 07/06/23 at 1:28 P.M. The resident indicated he had fallen a few times a while ago. He had some bumps and bruises from the falls and injured his shoulder. He hadn't had any recent falls. The resident's clinical record was reviewed on 07/12/23 at 1:39 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/10/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, dementia, anxiety, and diabetes. The resident required limited staff assistance with transfers and personal hygiene, extensive staff assistance with toileting, and supervision for walking. The resident had one fall without injury since the last assessment. The resident participated in speech, occupational, and physical therapy since the last assessment. During an interview on 07/10/23 at 11:18 A.M., the Therapy Manager indicated the resident had experienced some falls recently. The resident participated in physical therapy and was discharged from physical therapy with a restorative nursing program on 06/12/23. They had two restorative aides that tried to see the residents on the restorative program 2 to 5 times a week. The aides kept daily notes of the residents they saw and what type of restorative services they provided in addition to a monthly tracking log for each resident. If a resident refused restorative services, the aides were to indicate the refusal on the monthly tracking log. The resident was on a restorative program for walking and to improve his strength. The Therapy Manager reviewed the monthly tracking logs for the resident for June and July 2023 and indicated the only documentation on the tracking log was that the resident refused to participate in the restorative program on 07/06/23. The Therapy Manager reviewed the Restorative Aide Daily Notes from 06/12/23 to 07/07/23 and indicated the only time the resident was listed on the daily notes was on 07/06/23 when he refused services. The resident's restorative program was provided by the Therapy Manager on 07/12/23 at 3:02 P.M. The program indicated the resident was enrolled in walking and strength programs, with a start date of 06/12/23. Specific program instructions included, but were not limited to the following: - Ambulate 100 feet with handheld support down the hallway, and - Perform bilateral lower extremity active range of motion exercises in a sitting or supine position, 10 repetitions x (times) 2 sets. The goal was to maintain the residents' mobility and the restorative program was signed by PT (Physical Therapist) 10. During an interview on 07/12/23 at 2:59 P.M., the Therapy Manager indicated she looked into what happened with the resident and it seemed each of the restorative aides thought the other one was working with the resident so neither of them put the resident on their list for restorative services until 07/06/23. During an interview on 07/13/23 at 11:32 A.M., PT 10 indicated the resident was discharged from therapy (6/12/23) and a restorative program was initiated for the resident. The resident was expected to participate in a restorative program. The current facility policy, titled RESTORATIVE NURSING SERVICES, dated 10/2014, was provided by the Regional Director on 07/13/23 at 12:06 P.M. The policy indicated, .Residents identified as those who would benefit from restorative nursing services shall have the appropriate services initiated . 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to investigate a fall for 1 of 4 residents reviewed for accidents. (Resident 90) Findings include: During an observation and interview on 07/10/23 at 10:35 A.M., Resident 90 was sitting in her recliner in her room. She indicated she had a fall at home and broke her wrist, multiple ribs, and one side of her collar bone. While in the facility she had a fall that sent her to the hospital. Her family member was with her, and she was trying to move to her recliner from her wheelchair when she fell . She hit her left side. She lost consciousness for a while and was sent to the hospital. She stayed at the hospital for about four days. During an interview on 07/11/23 at 2:26 P.M., RN 14 indicated the resident had admitted to the facility with a broken collar bone, radial fracture, and broken ribs. She had an unsteady gait. Since she admitted to the facility, she had a fall that resulted in her going to the hospital. The family member was with the resident at the time of the fall. LPN (Licensed Practical Nurse) 15 was on duty the night of the fall. During an interview on 07/11/23 at 2:42 P.M., LPN 15 indicated on the night of the incident on June 11th, she was at the medication cart when she heard the family member's voice call out to the resident. She and a CNA (Certified Nurse Aide) started going to the room at the same time. Resident 90 was lying on the floor on her left side and was unresponsive but breathing. The family member indicated the resident had just fell to the floor like a tree falling to the ground. She obtained the residents vital signs and called 911. By the time the emergency transport arrived the resident had regained consciousness. She was alert with slurred speech. The resident was admitted to the hospital with a brain bleed and a broken clavicle. When a resident had a fall, the nurse would complete a fall report and then submit it to the DON (Director of Nursing). She wasn't sure that she completed a fall report for the resident's fall. But she did complete a nurse note. The clinical record for the resident was reviewed on 07/10/23 at 11:28 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 06/20/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Parkinson's disease, malnutrition, anxiety, and depression. A Nurse Note, dated 05/11/23 ( 06/11/23 per LPN 15) at 3:45 P.M., indicated the nurse was in the hallway and she heard a noise and a man asking for help. The nurse went to the resident's room and the resident was lying on their left side, unresponsive with pursed lip breathing. The family member was in the room with the resident at the time of the incident and indicated the resident was standing to sit in the recliner from her wheelchair and she fell to the ground. The resident's blood pressure was 167/78, pulse was 92, respirations were 18, and the oxygen was 94%. She called 911 and the resident had regained consciousness prior to the emergency personnel arriving. The resident was able to answer questions appropriately with slurred speech. The DON and MD had been made aware. A hospital record, dated 06/11/23, indicated the resident was getting up and had a fall and hit her head and lost consciousness. She denied significant headache or dizziness. There were no changes in her vision. She complained of clavicle discomfort. A Hospital Discharge Summary, dated 06/15/23, indicated the resident discharge diagnoses included, but were not limited to: - acute intraparenchymal hemorrhage along the left frontal convexity, and - bilateral clavicle fracture, she had initially broken the left side approximately 6 weeks ago and broke the right side from a fall on 06/11/23. The clinical record lacked a documented fall incident report or investigation. During an interview on 07/11/23 at 3:03 P.M., the DON indicated a fall report was not completed for the fall and should have been. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to urinary catheters for a resident who had a history of urinary tract infections for 1 of 2 residents reviewed for urinary catheters/UTIs. (Resident 58) Findings include: During a continuous observation and interview on 07/06/23 at 1:37 P.M., Resident 58 was sitting in a recliner in his room. His urinary catheter bag was hanging on the side of a small trash can that was sitting next to his chair. The bottom inch or two of the urinary catheter bag was in a wash pan that was sitting on the floor next to the trash can. At 1:43 P.M., Student Nurse Aide 2 entered the room to empty the resident's catheter bad. She donned gloves in the bathroom, checked the catheter bag, saw that it didn't have very much urine in it, decided to not empty the catheter bag, left it hanging on the side of the small trash can, and exited the room. During an interview on 07/12/23 at 10:12 A.M., the ADON indicated the resident had a urinary catheter due to his BPH (Benign Prostate Hyperplasia) and was followed by urology. Staff were trained on urinary catheter care upon hire and at least annually. The resident had had several UTI's (Urinary Tract Infections). He was admitted with one and was currently on an antibiotic a preventative measure. The catheter bag should be hanging below the bladder and not on the floor. Catheters should be hanging on the frame of the bed in a privacy bag. When up in a recliner the bag should not be hanging on a trash can. It could be placed in a wash basin free of contaminants. The clinical record was reviewed on 07/11/23 at 10:20 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/16/23, indicated the resident was moderately cognitively impaired. The resident had an indwelling catheter and was occasionally incontinent of bowel. The diagnoses included, but were not limited to, cancer, heart failure, obstructive uropathy, and a UTI in the last 30 days. The current urinary catheter Care Plan was provided by the Regional Director on 07/12/23 at 11:05 A.M. The Care Plan indicated the goal was for the resident to be free from signs and symptoms of infection. The resident had a current physician's order for Macrodantin, an antibiotic, 50 mg at bedtime with a start date of 05/17/23, for lower urinary tract symptoms and the following order history for antibiotics for a UTI: - Doxycyline 100 mg twice a day from 06/21/23 to 06/28/23, - Macrobid 100 mg every 12 hours from 04/30/23 to 05/05/23, - Macrobid 100 mg every 12 hours from 04/24/23 to 04/29/23, and - Macrobid 100 mg every 12 hours from 03/15/23 to 03/22/23. The current Urinary Catheter policy, dated 10/2014, was provided by the Regional Director on 07/12/23 at 1:25 P.M. The policy indicated, .Care provided for an indwelling catheter will promote good hygiene and reduce the potential for infection . 3.1-41(a)(2)

Based on interview and record review the facility failed to ensure a resident was free from physical and verbal abuse resulting in an immediate change of behavior. (Resident B) Using the reasonable person concept, it is likely this would lead to recurrent fear, anxiety or depression. Findings include: During an interview on 4/15/21 at 9:40 a.m., the Director of Nursing (DON) indicated there was a staff to resident incident on the locked memory unit. On 4/15/21 at 10:00 a.m., the Administrator provided an Incident Report dated 4/8/21 at 7:15 p.m. The report indicated Certified Nursing Aide (CNA) 2 had witnessed Registered Nurse (RN) 3 strike Resident B. The clinical record for Resident B was reviewed on 4/15/21 at 10:28 a.m. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 2/27/20 and revised on 1/25/21, indicated the resident had a cognitive loss with difficulty understanding and making herself understood. A Progress Note, dated 4/8/21 at 7:20 p.m., indicated CNA 2 reported to RN 4 that she had witnessed RN 3 smack Resident B. RN 4 immediately went to the locked unit and asked RN 3 if she struck Resident B. RN 3 indicated, I might have. During an interview on 4/15/21 at 11:00 a.m., CNA 2 indicated she had been down the hall on the locked unit assisting another resident. She was coming up the hall and observed Resident B sitting in the lounge area. The resident was carrying on making noises and not making sense. The resident was wound up, but her behavior was normal for her. She observed RN 3 get up close to the resident and then she slapped Resident B in the face and told her to shut the f . up. The RN then turned and saw the CNA with a shocked look on her face. The slap was loud enough to be heard from down the hall. After the resident was slapped she stopped making noises for about 10 minutes. During an interview on 4/15/21 at 12:22 p.m., RN 4 indicated on 4/8/21 there was an incident on the locked unit. She was on the other side of the building and had received a report on three maybe four residents, when CNA 2 came over and told her RN 3 had just hit a resident. She immediately went to the locked unit, and verified Resident B was ok. RN 3 was standing at the medication cart. RN 4 asked RN 3 if she just hit one of the residents. RN 3 indicated I guess I did. During an interview on 4/15/21 at 2:15 p.m., the Assistant Director of Nursing (ADON) indicated RN 3 was acting like her normal self during the time she was with her after the incident on the 4/8/21. On 4/15/21 at 2:40 p.m., the Administrator provided a hand written statement dated 4/8/21 at 7:45 p.m. and signed by RN 3. The statement indicated RN 3 couldn't stand the guttural sounds Resident B was making. She asked Resident B to be quiet and slapped her with an open hand, hitting her nose. During an interview on 4/15/21 at 3:18 p.m., the Administrator indicated RN 3 was reported to have been acting her normal self prior to the incident. The current facility policy Abuse Prohibition, Reporting and Investigation and dated 9/17, was provided by the Administrator on 4/15/21 at 9:52 a.m. The policy indicated, .This facility shall prohibit and prevent abuse .This includes but is not limited to freedom from . verbal abuse .physical abuse .Willful .means the individual must have acted deliberately .Physical Abuse includes .slapping .Verbal Abuse includes .disparaging and derogatory terms, regardless of .ability to comprehend .1. This facility shall not permit residents to be subjected to abuse by anyone . Although Resident B, showed immediate change in behavior in response to the incident that occurred on 4/8/21, using the reasonable person concept it is likely that a vulnerable person who is unable to defend herself could experience chronic or recurrent fear, anxiety or depression. According to the National Institute of Aging website found at www.nia.nih.gov/health/elder-abuse#effect, .Any type of mistreatment can leave the abused person feeling fearful and depressed. Sometimes, the victim thinks the abuse is his or her fault This Federal tag relates to Complaint IN 293.

Based on interview and record review, the facility failed to ensure residents' medications were administered as ordered by the physician for 2 of 3 residents reviewed for medication administration resulting in 1 resident having a [MEDICAL CONDITION] and 1 resident having pain. (Residents B and C) Findings include: 1. The clinical record for Resident B was reviewed on 9/21/17 at 3:00 P.M. [DIAGNOSES REDACTED]. A Nursing Progress note, dated 9/15/17 at 9:45 A.M., indicated the nurse was notified Resident B was having a [MEDICAL CONDITION] in the activity room [MEDICATION NAME] for approximately 2 minutes. On 9/22/17 at 12:25 P.M. during an interview with the Regional Director of Clinical Operations, she indicated during a medication audit medications were signed out on the MAR (Medication Administration Record) but were not signed out on the Narcotic Count Sheets. This indicated Resident B had missed medication doses on the evening of 9/14/17. The resident had a [MEDICAL CONDITION] medication due that was not given and the resident was noted to have had a [MEDICAL CONDITION] on the morning of 9/15/17. The Physician orders [REDACTED].M. with a start date of 5/28/17 and [MEDICATION NAME] 32.4 mg tablet to be administered two at 8:00 A.M. with a start date of 5/29/17, [MEDICATION NAME] 2 mg tablet to be administered two times a day for [MEDICAL CONDITION] with a start date of 5/28/17, and [MEDICATION NAME] 200 mg tablet to be administered two times a day for [MEDICAL CONDITION] with a start date of 7/31/17. On 9/22/17 at 12:35 P.M. during an interview with Registered Nurse (RN) 2, she indicated management had looked at the Narcotic Book and noted three night time narcotics were not signed out for Resident B but they had been signed out on the MAR. The narcotic count sheets and the narcotic pill count matched. On Friday 9/15/17 it was discovered the 9/14/17 medications for Resident B were not given. A Nursing Progress note, dated 9/21/17 at 8:30 A.M., indicated a medication error had occurred. A Nursing Progress note, dated 9/21/17 at 6:47 P.M., indicated Resident B was noted to be sitting at the nurse's desk, made a loud noise, and had [MEDICAL CONDITION] type activity. On 9/22/17 at 1:40 P.M. during an interview with Resident B's family member, she indicated she was here on the evening of 9/21/17. She recalled the nurse saying [MEDICATION NAME] 2 tablets. The next morning at 8:37 A.M. the Unit Manager called to let her know the resident had only received two tablets on 9/20/17 for her night time dose and she should have received three tablets. On 9/22/17 at 2:30 P.M. during an interview with Licensed Practical Nurse (LPN) 3, she indicated while doing a narcotic count it was discovered the 9/21/17 dose had been administered incorrectly as two pills and not three pills given. 2. The clinical record for Resident C was reviewed on 9/21/17 at 4:00 P.M. [DIAGNOSES REDACTED]. The physician order's for Resident C's medications included, but was not limited to, [MEDICATION NAME] 50 mg (milligrams) one capsule three times a day for pain with a start date of 2/12/16. A Nursing Progress note, dated 9/16/17 at 00:02 A.M., indicated Resident C's bedtime dose of [MEDICATION NAME] due on 9/15/17 was unavailable. There was no pain assessment noted. A Nursing Progress note, dated 9/16/17 at 00:07 A.M., indicated the [MEDICATION NAME] was not given as it was not available in the EDK (Emergency Drug Kit). A Nursing Progress note, dated 9/16/17 at 7:30 A.M., indicated the [MEDICATION NAME] was not given and not available in the EDK (Emergency Drug Kit). There was no pain assessment noted. On 9/22/17 at 10:35 A.M. during an interview with Resident C, she indicated sometimes her legs hurt. Not sure of the days but sometimes they hurt. On 9/22/17 at 11:45 A.M., during an interview with the Director of Nursing (DON), she indicated Resident C's [MEDICATION NAME] was signed in on 9/13/17 at 3:43 A.M., but it had not actually been received. When they checked the morning of 9/13/17 they found it was not here. A record review of the Incident Report dated 9/15/17 was provided and review at that time and indicated the [MEDICATION NAME] had been signed off on the MAR but had not been given. A Narcotic Count Sheet for the month of September was provided and reviewed at that time. The count sheet indicated Resident C had not received [MEDICATION NAME] on 9/11/17 or on 9/12/17. The current facility policy, titled Oral Medication Administration and dated 4/28/09, was provided by the DON on 9/22/17 at 3:12 P.M. and was reviewed at that time. The policy indicated .Procedure .Right Time . The current facility policy, titled .Medication Errors and dated 9/21/16, was provided by the DON on 9/22/17 at 3:25 P.M. and was reviewed at that time. The policy indicated .administering a drug 60 minutes earlier or later than its scheduled time of administration .cause the patient discomfort or jeopardize the patient's health and safety . This Federal Tag relates to Complaint IN 017. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to prevent the acquisition and the increase in size of a pressure ulcer on a resident's heel resulting in an unstageable wound for 1 of 3 residents reviewed for pressure ulcers. (Resident 116) Findings include: During an observation of a dressing change on 07/24/2017 at 3:02 P.M., Resident 116 was noted to have an unstageable (full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcer on his left heel. During an interview on 07/21/2017 at 1:33 P.M., Resident 116's POA (Power of Attorney) indicated he was concerned about a wound on the resident's heel. The facility frequently failed to get the resident to his appointments at the wound care facility. The resident had missed his appointment today and several appointments at the wound care facility. The POA usually went with the resident to his appointments. The resident often did not have his pressure relieving boots on or lotion applied to his legs and feet by staff. During an interview on 07/25/2017 at 4:27 P.M., the wound care nurse indicated Resident 116 had appointments every 1 to 2 weeks. At times the resident came too late to be seen or did not show up at all. The long term care facility would indicate the resident did not have transportation or they did not know he had an appointment. During an interview on 07/28/2017 at 8:20 A.M., the wound care assistant indicated the resident rarely came to his appointments wearing his prescribed pressure relieving footwear nor were his feet elevated. The repeated exclamation points on the Physician order [REDACTED]. During an interview on 07/28/2017 at 8:40 A.M., the wound care physician indicated the lack of following orders and missed appointments had contributed to the increase in size and the delay in healing of the pressure ulcer on Resident 116's heel. The resident had arrived at the wound clinic on several occasions without a dressing on the heel or wearing the prescribed pressure relieving boots. The appointment record was provided by the wound care center on 07/27/2017 at 12:28 P.M. and reviewed at that time. The record indicated Resident 116 missed appointments on 04/26/2017, 06/02/2017, and 07/07/2017. The wound care facility assessment records were provided by Corporate Nurse 1 on 07/28/2017 at 2:25 P.M. and reviewed at that time. The records indicated the heel wound was first acquired on 02/22/2017 and assessed on 03/08/2017 by the wound care center. The wound measured 2.2 x 2.3 x 0.1 cm (centimeters), was open, and classified as unstageable. The wound record, dated 07/14/2017 indicated the wound measured 3.5 x 6.5 x 0.2 cm, was open, and classified as unstageable. The orders dated 04/12/2017, 04/19/2017, 05/03/2017, and 07/14/2017 included, but were not limited to, apply moisturizing lotion to surrounding skin and wear pressure relieving boots at all times. The current Prevention and treatment of [REDACTED].M. and reviewed at that time. The policy indicated, .Pressure ulcer .related interventions are created .and implemented in order to .prevent or reduce the risk of acquiring pressure .related wounds or skin issues . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the resident had on proper foot ware and devices were in place to prevent a fall from bed - resulting in a facial injury for 1 of 3 residents reviewed for falls. (Resident C) Findings include: During an observation on 6/5/17 at 5:45 PM, Resident C was observed sitting in her wheelchair in her room. The resident had a yellowish discoloration with small scattered bruises to the left orbital area. Her feet were covered with plain white socks. The resident did not have non-skid socks, shoes, or z-boots on her feet. The clinical record for Resident C was reviewed on 6/5/17 at 5:15 P.M. The Care Plan for falls indicated the resident was at risk for falls related to a history of falls, medications, confusion, and required assistance with transfers and bed mobility. Interventions for this care area included, but were not limited to, provide non-skid footwear, low air mattress must have bolsters, and be on the correct setting. The resident had documented falls, dated 5/30/2017 and 3/24/2017. The MDS (Minimum Data Set) Quarterly Review assessment, dated 5/23/17, indicated Resident C had a BIMS (Brief Interview of Mental Status) score of 9, which indicated the resident was moderately cognitively impaired. The [DIAGNOSES REDACTED]. The resident required extensive, two person assistance for bed mobility, transfers, and was totally dependent on staff for dressing. The resident was not steady and was only able to stabilize with human assistance for moving from seated to standing position in order to pivot. The Post Fall Investigation, dated 03/24/2017 at 8:30 P.M., indicated Resident C was found on the floor in her room. The resident was barefoot and had no injuries. The Incident Note, dated 03/27/2017 at 9:34 A.M. of the IDT (Interdisciplinary Team) review, indicated the resident was sitting on the side of her bed and was bare footed when she was found on the floor. The Post Fall Investigation, dated 05/15/2017 at 4:15 A.M., indicated the resident was found on the floor with no injury. The resident was sitting upright between the wheelchair and her bed. The resident was wearing gripper socks. The Bed Safety Evaluation, dated 05/23/2017 at 01:50 P.M., indicated the resident was unaware of proximity to edge of bed. The current treatment Plan included, but was not limited to, Bolster(s) and Low Bed The Post Fall Investigation, dated 05/31/2017 at 06:32 A.M., indicated Resident C had a fall on 05/30/2017 at 6:20 A.M. The resident was found in her room on the floor with an injury. The observation at time of fall was marked for rolled or slid out of bed. The Footwear at the time of fall was marked for barefoot. The Incident Note, dated 06/01/2017 at 9:40 A.M. of the IDT review, indicated the resident fell on [DATE]. The resident was found on the floor next to her bed with swelling on her face. The resident was sent to the emergency room . The IDT team recomended bolsters to the sides of the resident's bed to provide a boundary for the resident when turning. The current Resident Care Sheets, dated 06/05/2017, indicated Resident C's interventions included, but were not limited to, Hospice, Low air loss mattress and elevate heels while in bed. The resident care sheet lacked documentation of the interventions for bolsters, z-boots and non skid socks. The CT (Computerized Tomography) Facial final report dated 05/31/2017 at 7:35 A.M., indicated Resident C had a nondisplaced nasal fracture with overlying soft tissue swelling . During an interview on 6/5/17 at 5:30 P.M., the DON (Director of Nursing) indicated she did not know why the resident did not have bolsters on her bed when she was found on the floor after the 05/30/2017 fall. During an interview on 6/6/17 at 9:25 A.M., CNA (Certified Nurse Aide) 5, CNA 4, and CNA 8 indicated the resident specific care plan interventions were listed on the CNA resident care sheets. During an interview on 6/6/17 at 9:40 A.M., LPN (Licensed Practical Nurse) 7 indicated care plan interventions were on the CNA resident care sheet. She observed that the CNAs provide care to ensure care plan interventions were followed. The care plan updates were noted on the resident care sheet, and staff were verbally educated when updates were made. During an interview on 6/6/17 at 1:04 P.M., the Administrator indicated the resident care plan interventions are listed on the CNA Care Sheets. The Unit Managers usually make sure they are added. Before a nurse adds or revises a care plan, the nurse must communicate to the Unit Manager the need for the change. Changes would be reviewed during morning meeting when updates and needed updates are discussed. The current facility policy, titled NCD Care Plans and dated 11/28/2016, was provided by the Administrator on 6/6/17 at 1:15 P.M. and was reviewed at that time. The policy indicated .The comprehensive care plan is developed consistent with the patients' specific conditions .address risk factors that might lead to avoidable declines in functioning or functional levels . 3.1-45(a)(2)

Based on interview and record review, the facility failed to identify a Foley catheter for a resident (Resident D) upon readmission to the facility; failed to document urinary output; and failed to monitor for signs of occlusion which resulted in an occluded catheter for 1 of 1 resident reviewed for indwelling catheters. Findings include: The clinical record for Resident D was reviewed on 2/9/17 at 2:45 p.m. [DIAGNOSES REDACTED]. The re-admission assessment, dated 1/11/17, indicated Resident D did not have an indwelling Foley catheter. The nurses' note, dated 2/3/17 at 7:38 p.m., indicated at approximately 1:30 p.m. the resident was observed to be breathing rapidly with a pulse of 112 and respirations of 28. The NP (Nurse Practitioner) examined the resident and gave an order to send to the emergency room for evaluation. The hospital history and physical, dated 2/3/17 at 2:06 p.m., included, but was not limited to, the following: .was sent to the ER (emergency room ) today suspecting [MEDICAL CONDITION] given that the patient was shaking his extremities. However, his pupils were not changing, his eyes were not rolling back, he was not hypertonic .Upon arrival to the ER he was [MEDICAL CONDITION] (elevated heart rate) and with these shaking spells of and on. He was noted to have a Foley catheter in but with scant output. Decision in the ER in changing the catheter was made and immediate 1500 ml (milliliters) of cloudy, thick sedimented urine was obtained. After that the patient stopped having those episodes and his HR (heart rate) started to come down . During an interview on 2/10/17 at 11:38 a.m., the DON (Director of Nursing) indicated they did not know Resident D had a Foley catheter because when he was readmitted to the facility, on 1/11/17, the admitting nurse did not document it on the admission, therefore nothing related to the Foley catheter was triggered. The CNAs (Certified Nursing Assistant) documented the resident had a catheter but did not document his output. During an interview on 2/10/17 at 2:40 p.m., CNA 4 indicated she worked with the resident on 1/30/17 and 2/1/17. The resident did not have any output on 1/30/17 and very little output on 2/1/17, with leakage noted at the catheter insertion site which was reported to her nurse. She was not sure what the nurse had done after the leakage was reported. Resident D's treatment administration record for January 2017 lacked documentation of any Foley catheter orders, justification for the Foley catheter, measured output, or a care plan to reflect to the Foley catheter upon readmission on 1/11/17. The policy titled Indwelling Catheters, dated 9/27/16, included, but was not limited to, the following: .Policy .An indwelling catheter is used only when a patient's clinical condition demonstrates that catheterization is necessary. Care and treatment are provided .to reduce catheter associated complications .2. The medical record shows evidence of underlying factors supporting the use of an indwelling catheter .4. An indwelling catheter for which continuing use in not medically justified .6. Observe patient for signs and symptoms of catheter related complications such as .blocked catheter .8. The care plan reflects .d. The care plan goals are evaluated periodically and adjusted . This Federal tag relates to Complaint IN 693 3.1-37(a) 3.1-41(a)(1)

Based on interview and record review, the facility failed to ensure abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident #16) Findings include: The clinical record for Resident #16 was reviewed on 8/11/16 at 9:25 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/3/16, indicated Resident #16 had a BIMS (Brief Interview of Mental Status) score of 4, which signified severely impaired cognition. The clinical record for Resident #99 was reviewed on 8/11/16 at 10:48 a.m. [DIAGNOSES REDACTED]. The MDS assessment, dated 7/29/16, indicated Resident #99 had a BIMS score of 5, which signified severely impaired cognition. The incident report, dated 7/14/16 at 15 p.m., included, but was not limited to, the following: .Residents involved .(Resident # 16's name) .(Resident #99's name) .Brief Description of Incident .Staff heard resident in (Resident #99's room number) yelling for help .(Resident #16's initials) was found holding (Resident #99's initials) down leaning on his chest. (Resident #99's initials) was found to have a bruised eye .Type of Injury .(Resident #99's initials) sustained a purple bruise, swelling and small cut under .left eye .Immediate Action .The nurses separated the residents .(Resident #99's initials) was evaluated by the nurse .sent to (name of hospital) Emergency Department .Preventative Measures .(Resident #99's initials) was transported to (name of hospital) Emergency Department for evaluation and treatment .received a CT of the spine, face and head .A steri strip was placed on the laceration under the eye . The typed witness statement, undated and untimed, included, but was not limited to, the following: Resident .reported to me that on .way to room .witnessed (Resident #16's room number) standing in the doorway of (Resident #99's room number) asking .to let .outside. Resident .continued going to .room and a few minutes later when .came out of .room, .witnessed (Resident #16's room number) holding (Resident #99's room number) down on the bed and hitting him in the face with .fist .(Social Services signature) . The nurses note, dated 6/3/16 at 2:48 a.m., included, but was not limited to, the following: .Res. (resident) started yelling out .roommate asked .to stop yelling, and the Res. (sic) became more belligerent asking .roommate to leave the room . The nurses note, dated 6/3/16 at 6:51 p.m., included, but was not limited to, the following: .Resident became very agitated tonight before supper walking into the glass door down 300 hall and yelling and cursing at the residents. The CNA (Certified Nursing Assistant) working the hall seen resident in another residents room and said resident had .can and was going to strike another resident .Resident has been tearful .with periods of yelling and cursing and verbal threatening . The nurses note, dated 6/7/16 at 10:59 a.m., included, but was not limited to, the following: .Resident .wandering in others rooms and lying in other's beds . The nurses note, dated 6/10/16 at 6:40 p.m., indicated Resident #16 continued to be tearful with periods of agitation. The physician's progress note, dated 6/14/16, included, but was not limited to, the following: .(Resident #16's name) .Chief Complaint/Nature of Presenting Problem: Acute care visit per nursing request due to patient having increase in crying episodes and had a verbal altercation with another pt (patient) . The nurses note, dated 6/16/16 at 2:18 p.m., included, but was not limited to, the following: .Resident tearful with agitation this AM . The nurses note, dated 6/17/16 at 2:19 p.m., indicated Resident #16 was tearful and wandering frequently . The nurses note, dated 6/19/16 at 6:54 p.m., 6/21/16 at 6:34 p.m., 6/23/16 at 3:02 p.m., and 6/24/16 at 3:39 p.m., included, but was not limited to, the following: .Resident wandering in others rooms and around unit frequently . The nurses note, dated 6/28/16 at 5:22 p.m., indicated Resident #16 was being discharged to a psychiatric hospital. The nurses note, dated 6/30/16 at 2:20 p.m., included, but was not limited to, the following: .Received call for (name of psychiatric hospital) with update on resident. States (Resident #16's first name) has been combative and verbally aggressive with staff and peers. Has been in a physical altercations with another peer . The nurses note, dated 7/12/16 at 12:39 a.m., indicated Resident #16 was readmitted to the facility from the psychiatric hospital. The behavior note, dated 7/12/16 at 9:22 p.m., included, but was not limited to, the following: .Resident refusing to go to bed, wandering into other residents (sic) rooms, being verbal (sic) aggressive to others, (sic) tried to hit this nurse and cna (sic) with cane, (sic) assisted to lounge area but refuses to sit down, yelling out and cursing loudly upsetting other residents. Also beating on 200hall (sic) exit doors causing alarm to go off, (sic) was assisted away from doors per other male nurse but continued to be aggressive . The behavior note, dated 7/14/16 at 1:52 p.m., included, but was not limited to, the following: .(Resident #99's room number) was yelling, Help from room. This nurse and nurse 2 entered room and noted resident (Resident #16) on top of (Resident #99's room number) with both arms across (Resident #99's room number) neck. (Resident #99's room number) head was turned to the left and pressed into the mattress. Resident (Resident #16) appeared to be choking (Resident #99's room number) . The physicians progress note, dated 7/14/16, included, but was not limited to, the following: .(Resident #16's name) .Chief Complaint/Nature of Presenting Problem: Acute visit for readmission post hospital stay .History of Present Illness: Pt (patient) also just had an altercation with another resident in which staff found him on top of the other resident attempting to choke him. It is now known what provoked him, if anything . During an interview on 8/15/16 at 1:07 p.m., LPN (Licensed Practical Nurse) #19 indicated she was working on the day of the incident and responded to Resident #99's call for help. LPN #19 indicated Resident #16 was laying on top of Resident #99 with his forearm across Resident #99's neck. LPN #19 also indicated Resident #16 wandered a lot. LPN #19 further indicated it appeared Resident #16 was choking Resident #99. On 8/11/16 at 11:14 a.m., the Administrator provided a current document titled, Abuse, dated 7/28/14. It included, but was not limited to, the following: .Policy .Verbal .physical .abuse .are strictly prohibited .Rationale: Patients have the right to be free of verbal .physical .abuse .Definitions .Abuse .The willful infliction of injury .with resulting physical harm .Verbal Abuse .The use of oral .or gestured language that willfully includes disparaging and derogatory terms to residents .or with their hearing distance regardless of their age, ability to comprehend, or disability . 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to provide/administer pain medication to a resident with complaints of pain, following a fall which resulted in a left humeral neck fracture for 1 of 1 resident reviewed for falls with injury and failed to provide education to a resident prior to the resident self performing wound treatments for 1 of 1 resident reviewed for patient education.(Resident #211 & #B) Findings include: 1. The clinical record for Resident #B was reviewed on 8/11/16 at 10:30 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 7/12/16, indicated Resident #B had a BIMS (Brief Interview of Mental Status) score of 4, which signified severely impaired cognition. The nurses note, dated 7/17/16 at 3:40 a.m., included, but was not limited to, the following: .Was called to area in front of nurses station. Resident noted to be on floor in front of wheelchair. Resident buttocks was in the air, resident was face down. Resident assisted to sitting position. Resident confused, not able to describe what he/she was doing before he/she ended up on the floor .denies pain, but is rubbing his/her left arm . The physician progress notes [REDACTED].Chief Complaint/Nature of Presenting Problem: Acute visit for follow up fall .History of Present Illness: Pt (patient) fell over the wkend (weekend) and was complaining of L (left) shoulder pain. X rays were completed and negative. The patient is till complaining of pain and has limited ROM (range of motion) . The nurses note, dated 7/18/16 at 3:20 p.m., included the following: .New order received of lt (left) rib series r/t (related to) s/p (status [REDACTED]. Pt (patient) seen by NP (Nurse Practitioner) this day. The radiology report, dated 7/18/16 at 7:02 p.m., included, but was not limited to, the following: .Results .Impacted left humeral neck fracture .Conclusion .Left humeral neck fracture . The nurses note, dated 7/18/16 at 8:59 p.m., included, but was not limited to, the following: .x-ray results called to np (nurse practitioner). new (sic) order received to sent to ER (emergency room ) for eval (evaluation) et (and) tx (treatment) r/t (related to) abnormal xray (sic) result . The July 2016 MAR (Medication Administration Record) indicated, on 7/16/16, Resident #B had a pain level of 3 and on 7/17/16, a pain level of 2. The July 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]#B did not receive any pain medication upon return from the hospital on [DATE] at 11:48 p.m. until 7/19/16 at 5:18 a.m. for crying out pain. The hospital discharge record, dated 7/18/16 at 11:12 p.m.,indicated Resident #B did not receive any pain medication. During an interview on 8/16/16 at 3:05 p.m., the DDCO (District Director of Clinical Operations) indicated Resident #B was not given pain medication on 7/16/16 or 7/17/16 or prior to hospital discharge. 2. The clinical record for Resident #211 was reviewed on 8/11/16 at 1:45 p.m. [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 7/20/16, indicated Resident #211 had a BIMS (Brief Interview of Mental Status) score of 13 which signified intact cognition. On 8/10/16 at 10:02 a.m., [MEDICATION NAME] ointment was observed on Resident #211's bed side table. Dressing supplies were also observed on top of a built in dresser, which included, ABD pads, tape, scissors, and 4 x 4 gauze. During an interview on 8/10/16 at 10:02 a.m., Resident #211 indicated he/she does his/her own dressing changes, at times, to his/her left lower leg. Resident #211 also indicated staff told him/her that he/she could do the dressing changes and he/she just did the dressing change this morning. The August 2016 TAR (Treatment Administration Record) included, but was not limited to, the following: .[MEDICATION NAME] Ointment 500 unit/gm (gram) Apply to bilateral legs leg (sic) topically every shift for site care The nurses note, dated 8/8/16 at 7:00 p.m. and created on 8/9/16 at 9:45 a.m., indicated Resident #211 completed his/her own treatment to the left lower extremity. During an interview on 8/15/16 at 3:40 p.m., the Unit Manager indicated she was not aware of Resident #211 doing his/her own dressing changes. During an interview on 8/15/16 at 3:42 p.m., RN (Registered Nurse) #15 indicated Resident #211 has, on occasion, completed his/her own treatment to his/her left lower extremity. During an interview on 8/17/16 at 9:50 a.m., Resident #211 indicated, since admission, he/she has done the treatment to his/her left lower extremity ten times or better. The physician order, dated 8/15/16 at 4:12 p.m., included, but was not limited to, the following: .May perform own dressing changes . The Education Record (Patient/Family), dated 8/15/16 at 4:15 p.m., included, but was not limited to, the following: .Who was trained .patient .Education Needs .Procedure/Treatment .Specific Information Taught .how to complete dressing change and infection prevention .Training Method .Demonstration . This Federal tag relates to Complaint IN 249 3.1-37(a)

Based on interview and record review, the facility failed to ensure a prescribed medication ([MEDICATION NAME]) was administered, as ordered by the physician, for 1 of 5 residents reviewed for medications (Resident #B). This deficient practice resulted in Resident #B having to be rescheduled for a cystoscope and voiding trial and continue with a Foley catheter (urinary catheter) longer than planned, requiring surgical intervention related to complications from the Foley catheter. Findings include: Resident #B's closed, clinical record was reviewed on 09/17/2015 at 11:40 A.M. [DIAGNOSES REDACTED]. Review of the office note from Urologist #2, dated 07/06/2015, indicated Resident #B was diagnosed with [REDACTED]. Review of Resident #B's hospital discharge instructions, dated 07/29/2015, indicated Resident #B was to continue the [MEDICATION NAME] 0.4 mg by mouth every day. Review of Resident #B's admission orders [REDACTED].M. Review of Resident #B's medication record indicated the resident did not receive the medication, [MEDICATION NAME] 0.4 mg, from 08/01/2015 through 08/12/2015 and also on 08/24/2015. Review of the Urologist #2 office note, dated 08/13/2015, indicated Resident #B was an established patient, who was there for an enlarged prostate follow-up evaluation and Pt (patient) isn't on [MEDICATION NAME] due to error by NSP (nursing facility) after being discharged from the hospital, currently he is on [MEDICAL CONDITION] waiting for his lower urinary tract symptoms. The orders indicated urine culture and sensitivity and a CT of the abdomen and pelvis with and without IV contrast. The resident was scheduled for a return visit in two weeks for the cystoscope and voiding trial. The medication orders were to restart [MEDICATION NAME] 0.4 mg by mouth at bed time. Review of the letter written by the Urologist #2 , dated 08/28/2015, indicated the medication mistake for Resident #B, created unnecessary confusion for everyone involved and the patient had to be rescheduled. Review of the Computed Tomography (CT), dated 09/11/2015 and compared to the CT dated 08/22/2015, indicated there was a radiopaque density compatible with a Foley catheter which was seen within the urinary bladder extending through the prostatic urethra and into the mid penile urethra. This was compatible with a [MEDICAL CONDITION] catheter causing a retained foreign body. There was a second portion of the catheter within the urinary bladder. During an interview, on 09/17/2015 at 11:00 A.M., Urologist #2 indicated due to the medication [MEDICATION NAME] not being given on 08/01/2015 through 08/12/15, the resident had to be sent back to the facility and transported on a later date. This delay caused the resident's catheter to be in place longer then originally planned. The Urologist #2 indicated Resident #B had complications related to the Foley Catheter and will require an open surgical procedure to remove two fractured, fragmented pieces of the Foley catheter from the resident's urinary bladder and mid penile urethra. During an interview on 09/18/2015 at 10:56 A.M., the Director of Nursing (DON) indicated Resident #B's medication order for [MEDICATION NAME] 0.4 mg, was not transferred onto the August Medication Administration Record [REDACTED]. Admission Minimum Data Set (MDS) assessment, dated 06/11/2015, indicated a Brief Interview for Mental Status (BIMS) score of 99, indicating Resident #B was severely cognitively impaired. MDS assessment further indicated that Resident #B required extensive, one person physical assist for toileting. MDS assessment indicated Resident #B had no indwelling catheter. The 30 day Prospective Payment System MDS assessment, dated 07/02/2015, indicated a BIMS score of 99, indicating Resident #B was severally cognitively impaired. MDS assessment further indicated that Resident #B required extensive, two person physical assist for toileting. MDS assessment indicated Resident #B had an indwelling caterer. 3.1-25(b)(9) 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure that residents were free from verbal abuse, as evidenced by demeaning and humiliating statements, threats and insults to the residents and to the staff in front of the residents by the Administrator which has created culture of fear and intimidation for 5 of 9 residents reviewed for abuse (Residents D, G, H, F and J). This had the potential to affect 143 of 143 residents in the facility at risk for being verbally abused by the Administrator. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/27/2014 when the Administrator yelled at the Generations Unit nurses station, "That's why you don't send a bunch of idiot CNAs over with labs!" in front of staff and residents. The Administrator, Director of Nursing, and Corporate Director of Clinical Operations were notified of the Immediate Jeopardy at 7:45 p.m. on 7/10/2014. The Immediate Jeopardy was removed on 7/11/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated, "She's (Administrator) a bully...she bullies the residents...she bullies the employees." Employee #2 recalled an incident which occurred on 5/27/2014 involving some mislabeled labs which were delivered to the lab from the facility by a CNA. Employee #2 indicated that the Administrator was "screaming" at the Generations Unit nurse's station, "That's why you don't send a bunch of idiot CNAs over with labs!" She further indicated that she reported the incident to Corporate Nurse #1, as well as reporting that the Administrator "bullies" the staff and residents, and was told by Corporate Nurse #1, "Well, (Administrator) just doesn't think before she opens her mouth." Employees #1, #4, #5, #6 and #9 corroborated the 5/27/2014 incident. Employee #2 indicated that staff and residents are "afraid" of the Administrator and that she reported the Administrator's behavior to "Corporate" approximately two months ago. She further indicated, "I know at least three of us (staff) have filed complaints (via the corporate hotline and/or to Corporate Nursing staff at the facility) about (Administrator). They just blow it off. What are you supposed to do? Where are you supposed to go when it's the administrator that's doing it?" Employee #1 was interviewed on 7/9/2014 at 4:20 p.m. and again on 7/10/2014 at 1:35 p.m. She indicated that on 5/27/2014, the Administrator was "yelling", indicating, "What are you idiots doing? Why can't you manage to get anything done properly?" She indicated that the Administrator raises her voice to residents and staff "on a daily basis" and indicated, "Just the other day (during first and second shift change) she went running down the hall calling us a bunch of idiots. It makes me feel 3 feet tall. I can't imagine what it does to those residents." She further indicated, "I know you talked to (Employee #11). She came up to me and said you talked to her and she said, 'I should have said something.' and I said, 'Why didn't you?' and she said she was afraid because management was spying on you while you were talking and she didn't want to get in trouble." Employee #1 recounted an incident "about two weeks ago" in which the Administrator indicated loudly to Resident J during a meal in the main dining room, "I'm the boss here, not you. You'll do what I tell you to do!" Employee #1 indicated that residents and staff are fearful of the Administrator. Employee #5 was interviewed on 7/10/2014 at 1:50 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff in front of, and within earshot, of residents. She indicated, "She (Administrator) said the CNAs aren't smart enough to keep them straight and get them where they need them to be." Employee #5 further indicated, "She's notorious for calling the CNAs 'stupid'...it's within earshot of the residents...I don't think that's right. 'Idiot' and 'stupid' is interchangeable with her." Employee #6 was interviewed on 7/10/2014 at 2:20 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff and called the CNAs "idiots." She indicated, "I've called the (corporate) hotline before after she's belittled me in front of everybody...I've been in tears." Employee #4 was interviewed on 7/10/2014 at 2:55 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated, "(Administrator) went off. She said, 'That's why they're just CNAs.' She doesn't show us respect." Employee #4 additionally indicated, "The other day, (Resident B, who's cognition is severely impaired), was throwing her food in the feed room. We asked her (Administrator) what to do and she said 'You just take her food and take her to bed.' I don't like doing that to her." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated that the Administrator was yelling at staff and called them "stupid." She indicated, "(Administrator) gets MAD. Nobody messes with (Administrator)." 2. Employee #1 was interviewed on 7/10/2014 at 1:35 p.m. and recounted the lunch meal in the main dining room on 7/2/2014. She indicated that the Administrator delivered a meal to Resident F, who was blind and receiving Hospice care prior to her passing on 7/7/2014. Resident F asked the Administrator to identify the meal, and then indicated, "I don't want that." The Administrator indicated loudly, "You need to eat the food that we give you. I pay good money for it and you need to eat it." Employee #1 indicated, "Everyone's mouth just dropped." She further indicated that Resident F's family indicated to her that they were going to file a corporate grievance related to the incident. 3. During an interview with Employee #1 on 7/9/2014 at 4:20 p.m., she indicated that Resident H frequently asks for second and third servings at meals. She indicated that, during the lunch meal in the main dining room on 7/9/2014, the Administrator indicated to Resident H that he was only allowed two servings and stated, "I can't afford to feed your appetite." Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated that she was not on duty 7/8/2014, but has witnessed the Administrator indicate to Resident H, "You're not getting seconds. You've gotten way too heavy." in the main dining room in front of other residents. Employee #3 was interviewed on 7/10/2014 at 1:30 p.m. She indicated, "She tells him (Resident H) he can't have more than two servings because she doesn't have enough money to feed his appetite." She further indicated, "A day or two ago, (Administrator) approached (Resident J) in a rude way and said she needed to learn to shut her mouth and she doesn't have the right to tell other people they stink because she stinks just as bad as they do. They'll (dietary staff) get to you when they can." Resident H was interviewed on 7/10/2014 at 2:40 p.m. and found to be alert and oriented to person, place and time. When queried regarding the incident in the dining room on 7/9/2014, he indicated, "She (Administrator) said I was eating too much food or some b---s---...she said something about my weight." When queried as to how it made him feel, he indicated, "I just couldn't believe she said it." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated, "He (Resident H) always gets yelled at (by the Administrator). She'll say, 'No you don't need no more, you eat enough...or you're already heavy enough." She further indicated, "He (Resident H) was scared to talk. He came to me and said, 'The lady asked me and I had to tell.' He was afraid he'd get in trouble." Resident H's clinical record was reviewed on 7/10/14 at 4:04 p.m. The [DIAGNOSES REDACTED]. Diet orders indicated, "1800 cal ADA (American Dietetic Association) reg (regular)." 4. Resident D's record was reviewed on 7/10/2014 at 12:35. His most recent Minimum Data Set (MDS) assessment, completed on 5/9/2014, indicated a Brief Interview for Mental Status (BIMS) score of 15 of 15; which indicated he was cognitively intact. Resident D was interviewed on 7/10/2014 at 2:00 p.m. He indicated, She's (Administrator) very very rude...that one day she was mad at all the girls and screamed (in the main dining room), "Things are going to go my way or else!" When queried as to how often the Administrator is heard yelling and/or being verbally abusive to staff, he indicated, "I know she loses her temper a lot....She does it quite often; usually on a daily basis." He further indicated, "No, I don't like it. It makes me feel uneasy...like if she's that way to the girls, what's next...us? This should be a nice place to live, but how can it be when somebody's always so negative?" Employee # 8 was interviewed on 7/10/2014 at 2:00 p.m. She indicated that the Administrator yells at staff in front of residents and that residents and staff are intimidated by her. Resident #G was interviewed on 7/10/2014 at 2:30 p.m. She indicated, "She's (Administrator) always yelling at the staff...the aides or nurses. I can't always make out what she says....It makes us all feel on edge." Employee #7 was interviewed on 7/10/2014 at 2:50 p.m. and indicated that the Administrator "flips out." She further indicated that the Administrator threatened staff in front of residents and indicated, "It (yelling) was so bad that they could hear it on the Memory Unit (located on the opposite side of the facility). A nurse even came down to ask if everything was ok" She further indicated that residents have complained to her about the Administrator, indicating, "They just think all the yelling is unnecessary." Employee #10 (Social Service Director), was interviewed on 7/10/2014 at 5:20 p.m. She indicated that she has witnessed the Administrator yelling at residents and/or staff "on occasion" and indicated that her behavior was "intimidating" to both residents and staff. She stated, "I have seen (Administrator) get more verbal than she should in front of residents....I do feel she does not have good bedside manners....She's not nice...she calls the staff 'idiots' and talks about them in morning meeting....It feels like we're on pins and needles all the time." She further indicated that a recent visitor to the facility was "appalled" by the Administrators behavior and asked for the corporate hotline/grievance number, which she provided. She indicated that she had not filed any complaints or grievances herself related to the Administrator's verbal abuse on behalf of residents or staff. The Director of Nursing (DoN) was interviewed on 7/10/2014 and indicated, "I've never heard her (Administrator) yell." She denied being aware of any complaints by residents or staff related to the Administrator's verbal abuse, indicating, "Nothing stands out." The Administrator was interviewed on 7/10/2014 at 5:40 p.m. She indicated, "My staff hates me and my residents love me." She denied losing her temper or yelling at staff "except for one time about a year and a half ago....If they (staff) didn't like the way I treated them, why didn't they come talk to me?" When queried as to whether or not she ever referred to the staff as "idiots", she indicated, "Maybe behind closed doors, but not out on the floor." In an interview with Corporate Nurse #1 on 7-14-14 at 1:35 p.m., she indicated any report related to any situation of this facility would not have gone to her in May, 2014, as this was not one of her usual buildings to provide coverage. She indicated she had been assisting with clinical oversight during the last week due to vacation time for the corporate nurse who usually assists with clinical oversight. In an interview with Corporate Nurse #2 on 7-14-14 at 1:50 p.m., she indicated she recalled speaking to a staff CNA in late May, 2014 regarding concerns related to improperly labeled lab specimens. She indicated the CNA was concerned that the CNA's were doing something incorrectly by transporting lab specimens to an area laboratory. She indicated the Administrator had apparently questioned facility nursing staff as to why they had requested staff CNA's to transport improperly labeled lab specimens to an area laboratory and then be asked to label the lab specimen with a resident's name. Corporate Nurse #2 indicated she did not recall any other concerns that were voiced by this particular CNA, "that I have in my documentation." The Immediate Jeopardy that began on 5-27-14 was removed 7-14-14, with an effective date of 7-11-14, when an interim Administrator was appointed to replace the previous Administrator. Additionally, staff education was initiated on 7-11-14 regarding abuse and abuse prevention, which included education on identification of abuse, how to report abuse, when to report abuse, to whom to report abuse and timeliness of abuse reporting without fear of reprisal. Information was also initiated on 7-11-14 to residents and/or families of residents on how and to whom to report any concerns, including abuse or other concerns without fear of reprisal. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of on-going monitoring to ensure residents were free of abuse. This federal tag relates to Complaints IN 904 and IN 091. 3.1(a)(1) 3.1-27(b)

In an interview with Corporate Nurse #1 on 7-14-14 at 1:35 p.m., she indicated any report related to any situation of this facility would not have gone to her in May, 2014, as this was not one of her usual buildings to provide coverage. She indicated she had been assisting with clinical oversight during the last week due to vacation time for the corporate nurse who usually assists with clinical oversight. In an interview with Corporate Nurse #2 on 7-14-14 at 1:50 p.m., she indicated she recalled speaking to a staff CNA in late May, 2014 regarding concerns related to improperly labeled lab specimens. She indicated the CNA was concerned that the CNA's were doing something incorrectly by transporting lab specimens to an area laboratory. She indicated the Administrator had apparently questioned facility nursing staff as to why they had requested staff CNA's to transport improperly labeled lab specimens to an area laboratory and then be asked to label the lab specimen with a resident's name. Corporate Nurse #2 indicated she did not recall any other concerns that were voiced by this particular CNA, "that I have in my documentation." The Immediate Jeopardy that began on 5-27-14 was removed 7-14-14, with an effective date of 7-11-14, when an interim Administrator was appointed to replace the previous Administrator. Additionally, staff education was initiated on 7-11-14 regarding abuse and abuse prevention, which included education on identification of abuse, how to report abuse, when to report abuse, to whom to report abuse and timeliness of abuse reporting without fear of reprisal. Information was also initiated on 7-11-14 to residents and/or families of residents on how and to whom to report any concerns, including abuse or other concerns without fear of reprisal. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of on-going monitoring to ensure all allegations of abuse were investigated and reported. This federal tag relates to Complaints IN 904 and IN 091. 3.1-28(c) 3.1-28(d) 3.1-28(e) Based on interview and record review, the facility failed to ensure that allegations of verbal abuse by the Administrator were investigated, reported to proper authorities, including state agencies, and that necessary corrective actions were taken, including suspension of the Administrator for 5 of 9 residents reviewed for verbal abuse. (Residents D, G, H, F and J)The on-going verbal abuse by the Administrator resulted in a culture of fear and intimidation with the potential to affect 143 of 143 residents in the facility. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/27/2014 when the Administrator yelled at the Generations Unit nurses station, "That's why you don't send a bunch of idiot CNAs over with labs!" in front of staff and residents. The Administrator, Director of Nursing, and Corporate Director of Clinical Operations were notified of the Immediate Jeopardy at 7:45 p.m. on 7/10/2014. The Immediate Jeopardy was removed on 7/11/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated, "She's (Administrator) a bully...she bullies the residents...she bullies the employees." Employee #2 recalled an incident which occurred on 5/27/2014 involving some mislabeled labs which were delivered to the lab from the facility by a CNA. Employee #2 indicated that the Administrator was "screaming" at the Generations Unit nurse's station, "That's why you don't send a bunch of idiot CNAs over with labs!" She further indicated that she reported the incident to Corporate Nurse #1, as well as reporting that the Administrator "bullies" the staff and residents, and was told by Corporate Nurse #1, "Well, (Administrator) just doesn't think before she opens her mouth." Employees #1, #4, #5, #6 and #9 corroborated the 5/27/2014 incident. Employee #2 indicated that staff and residents are "afraid" of the Administrator and that she reported the Administrator's behavior to "Corporate" approximately two months ago. She further indicated, "I know at least three of us (staff) have filed complaints (via the corporate hotline and/or to Corporate Nursing staff at the facility) about (Administrator). They just blow it off. What are you supposed to do? Where are you supposed to go when it's the administrator that's doing it?" Employee #1 was interviewed on 7/9/2014 at 4:20 p.m. and again on 7/10/2014 at 1:35 p.m. She indicated that on 5/27/2014, the Administrator was "yelling", indicating, "What are you idiots doing? Why can't you manage to get anything done properly?" She indicated that the Administrator raises her voice to residents and staff "on a daily basis" and indicated, "Just the other day (during first and second shift change) she went running down the hall calling us a bunch of idiots. It makes me feel 3 feet tall. I can't imagine what it does to those residents." She further indicated, "I know you talked to (Employee #11). She came up to me and said you talked to her and she said, 'I should have said something.' and I said, 'Why didn't you?' and she said she was afraid because management was spying on you while you were talking and she didn't want to get in trouble." Employee #1 recounted an incident "about two weeks ago" in which the Administrator indicated loudly to Resident J during a meal in the main dining room, "I'm the boss here, not you. You'll do what I tell you to do!" Employee #1 indicated that residents and staff are fearful of the Administrator. Employee #5 was interviewed on 7/10/2014 at 1:50 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff in front of, and within earshot, of residents. She indicated, "She (Administrator) said the CNAs aren't smart enough to keep them straight and get them where they need them to be." Employee #5 further indicated, "She's notorious for calling the CNAs 'stupid'...it's within earshot of the residents...I don't think that's right. 'Idiot' and 'stupid' is interchangeable with her." Employee #6 was interviewed on 7/10/2014 at 2:20 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff and called the CNAs "idiots." She indicated, "I've called the (corporate) hotline before after she's belittled me in front of everybody...I've been in tears." Employee #4 was interviewed on 7/10/2014 at 2:55 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated, "(Administrator) went off. She said, 'That's why they're just CNAs.' She doesn't show us respect." Employee #4 additionally indicated, "The other day, (Resident B, who's cognition is severely impaired), was throwing her food in the feed room. We asked her (Administrator) what to do and she said 'You just take her food and take her to bed.' I don't like doing that to her." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated that the Administrator was yelling at staff and called them "stupid." She indicated, "(Administrator) gets MAD. Nobody messes with (Administrator)." 2. Employee #1 was interviewed on 7/10/2014 at 1:35 p.m. and recounted the lunch meal in the main dining room on 7/2/2014. She indicated that the Administrator delivered a meal to Resident F, who was blind and receiving Hospice care prior to her passing on 7/7/2014. Resident F asked the Administrator to identify the meal, and then indicated, "I don't want that." The Administrator indicated loudly, "You need to eat the food that we give you. I pay good money for it and you need to eat it." Employee #1 indicated, "Everyone's mouth just dropped." She further indicated that Resident F's family indicated to her that they were going to file a corporate grievance related to the incident. 3. During an interview with Employee #1 on 7/9/2014 at 4:20 p.m., she indicated that Resident H frequently asks for second and third servings at meals. She indicated that, during the lunch meal in the main dining room on 7/9/2014, the Administrator indicated to Resident H that he was only allowed two servings and stated, "I can't afford to feed your appetite." Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated that she was not on duty 7/8/2014, but has witnessed the Administrator indicate to Resident H, "You're not getting seconds. You've gotten way too heavy." in the main dining room in front of other residents. Employee #3 was interviewed on 7/10/2014 at 1:30 p.m. She indicated, "She tells him (Resident H) he can't have more than two servings because she doesn't have enough money to feed his appetite." She further indicated, "A day or two ago, (Administrator) approached (Resident J) in a rude way and said she needed to learn to shut her mouth and she doesn't have the right to tell other people they stink because she stinks just as bad as they do. They'll (dietary staff) get to you when they can." Resident H was interviewed on 7/10/2014 at 2:40 p.m. and found to be alert and oriented to person, place and time. When queried regarding the incident in the dining room on 7/9/2014, he indicated, "She (Administrator) said I was eating too much food or some b---s---...she said something about my weight." When queried as to how it made him feel, he indicated, "I just couldn't believe she said it." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated, "He (Resident H) always gets yelled at (by the Administrator). She'll say, 'No you don't need no more, you eat enough...or you're already heavy enough." She further indicated, "He (Resident H) was scared to talk. He came to me and said, 'The lady asked me and I had to tell.' He was afraid he'd get in trouble." Resident H's clinical record was reviewed on 7/10/14 at 4:04 p.m. The [DIAGNOSES REDACTED]. Diet orders indicated, "1800 cal ADA (American Dietetic Association) reg (regular)." 4. Resident D's record was reviewed on 7/10/2014 at 12:35. His most recent Minimum Data Set (MDS) assessment, completed on 5/9/2014, indicated a Brief Interview for Mental Status (BIMS) score of 15 of 15; which indicated he was cognitively intact. Resident D was interviewed on 7/10/2014 at 2:00 p.m. He indicated, She's (Administrator) very very rude...that one day she was mad at all the girls and screamed (in the main dining room), "Things are going to go my way or else!" When queried as to how often the Administrator is heard yelling and/or being verbally abusive to staff, he indicated, "I know she loses her temper a lot....She does it quite often; usually on a daily basis." He further indicated, "No, I don't like it. It makes me feel uneasy...like if she's that way to the girls, what's next...us? This should be a nice place to live, but how can it be when somebody's always so negative?" Employee # 8 was interviewed on 7/10/2014 at 2:00 p.m. She indicated that the Administrator yells at staff in front of residents and that residents and staff are intimidated by her. Resident #G was interviewed on 7/10/2014 at 2:30 p.m. She indicated, "She's (Administrator) always yelling at the staff...the aides or nurses. I can't always make out what she says....It makes us all feel on edge." Employee #7 was interviewed on 7/10/2014 at 2:50 p.m. and indicated that the Administrator "flips out." She further indicated that the Administrator threatened staff in front of residents and indicated, "It (yelling) was so bad that they could hear it on the Memory Unit (located on the opposite side of the facility). A nurse even came down to ask if everything was ok" She further indicated that residents have complained to her about the Administrator, indicating, "They just think all the yelling is unnecessary." Employee #10 (Social Service Director) was interviewed on 7/10/2014 at 5:20 p.m. She indicated that she has witnessed the Administrator yelling at residents and/or staff "on occasion" and indicated that her behavior was "intimidating" to both residents and staff. She stated, "I have seen (Administrator) get more verbal than she should in front of residents....I do feel she does not have good bedside manners....She's not nice...she calls the staff 'idiots' and talks about them in morning meeting....It feels like we're on pins and needles all the time." She further indicated that a recent visitor to the facility was "appalled" by the Administrators behavior and asked for the corporate hotline/grievance number, which she provided. She indicated that she had not filed any complaints or grievances herself related to the Administrator's verbal abuse on behalf of residents or staff. The Complaint/Concern Log and Reportable Incidents for 3/1/2014 through 7/9/2014 were provided by the Administrator on 7/9/2014 at 1:59 p.m. and reviewed at that time. None of the allegations of verbal abuse by the Administrator for Residents D, F, G, H or J were indicated. The Director of Nursing (DoN) was interviewed on 7/10/2014 and indicated, "I've never heard her (Administrator) yell." She denied being aware of any complaints by residents or staff related to the Administrator's verbal abuse, indicating, "Nothing stands out." The Administrator was interviewed on 7/10/2014 at 5:40 p.m. She indicated, "My staff hates me and my residents love me." She denied that any complaints or grievances were reported to her or any of her management staff related to the above allegations of verbal abuse by the Administrator. She denied ever "losing her temper or yelling at staff", "except for one time about a year and a half ago....If they (staff) didn't like the way I treated them, why didn't they come talk to me?" When queried as to whether or not she ever referred to the staff as "idiots", she indicated, "Maybe behind closed doors, but not out on the floor." A copy of Abuse Prevention Policy and Procedure was provided by the DoN on 7/9/2014 at 11:10 a.m. She indicated that facility Point of Contact (POC) for abuse was the Administrator. The Abuse Prevention Policy and Procedure included, but was not limited to, "Rationale: Provide information to residents, families and staff on how and to whom they report concerns, incidents and complaints/concerns without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse...are more likely to occur through analysis of: ....Monitoring residents, visitors and staff to identify inappropriate behaviors, such as using derogatory language, rough handling, etc....Procedure: ...2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution." The Administrator was interviewed on 7/9/2014 at 2:30 p.m. regarding Abuse Prohibition Protocol. She indicated that she ensures that abuse/neglect does not occur by doing Angel Rounds "at least twice per shift." She indicated that all department heads and nurse managers are to round using the Angel Care. Additionally, she indicated, "We do monthly education, inservices, one-on-one teachable moments, and town hall." When queried as to how she ensures that residents, families and staff feel free to communicate concerns without fear of reprisals, she indicated, "I have an open door. We have good communication with residents and families. We ask if there are any problems during Angel Care Rounds. The Administrator provided a copy of the Angel Care Rounds Sheet, which listed 33 items to check. There was nothing on the form to indicate that residents are asked about abuse. The Abuse Prevention Policy and Procedure did not indicate how and to whom residents, families and staff are to report concerns, incidents and complaints/concerns without fear of retribution or what corrective actions would be taken in the event of an allegation of abuse (other than posting the State Abuse Hotline at each nursing station) or the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities or the time-frame for reporting allegations of abuse. Additionally, Employee #10's position was indicated as the "primary" responsible party regarding "...2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution." There was no indication in the Abuse Policy and Procedure as to who the designated representative was in the event that the allegation(s) of abuse involve the Point of Contact/Administrator.

In an interview with Corporate Nurse #1 on 7-14-14 at 1:35 p.m., she indicated any report related to any situation of this facility would not have gone to her in May, 2014, as this was not one of her usual buildings to provide coverage. She indicated she had been assisting with clinical oversight during the last week due to vacation time for the corporate nurse who usually assists with clinical oversight. In an interview with Corporate Nurse #2 on 7-14-14 at 1:50 p.m., she indicated she recalled speaking to a staff CNA in late May, 2014 regarding concerns related to improperly labeled lab specimens. She indicated the CNA was concerned that the CNA's were doing something incorrectly by transporting lab specimens to an area laboratory. She indicated the Administrator had apparently questioned facility nursing staff as to why they had requested staff CNA's to transport improperly labeled lab specimens to an area laboratory and then be asked to label the lab specimen with a resident's name. Corporate Nurse #2 indicated she did not recall any other concerns that were voiced by this particular CNA, "that I have in my documentation." The Immediate Jeopardy that began on 5-27-14 was removed 7-14-14, with an effective date of 7-11-14, when an interim Administrator was appointed to replace the previous Administrator. Additionally, staff education was initiated on 7-11-14 regarding abuse and abuse prevention, which included education on identification of abuse, how to report abuse, when to report abuse, to whom to report abuse and timeliness of abuse reporting without fear of reprisal. Information was also initiated on 7-11-14 to residents and/or families of residents on how and to whom to report any concerns, including abuse or other concerns without fear of reprisal. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because of on-going monitoring to ensure the abuse policy and procedures were implemented. This federal tag relates to Complaints IN 904 and IN 091. 3.1-28(a) Based on interview and record review, the facility failed to develop and implement policies and procedures which ensured the identification, investigation, and reporting of verbal abuse, including the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities for 5 of 9 residents reviewed for verbal abuse (Residents D, G, H, F and J). The on-going verbal abuse by the Administrator resulted in a culture of fear and intimidation with the potential to affect 143 of 143 residents in the facility. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/27/2014 when the Administrator yelled at the Generations Unit nurses station, "That's why you don't send a bunch of idiot CNAs over with labs!" in front of staff and residents. The Administrator, Director of Nursing and Corporate Director of Clinical Operations were notified of the Immediate Jeopardy at 7:45 p.m. on 7/10/2014. The Immediate Jeopardy was removed on 7/11/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated, "She's (Administrator) a bully...she bullies the residents...she bullies the employees." Employee #2 recalled an incident which occurred on 5/27/2014 involving some mislabeled labs which were delivered to the lab from the facility by a CNA. Employee #2 indicated that the Administrator was "screaming" at the Generations Unit nurse's station, "That's why you don't send a bunch of idiot CNAs over with labs!" She further indicated that she reported the incident to Corporate Nurse #1, as well as reporting that the Administrator "bullies" the staff and residents, and was told by Corporate Nurse #1, "Well, (Administrator) just doesn't think before she opens her mouth." Employees #1, #4, #5, #6 and #9 corroborated the 5/27/2014 incident. Employee #2 indicated that staff and residents are "afraid" of the Administrator and that she reported the Administrator's behavior to "Corporate" approximately two months ago. She further indicated, "I know at least three of us (staff) have filed complaints (via the corporate hotline and/or to Corporate Nursing staff at the facility) about (Administrator). They just blow it off. What are you supposed to do? Where are you supposed to go when it's the administrator that's doing it?" Employee #1 was interviewed on 7/9/2014 at 4:20 p.m. and again on 7/10/2014 at 1:35 p.m. She indicated that on 5/27/2014, the Administrator was "yelling", indicating, "What are you idiots doing? Why can't you manage to get anything done properly?" She indicated that the Administrator raises her voice to residents and staff "on a daily basis" and indicated, "Just the other day (during first and second shift change) she went running down the hall calling us a bunch of idiots. It makes me feel 3 feet tall. I can't imagine what it does to those residents." She further indicated, "I know you talked to (Employee #11). She came up to me and said you talked to her and she said, 'I should have said something.' and I said, 'Why didn't you?' and she said she was afraid because management was spying on you while you were talking and she didn't want to get in trouble." Employee #1 recounted an incident "about two weeks ago" in which the Administrator indicated loudly to Resident J during a meal in the main dining room, "I'm the boss here, not you. You'll do what I tell you to do!" Employee #1 indicated that residents and staff are fearful of the Administrator. Employee #5 was interviewed on 7/10/2014 at 1:50 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff in front of, and within earshot, of residents. She indicated, "She (Administrator) said the CNAs aren't smart enough to keep them straight and get them where they need them to be." Employee #5 further indicated, "She's notorious for calling the CNAs 'stupid'...it's within earshot of the residents...I don't think that's right. 'Idiot' and 'stupid' is interchangeable with her." Employee #6 was interviewed on 7/10/2014 at 2:20 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff and called the CNAs "idiots." She indicated, "I've called the (corporate) hotline before after she's belittled me in front of everybody...I've been in tears." Employee #4 was interviewed on 7/10/2014 at 2:55 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated, "(Administrator) went off. She said, 'That's why they're just CNAs.' She doesn't show us respect." Employee #4 additionally indicated, "The other day, (Resident B, who's cognition is severely impaired), was throwing her food in the feed room. We asked her (Administrator) what to do and she said 'You just take her food and take her to bed.' I don't like doing that to her." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated that the Administrator was yelling at staff and called them "stupid." She indicated, "(Administrator) gets MAD. Nobody messes with (Administrator)." 2. Employee #1 was interviewed on 7/10/2014 at 1:35 p.m. and recounted the lunch meal in the main dining room on 7/2/2014. She indicated that the Administrator delivered a meal to Resident F, who was blind and receiving Hospice care prior to her passing on 7/7/2014. Resident F asked the Administrator to identify the meal, and then indicated, "I don't want that." The Administrator indicated loudly, "You need to eat the food that we give you. I pay good money for it and you need to eat it." Employee #1 indicated, "Everyone's mouth just dropped." She further indicated that Resident F's family indicated to her that they were going to file a corporate grievance related to the incident. 3. During an interview with Employee #1 on 7/9/2014 at 4:20 p.m., she indicated that Resident H frequently asks for second and third servings at meals. She indicated that, during the lunch meal in the main dining room on 7/9/2014, the Administrator indicated to Resident H that he was only allowed two servings and stated, "I can't afford to feed your appetite." Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated that she was not on duty 7/8/2014, but has witnessed the Administrator indicate to Resident H, "You're not getting seconds. You've gotten way too heavy." in the main dining room in front of other residents. Employee #3 was interviewed on 7/10/2014 at 1:30 p.m. She indicated, "She tells him (Resident H) he can't have more than two servings because she doesn't have enough money to feed his appetite." She further indicated, "A day or two ago, (Administrator) approached (Resident J) in a rude way and said she needed to learn to shut her mouth and she doesn't have the right to tell other people they stink because she stinks just as bad as they do. They'll (dietary staff) get to you when they can." Resident H was interviewed on 7/10/2014 at 2:40 p.m. and found to be alert and oriented to person, place and time. When queried regarding the incident in the dining room on 7/9/2014, he indicated, "She (Administrator) said I was eating too much food or some b---s---...she said something about my weight." When queried as to how it made him feel, he indicated, "I just couldn't believe she said it." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated, "He (Resident H) always gets yelled at (by the Administrator). She'll say, 'No you don't need no more, you eat enough...or you're already heavy enough." She further indicated, "He (Resident H) was scared to talk. He came to me and said, 'The lady asked me and I had to tell.' He was afraid he'd get in trouble." Resident H's clinical record was reviewed on 7/10/14 at 4:04 p.m. The [DIAGNOSES REDACTED]. Diet orders indicated, "1800 cal ADA (American Dietetic Association) reg (regular)." 4. Resident D's record was reviewed on 7/10/2014 at 12:35. His most recent Minimum Data Set (MDS) assessment, completed on 5/9/2014, indicated a Brief Interview for Mental Status (BIMS) score of 15 of 15; which indicated he was cognitively intact. Resident D was interviewed on 7/10/2014 at 2:00 p.m. He indicated, She's (Administrator) very very rude...that one day she was mad at all the girls and screamed (in the main dining room), "Things are going to go my way or else!" When queried as to how often the Administrator is heard yelling and/or being verbally abusive to staff, he indicated, "I know she loses her temper a lot....She does it quite often; usually on a daily basis." He further indicated, "No, I don't like it. It makes me feel uneasy...like if she's that way to the girls, what's next...us? This should be a nice place to live, but how can it be when somebody's always so negative?" Employee # 8 was interviewed on 7/10/2014 at 2:00 p.m. She indicated that the Administrator yells at staff in front of residents and that residents and staff are intimidated by her. Resident #G was interviewed on 7/10/2014 at 2:30 p.m. She indicated, "She's (Administrator) always yelling at the staff...the aides or nurses. I can't always make out what she says....It makes us all feel on edge." Employee #7 was interviewed on 7/10/2014 at 2:50 p.m. and indicated that the Administrator "flips out." She further indicated that the Administrator threatened staff in front of residents and indicated, "It (yelling) was so bad that they could hear it on the Memory Unit (located on the opposite side of the facility). A nurse even came down to ask if everything was ok" She further indicated that residents have complained to her about the Administrator, indicating, "They just think all the yelling is unnecessary." Employee #10 (Social Service Director) was interviewed on 7/10/2014 at 5:20 p.m. She indicated that she has witnessed the Administrator yelling at residents and/or staff "on occasion" and indicated that her behavior was "intimidating" to both residents and staff. She stated, "I have seen (Administrator) get more verbal than she should in front of residents....I do feel she does not have good bedside manners....She's not nice...she calls the staff 'idiots' and talks about them in morning meeting....It feels like we're on pins and needles all the time." She further indicated that a recent visitor to the facility was "appalled" by the Administrators behavior and asked for the corporate hotline/grievance number, which she provided. She indicated that she had not filed any complaints or grievances herself related to the Administrator's verbal abuse on behalf of residents or staff. The Complaint/Concern Log and Reportable Incidents for 3/1/2014 through 7/9/2014 were provided by the Administrator on 7/9/2014 at 1:59 p.m. and reviewed at that time. None of the allegations of verbal abuse by the Administrator for Residents D, F, G, H or J were indicated. The Director of Nursing (DoN) was interviewed on 7/10/2014 and indicated, "I've never heard her (Administrator) yell." She denied being aware of any complaints by residents or staff related to the Administrator's verbal abuse, indicating, "Nothing stands out." The Administrator was interviewed on 7/10/2014 at 5:40 p.m. She indicated, "My staff hates me and my residents love me." She denied that any complaints or grievances were reported to her or any of her management staff related to the above allegations of verbal abuse by the Administrator. She denied ever "losing her temper or yelling at staff", "except for one time about a year and a half ago....If they (staff) didn't like the way I treated them, why didn't they come talk to me?" When queried as to whether or not she ever referred to the staff as "idiots", she indicated, "Maybe behind closed doors, but not out on the floor." A copy of Abuse Prevention Policy and Procedure was provided by the DoN on 7/9/2014 at 11:10 a.m. She indicated that facility Point of Contact (POC) for abuse was the Administrator. The Abuse Prevention Policy and Procedure included, but was not limited to, "Rationale: Provide information to residents, families and staff on how and to whom they report concerns, incidents and complaints/concerns without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect...are more likely to occur through analysis of: ....Monitoring residents, visitors and staff to identify inappropriate behaviors, such as using derogatory language, rough handling, etc....Procedure: ...2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution." The Administrator was interviewed on 7/9/2014 at 2:30 p.m. regarding Abuse Prohibition Protocol. She indicated that she ensures that abuse/neglect does not occur by doing Angel Rounds "at least twice per shift." She indicated that all department heads and nurse managers are to round using the Angel Care. Additionally, she indicated, "We do monthly education, inservices, one-on-one teachable moments, and town hall." When queried as to how she ensures that residents, families and staff feel free to communicate concerns without fear of reprisals, she indicated, "I have an open door. We have good communication with residents and families. We ask if there are any problems during Angel Care Rounds. The Administrator provided a copy of the Angel Care Rounds Sheet, which listed 33 items to check. There was nothing on the form to indicate that residents are asked about abuse. The Abuse Prevention Policy and Procedure did not indicate how and to whom residents, families and staff are to report concerns, incidents and complaints/concerns without fear of retribution or what corrective actions would be taken in the event of an allegation of abuse (other than posting the State Abuse Hotline at each nursing station) or the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities or the time-frame for reporting allegations of abuse. Additionally, Employee #10's position was indicated as the "primary" responsible party regarding "...2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution." There was no indication in the Abuse Policy and Procedure as to who the designated representative was in the event that the allegation(s) of abuse involve the Point of Contact/Administrator.

In an interview with Corporate Nurse #1 on 7-14-14 at 1:35 p.m., she indicated any report related to any situation of this facility would not have gone to her in May, 2014, as this was not one of her usual buildings to provide coverage. She indicated she had been assisting with clinical oversight during the last week due to vacation time for the corporate nurse who usually assists with clinical oversight. In an interview with Corporate Nurse #2 on 7-14-14 at 1:50 p.m., she indicated she recalled speaking to a staff CNA in late May, 2014 regarding concerns related to improperly labeled lab specimens. She indicated the CNA was concerned that the CNA's were doing something incorrectly by transporting lab specimens to an area laboratory. She indicated the Administrator had apparently questioned facility nursing staff as to why they had requested staff CNA's to transport improperly labeled lab specimens to an area laboratory and then be asked to label the lab specimen with a resident's name. Corporate Nurse #2 indicated she did not recall any other concerns that were voiced by this particular CNA, "that I have in my documentation." The Immediate Jeopardy that began on 5-27-14 was removed 7-14-14, with an effective date of 7-11-14, when an interim Administrator was appointed to replace the previous Administrator. Additionally, staff education was initiated on 7-11-14 regarding abuse and abuse prevention, which included education on identification of abuse, how to report abuse, when to report abuse, to whom to report abuse and timeliness of abuse reporting without fear of reprisal. Information was also initiated on 7-11-14 to residents and/or families of residents on how and to whom to report any concerns, including abuse or other concerns without fear of reprisal. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of on-going monitoring to ensure residents were free of abuse. This federal tag relates to Complaints IN 904 and IN 091. 3.1-13(q) Based on interview and record review, the management failed to ensure the facility was administered in a manner to attain or maintain the highest practicable mental and psychosocial well-being of each resident by failing to ensure that residents were free from verbal abuse, as evidenced by demeaning and humiliating statement, threats and insults, by the Administrator for 5 of 9 residents reviewed for abuse (Residents D, G, H, F and J). The verbal abuse by the Administrator resulted in a culture of fear and intimidation with the potential to affect 143 of 143 residents in the facility. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/27/2014 when the Administrator yelled at the Generations Unit nurses station, "That's why you don't send a bunch of idiot CNAs over with labs!" in front of staff and residents. The Administrator, Director of Nursing and Corporate Director of Clinical Operations were notified of the Immediate Jeopardy at 7:45 p.m. on 7/10/2014. The Immediate Jeopardy was removed on 7/11/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated, "She's (Administrator) a bully...she bullies the residents...she bullies the employees." Employee #2 recalled an incident which occurred on 5/27/2014 involving some mislabeled labs which were delivered to the lab from the facility by a CNA. Employee #2 indicated that the Administrator was "screaming" at the Generations Unit nurse's station, "That's why you don't send a bunch of idiot CNAs over with labs!" She further indicated that she reported the incident to Corporate Nurse #1, as well as reporting that the Administrator "bullies" the staff and residents, and was told by Corporate Nurse #1, "Well, (Administrator) just doesn't think before she opens her mouth." Employees #1, #4, #5, #6 and #9 corroborated the 5/27/2014 incident. Employee #2 indicated that staff and residents are "afraid" of the Administrator and that she reported the Administrator's behavior to "Corporate" approximately two months ago. She further indicated, "I know at least three of us (staff) have filed complaints (via the corporate hotline and/or to Corporate Nursing staff at the facility) about (Administrator). They just blow it off. What are you supposed to do? Where are you supposed to go when it's the administrator that's doing it?" Employee #1 was interviewed on 7/9/2014 at 4:20 p.m. and again on 7/10/2014 at 1:35 p.m. She indicated that on 5/27/2014, the Administrator was "yelling", indicating, "What are you idiots doing? Why can't you manage to get anything done properly?" She indicated that the Administrator raises her voice to residents and staff "on a daily basis" and indicated, "Just the other day (during first and second shift change) she went running down the hall calling us a bunch of idiots. It makes me feel 3 feet tall. I can't imagine what it does to those residents." She further indicated, "I know you talked to (Employee #11). She came up to me and said you talked to her and she said, 'I should have said something.' and I said, 'Why didn't you?' and she said she was afraid because management was spying on you while you were talking and she didn't want to get in trouble." Employee #1 recounted an incident "about two weeks ago" in which the Administrator indicated loudly to Resident J during a meal in the main dining room, "I'm the boss here, not you. You'll do what I tell you to do!" Employee #1 indicated that residents and staff are fearful of the Administrator. Employee #5 was interviewed on 7/10/2014 at 1:50 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff in front of, and within earshot, of residents. She indicated, "She (Administrator) said the CNAs aren't smart enough to keep them straight and get them where they need them to be." Employee #5 further indicated, "She's notorious for calling the CNAs 'stupid'...it's within earshot of the residents...I don't think that's right. 'Idiot' and 'stupid' is interchangeable with her." Employee #6 was interviewed on 7/10/2014 at 2:20 p.m. She indicated that she was on duty 5/27/2014 and corroborated that the Administrator was "yelling" at staff and called the CNAs "idiots." She indicated, "I've called the (corporate) hotline before after she's belittled me in front of everybody...I've been in tears." Employee #4 was interviewed on 7/10/2014 at 2:55 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated, "(Administrator) went off. She said, 'That's why they're just CNAs.' She doesn't show us respect." Employee #4 additionally indicated, "The other day, (Resident B, who's cognition is severely impaired), was throwing her food in the feed room. We asked her (Administrator) what to do and she said 'You just take her food and take her to bed.' I don't like doing that to her." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated that she was on duty on the Generations Unit on 5/27/2014. She indicated that the Administrator was yelling at staff and called them "stupid." She indicated, "(Administrator) gets MAD. Nobody messes with (Administrator)." 2. Employee #1 was interviewed on 7/10/2014 at 1:35 p.m. and recounted the lunch meal in the main dining room on 7/2/2014. She indicated that the Administrator delivered a meal to Resident F, who was blind and receiving Hospice care prior to her passing on 7/7/2014. Resident F asked the Administrator to identify the meal, and then indicated, "I don't want that." The Administrator indicated loudly, "You need to eat the food that we give you. I pay good money for it and you need to eat it." Employee #1 indicated, "Everyone's mouth just dropped." She further indicated that Resident F's family indicated to her that they were going to file a corporate grievance related to the incident. 3. During an interview with Employee #1 on 7/9/2014 at 4:20 p.m., she indicated that Resident H frequently asks for second and third servings at meals. She indicated that, during the lunch meal in the main dining room on 7/9/2014, the Administrator indicated to Resident H that he was only allowed two servings and stated, "I can't afford to feed your appetite." Employee #2 was interviewed on 7/9/2014 at 4:50 p.m. She indicated that she was not on duty 7/8/2014, but has witnessed the Administrator indicate to Resident H, "You're not getting seconds. You've gotten way too heavy." in the main dining room in front of other residents. Employee #3 was interviewed on 7/10/2014 at 1:30 p.m. She indicated, "She tells him (Resident H) he can't have more than two servings because she doesn't have enough money to feed his appetite." She further indicated, "A day or two ago, (Administrator) approached (Resident J) in a rude way and said she needed to learn to shut her mouth and she doesn't have the right to tell other people they stink because she stinks just as bad as they do. They'll (dietary staff) get to you when they can." Resident H was interviewed on 7/10/2014 at 2:40 p.m. and found to be alert and oriented to person, place and time. When queried regarding the incident in the dining room on 7/9/2014, he indicated, "She (Administrator) said I was eating too much food or some b---s---...she said something about my weight." When queried as to how it made him feel, he indicated, "I just couldn't believe she said it." Employee #9 was interviewed on 7/10/2014 at 3:30 p.m. She indicated, "He (Resident H) always gets yelled at (by the Administrator). She'll say, 'No you don't need no more, you eat enough...or you're already heavy enough." She further indicated, "He (Resident H) was scared to talk. He came to me and said, 'The lady asked me and I had to tell.' He was afraid he'd get in trouble." Resident H's clinical record was reviewed on 7/10/14 at 4:04 p.m. The [DIAGNOSES REDACTED]. Diet orders indicated, "1800 cal ADA (American Dietetic Association) reg (regular)." 4. Resident D's record was reviewed on 7/10/2014 at 12:35. His most recent Minimum Data Set (MDS) assessment, completed on 5/9/2014, indicated a Brief Interview for Mental Status (BIMS) score of 15 of 15; which indicated he was cognitively intact. Resident D was interviewed on 7/10/2014 at 2:00 p.m. He indicated, She's (Administrator) very very rude...that one day she was mad at all the girls and screamed (in the main dining room), "Things are going to go my way or else!" When queried as to how often the Administrator is heard yelling and/or being verbally abusive to staff, he indicated, "I know she loses her temper a lot....She does it quite often; usually on a daily basis." He further indicated, "No, I don't like it. It makes me feel uneasy...like if she's that way to the girls, what's next...us? This should be a nice place to live, but how can it be when somebody's always so negative?" Employee # 8 was interviewed on 7/10/2014 at 2:00 p.m. She indicated that the Administrator yells at staff in front of residents and that residents and staff are intimidated by her. Resident #G was interviewed on 7/10/2014 at 2:30 p.m. She indicated, "She's (Administrator) always yelling at the staff...the aides or nurses. I can't always make out what she says....It makes us all feel on edge." Employee #7 was interviewed on 7/10/2014 at 2:50 p.m. and indicated that the Administrator "flips out." She further indicated that the Administrator threatened staff in front of residents and indicated, "It (yelling) was so bad that they could hear it on the Memory Unit (located on the opposite side of the facility). A nurse even came down to ask if everything was ok" She further indicated that residents have complained to her about the Administrator, indicating, "They just think all the yelling is unnecessary." Employee #10 (Social Service Director) was interviewed on 7/10/2014 at 5:20 p.m. She indicated that she has witnessed the Administrator yelling at residents and/or staff "on occasion" and indicated that her behavior was "intimidating" to both residents and staff. She stated, "I have seen (Administrator) get more verbal than she should in front of residents....I do feel she does not have good bedside manners....She's not nice...she calls the staff 'idiots' and talks about them in morning meeting....It feels like we're on pins and needles all the time." She further indicated that a recent visitor to the facility was "appalled" by the Administrators behavior and asked for the corporate hotline/grievance number, which she provided. She indicated that she had not filed any complaints or grievances herself related to the Administrator's verbal abuse on behalf of residents or staff. The Complaint/Concern Log and Reportable Incidents for 3/1/2014 through 7/9/2014 were provided by the Administrator on 7/9/2014 at 1:59 p.m. and reviewed at that time. None of the allegations of verbal abuse by the Administrator for Residents D, F, G, H or J were indicated. The Director of Nursing (DoN) was interviewed on 7/10/2014 and indicated, "I've never heard her (Administrator) yell." She denied being aware of any complaints by residents or staff related to the Administrator's verbal abuse, indicating, "Nothing stands out." The Administrator was interviewed on 7/10/2014 at 5:40 p.m. She indicated, "My staff hates me and my residents love me." She denied that any complaints or grievances were reported to her or any of her management staff related to the above allegations of verbal abuse by the Administrator. She denied ever "losing her temper or yelling at staff", "except for one time about a year and a half ago....If they (staff) didn't like the way I treated them, why didn't they come talk to me?" When queried as to whether or not she ever referred to the staff as "idiots", she indicated, "Maybe behind closed doors, but not out on the floor." A copy of Abuse Prevention Policy and Procedure was provided by the DoN on 7/9/2014 at 11:10 a.m. She indicated that facility Point of Contact (POC) for abuse was the Administrator. The Abuse Prevention Policy and Procedure included, but was not limited to, "Rationale: Provide information to residents, families and staff on how and to whom they report concerns, incidents and complaints/concerns without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect...are more likely to occur through analysis of: ....Monitoring residents, visitors and staff to identify inappropriate behaviors, such as using derogatory language, rough handling, etc....Procedure: ...2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution." The Administrator was interviewed on 7/9/2014 at 2:30 p.m. regarding Abuse Prohibition Protocol. She indicated that she ensures that abuse/neglect does not occur by doing Angel Rounds "at least twice per shift." She indicated that all department heads and nurse managers are to round using the Angel Care. Additionally, she indicated, "We do monthly education, inservices, one-on-one teachable moments, and town hall." When queried as to how she ensures that residents, families and staff feel free to communicate concerns without fear of reprisals, she indicated, "I have an open door. We have good communication with residents and families. We ask if there are any problems during Angel Care Rounds. The Administrator provided a copy of the Angel Care Rounds Sheet, which listed 33 items to check. There was nothing on the form to indicate that residents are asked about abuse. The Abuse Prevention Policy and Procedure did not indicate how and to whom residents, families and staff are to report concerns, incidents and complaints/concerns without fear of retribution or what corrective actions would be taken in the event of an allegation of abuse (other than posting the State Abuse Hotline at each nursing station) or the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities or the time-frame for reporting allegations of abuse. Additionally, Employee #10's position was indicated as the "primary" responsible party regarding "...2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution." There was no indication in the Abuse Policy and Procedure as to who the designated representative was in the event that the allegation(s) of abuse involve the Point of Contact/Administrator.

Based on record review and interview, the facility failed to ensure a newly admitted resident received assistance and assistive devices to prevent falls, in that one resident fell and sustained a dislocated hip while ambulating with inadequate assistance. This affected 1 of 5 residents reviewed for falls in a sample of 11. (Resident #E) Findings included: Resident #E's record was reviewed on 7/24/12 at 11:55 a.m. The record indicated Resident #E had [DIAGNOSES REDACTED]. A history and physical from the discharging hospital, dated 5/30/12, indicated: "...Past medical history...She does have a history of significant balance problems for which she is followed by (Physician's name)...Left hip exam...Gait is unsteady and she does nearly lose her balance and fall during the exam...Imaging...findings are consistent with degenerative arthritis...." Nursing progress notes, dated 6/2/12 at 2:22 p.m., indicated: "...(Resident #E) admitted via private car accompanied by (Family member)...." Nursing progress notes, dated 6/2/12 at 3:05 p.m., indicated: "...Pt had a lt (left) hip replaced - pt stated hip was 'worn out.' Pt also has had a rt (right) should(er) replacement in the past...Pt sees a Neurologist for a disease she has developed which causes slurred speech, flat affect, and severe loss of balance as reported by husband and pt. Lt hip incision is aproximated (sic) and healing with sterri (sic) strips-sterile dressing reapplied." Nursing progress notes, dated 6/2/12 at 9:30 p.m., indicated: "Called to pt's room. CNA sitting on floor with pt. Inquired about circumstances and was told pt was taken to bathroom and told by CNA she would return to assist her back to bed when CNA witnessed pt standing in bathroom doorway attempting to return to bed without assistance. Gait belt in place around pt's waist. CNA was ambulating pt to bed when she stated pt said her leg was going to give out so she eased her to the floor using the gait belt to lower her onto buttocks and rt hip area. v/s taken=T98 Pulse 92 Resp 24 b/p 138/80. Pt awake, alert, oriented. No hematoma, edema, loss of range of motion noted. 3 person lift to a standing position using gait belt. Pt able to bear weight on both legs. Ambulated to chair and sat down. Then proceeded to transfer to bed. Pt c/o discomfort in buttocks-no [DIAGNOSES REDACTED] (redness) noted...." Nurse's notes, dated 6/2/12 at 11:37 p.m., indicated: "Orders received for bed alarm placed on bed. Reeducated pt on use of call light and to wait for assistance before rising...Care Plan reevaluated and new problem added for high risk of falls...." Nurse's notes, dated 6/3/12 at 12:00 midnight, indicated: "(X-ray) technician arrives to perform X-rays...." Nurse's notes, dated 6/3/12 at 4:25 a.m., indicated: "(Physician) (partner of the doctor who performed total left hip replacement on (Resident #E)) called this nurse. He advised this nurse that (Resident #E) be transferred to an emergency room for a "hip reduction" based on the information provided to him by this nurse...." A radiology report dated 6/2/12 indicated results of "Conclusion: Dislocation of right hip arthroplasty (repair) ...." Nurse's notes, dated 6/3/12 at 5:35 a.m., indicated the ambulance service arrived to transport the resident to the hospital. A care plan for high risk for falls, dated 6/2/12, indicated: "(Resident #E) is high risk for falls r/t (related to) gait/balance problems, history of falls. Goals: (Resident #E) will comply with safety measures. (Resident #E) will express understanding of personal risk factors. Interventions: (Resident #E) needs to be in the "Falling Stars" program. Educate/remind (Resident #E) to request assistance prior to transfer/ambulation. Encourage (Resident #E) to request assistance in ambulating. Follow toileting regime/schedule. Keep adjustable bed in low position for safe transfers. Lock bed brakes. Monitor for gait changes. Monitor medication for side effects that may increase risk for falls. Notify physician as appropriate. Provide non-skid footwear. PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed). Use bed alarm/pressure pad alarm when in bed. Use chair alarm/pressure pad alarm when in chair/wheel chair." The care plan, as written, failed to indicate the number of staff needed to safely assist the resident during ambulation and transfers. On 7/26/12 at 9:25 a.m., the Executive Director indicated they could not find a fall risk assessment for Resident #E, that it was documented it was done, but it could not be found. A fall investigation was begun, on 6/2/12 at 9:37 p.m., by the Director of Nurses (DON). This investigation indicated, but was not limited to; "...(RN #1) stated to me that she told (CNA #3) that she was to tell the other c.n.a. on duty that (Resident #E) was a 2 person transfer and to toilet her every 1-2 hours...Both C.N.A.'s deny being told this. (CNA #2) states that they (her and CNA #3) were in (another resident's) room when she heard the resident's call light go off and heard (RN #1) holler for them to go get the new lady's light. (CNA #2) then left and reported that she entered (Resident #E's) room to find her in the restroom and starting to wipe herself standing up. (CNA #2) then states that she told (Resident #E) to please sit down and wait for assistance. The gait belt was on (Resident #E) along with gripper socks. (CNA #2) then stated that the resident then started walking. So (CNA #2) walked with her until midway in the room when (Resident #E) reported that her left leg was going to give out. (CNA #2) then states that she lowered her to the floor using the gaitbelt and assisted her down with her arms and legs over her but that no part of her body touched her...." On 6/3/12 at 3:47 p.m., the DON spoke with Resident #E's family member, who said the resident had a fractured right femur, and the physician said it happened from the "c.n.a. landing on her." "The resident is alert and oriented. The resident reports that she was up to the restroom and had used her call light to call for assistance back from the toilet. (Resident #E) stated that (CNA #2) entered the room to assist her back to her bed stating 'Come on we can do this.' (Resident #E) told the c.n.a. that she needed to sit down as her leg was about to give out and the c.n.a. wouldn't stop. (Resident #E's) leg gave out and the c.n.a. landed on top of her." During an interview on 7/25/12 at 4:50 p.m., the Executive Director indicated that CNA #2 said she did not "land on top of the resident" and she was terminated for lying during an investigation. The Executive Director said there were no other witnesses besides CNA #2 and the resident. During an interview on 7/25/12 at 4:58 p.m., RN #1 indicated she had two conflicting stories from the CNAs. She indicated a family member said the resident was a two person assist, and RN #1 told the CNAs she was a two person assist and to do hourly checks. She was told by one CNA the resident was observed in the bathroom door and she tried to assist her back to her bed, and then had to ease her onto the floor. RN #1 said she found out later that both CNAs assisted her to the bathroom then left her alone. She didn't have a gait belt on when she went to assess her. RN #1 indicated Resident #E had been assisted earlier with one CNA and a gait belt and her gait was unsteady. A policy and procedure for "Accidents and Supervision to Prevent Accidents" was provided by the Executive Director on 7/25/12 at 5:56 p.m. The policy included, but was not limited to: "Policy: The center provides an environment that is free from accident hazards over which the center has control and provides supervision and assistive devices to each patient to prevent avoidable accidents. This includes systems and processes designed to: Identify hazards(s) and risks(s); Evaluate and analyze hazard(s) and risk(s); Implement interventions to reduce hazards(s) and risk(s); and Monitor for effectiveness and modify approaches when necessary. Compliance Guidelines: 1. Center Administration acknowledges the high-risk nature of its population and setting...5. Center provides training to employee for identification of potential hazards, prevention of accidents, safe transfer techniques and safe use of mobility devices...Assistive Devices/Equipment Hazards: 30. Center assess patient to determine the patient's degree of mobility and physical impairment and the proper transfer method...." 3.1-45(a)(2)

Based on record review, observation, and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents in that one resident's personal pad alarm failed to sound when the resident stood unassisted which resulted in a fall. This affected 1 of 3 residents reviewed for falls in 3 sampled. (Resident #A) Findings included: Resident #A's record was reviewed on 9/22/11 at 9:00 a.m. The record indicated Resident #A was admitted with [DIAGNOSES REDACTED]. An admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated Resident #A was moderately impaired - decisions poor; cues/supervision required in cognitive skills for daily decision making, required extensive assistance of two or more persons for physical assistance for transfers and toileting, did not ambulate, and had a history of [REDACTED]. A care plan dated 8/18/11 indicated a problem of "Potential for falls and injuries r/t (related to) decreased safety awareness d/t (due to) dx ([DIAGNOSES REDACTED]. Goal: Will remain free from falls and injuries i.e. No falls and injuries. Approach: Call light in reach, bed in standard position, encourage to call for assist when getting up, amb(ulate) with assist, encourage to lock w/c (wheelchair) brakes before transferring, monitor for changes in mobility, sitting and standing balance, mental function, monitor for effectiveness and s/e (side effects) of medication, (9/4/11) sensor alarm chair & bed, (9/9/11) WBAT (weight bearing as tolerated), (9/12/11) toilet (after) & (before) meals; upon rising; before bed, (9/16/11) stand/ pivot/ transfer (with) max)imum) assist of 1)." Resident progress notes dated 9/4/11 at 9:00 a.m. indicated: "Staff nurse observed resident attempting to stand from w/c (wheelchair) and ambulate near nurses station. Unable to reach resident before landing on bottom on (R) side. (No) visible injury. Requesting to use restroom repeatedly. C/O pain (with) ROM (range of motion) majority of time. Difficult to assess for (increased) pain d/t (due to) dx (diagnosis): dementia...new order obtained for (L) hip & pelvis x-ray d/t hx (history) (L) hip fx, c/o pain...transport (awaiting) via stretcher to (local hospital) radiology at this time." A "Post Fall Evaluation" dated 9/4/11 indicated a new intervention for "PPA (pressure alarm) to bed and w/c. Bedrest." An "Emergency Department to Long-Term Care Discharge Summary" dated 9/4/11 indicated an unhealed fracture of the (L) hip with surgical hardware intact, an appointment was set up with ortho on 9/8/11, and "no intervention is necessary." An x-ray dated 9/4/11 indicated: "IMPRESSION: 1. Acute left femoral neck fracture/see below. 2. Postop right hip. DISCUSSION: There is an old internally fixed left femoral neck fracture using three surgical fixation screws extending from below the level of the left greater trochanter into the femoral neck and head. There is sharp angulation with narrow projecting at the inferior margin of the left femoral neck consistent with acute refracture. There is an anatomically positioned right hip prosthesis. No other acute osseous abnormalities. There is diffuse osseous demineralization without bony destruction...." An x-ray dated 9/4/11 indicated: "Trauma/right hip pain. IMPRESSION: 1. Anatomically positioned right hip arthroplasty. 2. No acute fractures. Resident progress notes dated 9/10/11 at 3:50 p.m. indicated: "Resident was heard yelling for help, upon arrival of Rm (room) on East hall, resident found on floor by sink, in BR (bathroom) by CNA, assessed per (name of RN), and assisted back to w/c. Alarm was not sounding. 2x2 hematoma on (L) occiput (back of head above collar) (with) 1 cm (centimeter) superficial cut, scant amt of bleeding, ice pack immed(iately) applied to head. 2x2 hematoma (L) (anterior) hand, skin intact, event was unobserved. Neuro (checks) initiated at this time, denies pain at this time..." Resident progress notes dated 9/10/11 at 4:10 p.m. indicated: "W/c alarm switched out, verified proper working order." A "Post Fall Evaluation" dated 9/10/11 indicated the intervention in place at the time of the fall was an alarm, which was checked and did not sound. A new intervention was put in place to change the pressure alarm (sounds when the resident is lifted off of it) to a personal safety alarm (clips to the resident and sounds when the connection is pulled away from the alarm) to the wheelchair. On 9/21/11 at 2:30 p.m., Resident #A was observed sitting in a wheelchair in her room with a family member seated beside her. The family member said Resident #A has had several falls since she has been in the facility. The personal safety alarm was in place and clipped to the resident's shirt. During an interview on 9/23/11 at 9:25 a.m., the Assistant Director of Nursing Services (ADNS) indicated nurses go through and check their alarms to make sure they're functioning and document this on the MARs (Medication Administration Records). She further indicated they did not know why the alarm did not sound, the nurse had documented for that shift the alarm was working, and the pad alarms are usually good for one year; it had just been placed on 9/4/11. A policy and procedure for "Accidents and Supervision to Prevent Accidents" with an effective date of 4/28/11, was provided by the Director of Health Services (DHS) on 9/22/11 at 9:10 a.m. The policy indicated, but was not limited to: "Policy: The center provides an environment that is free from accident hazards over which the center has control and provides supervision and assistive devices to each patient to prevent avoidable accidents. This included systems and processes designed to...Implement interventions to reduce hazard(s) and risk(s); and Monitor for effectiveness and modify approaches when necessary ...Monitoring and Modification: 11. Center has monitoring processes in place to: a. Ensure that interventions are implemented correctly and consistently b. Evaluate the effectiveness of interventions c. Modify or replace interventions, as necessary...." This Federal tag relates to Complaint #IN 255. 3.1-45(a)(2)