Every finding on record at Waters of Lebanon, The

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to answer call lights in a timely and appropriate manner as evidenced by delayed call light response times, residents left waiting for toileting assistance, residents left on bedpans, staff and resident interviews reporting inadequate staffing levels. This deficient practice had the potential to effect 43 of 43 residents who resided in the facility and received nursing care. Findings include:Upon the survey entrance on 9/7/25 from 9:40 a.m. until 10:30 a.m., the following was observed: No administrative staff were present, and the Manager on Duty/Charge Nurse was busy working on the floor as a nurse passing medication. Several call lights were illuminated, flashing, and sounding throughout the building. Licensed Practical Nurse (LPN) 4 indicated she was the only nurse in the building at that time, with two Qualified Medication Aides (QMAs) who were helping pass medications. There were only three Certified Nursing Aides (CNAs) who were all busy with other residents at that time, which was why so many call lights were on. On 9/7/25 at 9:50 a.m. the bathroom call light was on in Resident 18's room at this time CNA 11 was observed going into Resident 18's room and shutting the call light off. On 9/7/25 at 10:00 a.m. the bathroom call light in Resident 18's room came back on and loud banging on the wall was heard coming from the room. On 9/7/25 at 10:05 a.m. QMA 5 indicated it was Resident 18 banging on the wall. She indicated he did that sometimes when he got excited about football. At this time CNA 9 went into Resident 18's room and shut the bathroom call light off. On 9/7/25 at 10:30 a.m. Resident 18 indicated CNA 11 came in and said she was just going to get supplies and would be back. Resident 18 indicated CNA 11 shut the bathroom call light off but did not come back. He indicated CNA 11 was not his assigned aide, CNA 9 was. Resident 11 indicated staff did this all the time, they would say it wasn't their hall and he would have to wait until his aide was available. He indicated he wouldn't have been beating on the wall if they wouldn't have come in and said they were coming back when they weren't. On 9/7/25 at 10:45 a.m. LPN 4 was observed as she went into Resident 2s room to answer a call light. Resident 2 indicated to LPN 4 that he asked her to suction him and do a breathing treatment on him yesterday, but she didn't. LPN 4 indicated yesterday was a busy day and that she was sorry. Resident 2 indicated he had his call light on to get up out of bed for the church service. LPN 4 indicated his aide was coming soon, but she was busy right now so he would have to wait for his aide. LPN 4 shut the call light off and left the room. On 9/7/25 at 10:46 a.m. LPN 4 was observed conversing with other staff. After leaving the room with Resident 2. On 9/7/25 at 10:48 a.m. Resident 2 put his call light back on. The Activity Director walked by and asked if he wanted to get up for church services. LPN 4 indicated she had already talked to him and told him that he was next on the aides list to get up. On 9/7/25 at 10:50 a.m. CNA 11 was observed sitting at the nurses' station. LPN 4 observed speaking with ED who had just arrived. On 9/7/25 at 11:15 a.m. Resident 2 indicated staff were always on their phones while call lights were going off, and staff often came in. During an interview on 9/7/25 at 11:05 a.m., Resident 12 indicated the staff were all very good to her and she loved them all dearly, but felt bad for the aides because they worked so hard and did not have enough help. Resident 12 was able to meet most of her own needs, but at times had waited up to an hour for her call light to be answered. During an interview on 9/7/25 at 11:10 a.m., QMA 8 indicated the facility was very short staffed, especially on the weekends and like today there were only three CNAs trying to get everything done for everyone. QMA 8 indicated she was passing medication that morning and tried to help the aides when she could, but also did not want her medication administrations to be late. On 9/7/25 at 11:19 a.m., the Activity Director (AD) stopped Resident 7 and encouraged him to change his shirt, which was observed to have old food and beverage stains. The AD indicated, let's go change your shirt, this looks like it's from Friday. During a continuous observation, on 9/7/25 from 11:20 a.m. until 11:42 a.m., the following was observed: At 11:20 a.m., Resident 31's call light was activated. At 11:34 a.m., the Activity Director (AD) went to Resident 31's door and called into him, What do you need? In reply to the resident's answer the AD indicated back, your aides are busy, you'll have to wait a couple minutes. At 11:38 a.m., CNA 11 came running out of another resident's room with a bag of trash that she disposed of, then went to Resident 31's room and to turn off the light. During an interview at 11:40 a.m., CNA 11 indicated Resident 31 wanted to get up for lunch, but he required at least two people to transfer so she needed to wait for help. At that time the Medical Records Coordinator (MRC) indicated she would go and help. At 11:50 a.m., Residents 31 was observed as he propelled himself in his electric scooter up the hall to the dining room. During a continuous observation, on 9/8/25 from 9:50 a.m., until 10:30 a.m., the following was observed: On 9/8/25 at 9:51 a.m., Resident 28 was observed in his electric scooter in the doorframe of his room and appeared to be waiting. At that time, LPN 4 indicated she was passing medication and the two CNAs were in with another resident who required, care-in-pairs (two staff members of care) and was very time consuming. LPN 4 indicated Resident 28 was waiting for a shower. At 10:14 a.m., the MRC stopped and asked Resident 28 what he needed. Resident 28 indicated he was waiting for a shower. The MRC indicated the aides were passing ice water, but would get to him as soon as they could. At 10:20 a.m., CNA 9 asked CNA 11 if she could get Resident 28 in the shower, and she would go start on Resident 31. CNA 11 agreed and went to gather supplies as CNA 9 went to Resident 28's room. At 10:30 a.m., CNA 11 assisted Resident 28 into the shower room. During a continuous observation, on 9/8/25 from 10:30 a.m., until 10:47 a.m., the following was observed: At 10:30 a.m., LPN 4 was charting at the nurses' cart when the Assistant Director of Nursing (ADON) came down and indicated she wanted to go through the cart. LPN 4 handed over the keys and indicated she would go take a break while the ADON was on the cart. At 10:35 a.m., Resident 21's call light illuminated. At that time, CNA 11 was assisting a resident in the shower, and CNA 9 was assisting another resident in their room. At 10:41 a.m., the ADON stopped CNA 11, who had just exited the soiled utility room and told her to go check who light was on, but by that time, the Director of Nursing (DON) was at Resident 21's door and went in. She turned off the light and came to the nurses' station and asked CNA 11 to go help. During an interview at 10:43 a.m., the DON indicated Resident 21 would not wait for staff to assist him to the bathroom and he would often take himself, which would cause him to have accidents and his urine would wind up on the toilet seat, on the floor in front of him, and sometimes soil his clothes. At 10:47 a.m., CNA 11 had gathered supplies and went into Resident 21's room to assist him. On 9/8/25 at 10:52 a.m., CNA 9 exited Resident 31's room and came to the utility room to throw away soiled linen. She appeared out of breath and sweaty. Resident 21 was in the hallway and asked her a question, CNA 9 indicated with an exacerbated but apologetic tone, it's going to have to wait until after lunch, we're too busy. During an interview on 9/8/25 at10:53 a.m., CNA 9 indicated she needed to take a break because she was exhausted. She indicated her assignment was from rooms 101-117 by herself and they were all very heavy residents (meaning, required a lot of time, attention and assistance). She indicated Resident 31, who she had just finished with, required the use of a slide board for transfers, and staff had to do all the work for him. Another resident, who required two aides at all times due to behaviors, was also very particular and time consuming which left the floor short of staff because sometimes they would have to be in with her for over an hour to get everything right for her. The other aide helped when she could, but she also had a heavy load from rooms 118 and down. It's hard and some days they could not get it all done. During a continuous observation on 9/8/25 from 12:23 p.m., until 1:00 p.m., the following was observed: At 12:23 p.m., the call light for Resident 4 was activated. At 12:44 p.m., the Administrator (ADM) stopped at Resident 4's room and asked what she needed and the light was turned off. At 12:47 p.m., CNA 11 asked LPN 4 for assistance getting another resident into bed. At 12:50 p.m., Resident 4 was observed in her bed, her eyes were closed but she awake at the sound of her name. She indicated, she needed to be taken off the bedpan, and didn't realize she had fallen asleep while waiting. She did not know her call light had been turned off. At 1:00 p.m., LPN 4 was informed that Resident 4's call light had been turned off a while ago and she still needed to be assisted off the bedpan. LPN 4 went to assist the resident and the two aides were busy with other residents and other staff members were assisting residents out for a smoke break. During a continuous observation on 9/8/25 from 1:20 p.m. until 1:54 p.m., the following was observed: At 1:20 p.m., CNA 9 exited Resident 1's room and gave report to LPN 4 that the Resident reported she did not feel well and wanted to go to the hospital. CNA 9 described how Resident 1 seemed to be gagging in an attempt to vomit and reported that her stomach and head hurt. LPN 4 did not go to assess Resident 1. At 1:54 p.m., CNA 11 indicated Resident 1 was still not feeling well and wanted to go to the hospital. At this time, LPN 4 went to assess Resident 1. At 1:57 p.m., the DON came to the nurses' station and LPN 4 reported Resident 1's vital signs were within normal limits but she still requested to go to the hospital. The DON advised to go ahead and send her out 911. During a continuous observation on 9/9/25 from 12:50 p.m. until 12:57 p.m.: At 12:50 p.m., Resident 25 was seated in her wheelchair at the nurses' station. LPN 13 was seated behind the nurses' station and worked on the computer. At this time, Resident 25 asked for some tissues and indicated her nose was running. LPN 13 did not hear her, or did not answer, but QMA 8 passed by and indicated she would try to find the resident some tissues. At 12:53 p.m., Resident 25 requested tissues for a second time. At 12:55 p.m., Resident 25 requested tissues for a third time, and without a response, she stood unsteadily from her wheelchair and attempted to walk up to the nurses' station. Only then, did LPN 13 jump up and immediately requested that the resident sit back down so she would not fall. At 12:57 p.m., Resident 25 asked for tissues and LPN 13 went to find some. On 9/10/25 at 10:26 a.m., a meeting was conducted with the Resident Council President and three other residents who regularly attended the Resident Council Meetings. When asked about staffing and call light response time, the meeting consensus was that the facility was short staff for the CNAs and needed more CNA help especially on the weekends. The residents indicated they often waited for a very long time to get assistance and one of their biggest concerns was, the staff would come in the room, turn off the light and say they would come back, but never did. On 9/11/25 at 10:52 a.m., the AD came to the front offices and called down the hall, can anyone come help me, these call lights are going off like Christmas lights. On 9/8/25 to 10:37 a.m. the DON indicated if an aide or nurse went into a room and a resident had a need they were expected to help that resident whether they were assigned to that resident or not. She indicated staff should not turn a call light off unless the residents needs were met. On 9/10/25 at 1:50 p.m., the Administrator provided a copy of current facility policy titled, Standard Supervision and Monitoring, dated 11/25/11. The policy indicated, This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. Staff assignments are based on the resident needs as far as their acuity and their assessment results and their person-centered care planning. On 9/11/25 at 11:25 a.m., the Administrator provided a copy of current facility policy titled, Call Light, Use of, dated 1/1/20. The policy indicated, Procedure Purpose: to respond to resident's call light for assistance. All facility personnel must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident answer the call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room. Never make the resident feel you are too busy to give assistance. 3.1-17(a)

Based on observations, interview, and record review, the facility failed to ensure grievance forms and/or a grievance process was readily and easily accessible for residents for 43 of 43 residents who resided in the facility. Findings include: No grievance forms and/or posted grievance instructions were observed throughout the survey period during daily observations of the front lobby, outside of the Social Service Director's office, either nurses' station, or the activity room.There was one grievance note on a desk in the main front lobby, but no blank forms or other grievance material was found. On 9/10/25 at 10:26 a.m., a meeting was conducted with the Resident Council President and 3 other residents who regularly attended the Resident Council Meetings. When asked about how to file a grievance and if there were grievance forms accessible, the meeting consensus was no, there was no good way to file a grievances confidentially. The residents indicated, hopefully they and other residents would feel comfortable enough to let staff know and have the grievance filed on their behalf. On 9/10/25 at 10:50 a.m., LPN 4 indicated she did not know where any grievance forms were and had not seen any at the nurses' station. On 9/10 25 at 10:55 a.m., QMA 8 indicated since she had started working, she had not noticed or seen where any grievance forms were located. But from her previous facility experience she knew they were supposed to be accessible for residents to get without assistance at all times. On 9/20/15 at 10:57 a.m., an Activity Assistant indicated there were no grievance forms in the Activity room to his knowledge, and he did not know where else to look for them except in the Social Service Director's office, or maybe in the copier room. On 9/10/25 at 11:00 a.m., the DON checked the front lobby, the copier room, and front nurses' station. Grievance forms were not available. During an interview on 9/10/25 at 11:02 a.m. the Regional Clinical Consultant indicated grievance forms should always be accessible to the residents. On 9/10/25 at 1:50 p.m., the Administrator provided a copy of current facility policy titled, Grievance/Complaints/Missing Property, dated November 2016. The policy indicated, .It is the policy of the facility to see that the residents and their responsible parties are made aware upon admission and as indicated of the resident's rights to express a complaint or grievance orally, or in or in writing at any time this complaint or grievance may also be done anonymously. there will be posted information throughout the facility in prominent locations as to the resident individual right to express a complaint or a grievance in writing or anonymously as well as the contact information for the person (Grievance Official) in the facility who should be in receipt of the concern or complaint. 3.1-7(a)

Based on observation, interview, and record review, the facility failed to ensure the correct prescribed solutions were used for 3 of 8 peritoneal dialysis treatments, and failed to follow appropriate infection control measures to properly and timely dispose of the used dialysate (fluid pulled off during the dialysis treatment) (Resident 47). Findings include:On 9/9/25 at 9:50 a.m., Resident 47 was observed in his room. There was a bag of fluid left on his bedroom floor, that had leaked some fluid onto the floor. Resident 47 indicated he had just come off his dialysis treatment about 30 minute prior and the nurse had not disposed of the effluent fluid (bio-hazard waste material). There were two empty solution bags left on top of the dialysis cart. During an interview, Resident 47 indicated it seemed like the nurses were doing good with his dialysis, especially since they had all recently been trained on the treatment process. Resident 47 indicated he had to give them some reminders during his treatment but mostly relied on the staff as his current treatment plan was different from what he had been used to at home. On 9/9/25 at 10:30 a.m., Resident 47's medical record was reviewed. He was a short-term rehab resident. He had current diagnoses which included, but were not limited to, end stage renal disease and dependence on peritoneal dialysis. He was admitted to the facility 8/28/25 with new physician orders from his dialysis provider which indicated the following detailed and specific instructions: Target Weight: 229 lbs [pounds]. If weight is 229.0 lbs and under, use two yellow (1.5%) bags.If weight is 229.10233 lbs, use one green (2.5%) and one yellow (1.5%) bags.If weight is 233.1-236 lbs, use two green (2.5%) bags.If weight is 236.1-239 lbs, use one red (4.25%) bag and one green (2.5%) bag. If weight is 239 lbs, call dialysis clinic for further orders.If SBP (top blood pressure number) is below 110 before treatment, use two yellow (1/5%) bags, regardless of weight. These physician's order were on a printed piece of paper in the resident's room, but were not electronically entered into his medical record until 8/30/25. Resident 47's daily dialysis logs were reviewed and revealed the following: On 9/2/25, he weighed 231.3 lbs, his blood pressure was 132/64 and he was administered 2 yellow bags, which was a discrepancy to his parameter orders as he should have received one yellow and one green. On 9/5/25, he weighed 224.2 lbs, his blood pressure was 122/60 and he was administered 1 green and 1 yellow bag, which was a discrepancy to his parameter orders as he should have received 2 yellow bags. On 9/6/25, he weighed 224 lbs, his blood pressure was 158/78 and he was administered 1 green and 1 yellow bag, which was a discrepancy to his parameter orders as he should have received 2 yellow bags. On 9/10/25 at 10:18 a.m., the Director of Nursing (DON) provided a copy of recent nurse training and education on Peritoneal Dialysis. The education included skill validation to properly dispose and store contaminated or infectious waste (the pulled effluent) and how to properly end a treatment and dispose of the effluent fluid. During an interview on 9/10/25 at 10:20 a.m., the DON indicated the drained effluent needed to be measured and disposed of at the completion of the treatment session, and the parameters needed to be followed closely as prescribed as not to cause the potential for side effects or poor treatment outcomes. On 9/10/25 at 10:18 a.m., the DON provided a copy of current facility policy titled, In Peritoneal Dialysis. dated 2/4/25. The policy indicated, .Peritoneal dialysis is a method for removing waste products from the blood. During peritoneal dialysis, a cleansing fluid flows through a tube into part of the stomach/abdominal area. The inner lining of the abdomen- also known as the peritoneum, acts as a filter and removes waste products from the blood. After a certain amount of time, the fluid with the filtered waste flows out of the abdomen and is discarded appropriately. Any type of dialysis must have a detailed and specific physician's order. when drain is complete, cap transfer set with mini cap as per protocol or capping off procedure. assess appearance, color and clarity of drained effluent. measure drained effluent. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to prevent the potential for accidents when medications were left at bedside and the resident was not supervised to take his medications for 1 of 1 random observation (Resident 33). Findings include: On 9/8/25 at 12:53 a.m., a record review was completed for Resident 33. He had the following diagnoses which included, but were not limited to, alcoholic cirrhosis of the liver with ascites (a condition where excess fluid accumulates in the abdominal cavity, causing swelling and bloating), major depression, difficulty in walking, and low blood pressure. On 9/7/25 at 10:38 a.m., it was noted that Resident 33 had a cup of medications on his bedside table. Resident 33 indicated he did not take his medications because he was nauseous and would take them later. Resident 33's medical record lacked an assessment for him to self-administer his own medications. A review of resident's medication record indicated he took the following medications in the morning hours.a.) Ciprofloxacin HCI (an antibiotic) oral tablet 500 milligrams (mg) daily.b.) Folic Acid (a supplement) 1mg dailyc.) Furosemide (a diuretic) 40 mg dailyd.) Spironolactone (a diuretic) 50 mg dailye.) Thiamine (a supplement) 100 mg dailyf.) Zinc Sulfate (a supplement) 220 mg dailyg.) Promethazine (used for nausea) 25 mg two times dailyh.) Rifaximin (used to treat cirrhosis) 500 mg two times dailyi.) Midodrine (used to treat low blood pressure) 5 mg, 3 tablets The Director of Nursing (DON) was made aware of the medication being left at bedside. She indicated she educated QMA 5 regarding leaving medications at bedside for residents who had not been assessed to leave their medications at bedside. A policy titled, Medication Storage in the Facility was provided by the DON on 9/10/25 at 9:25 a.m. It indicated, .Residents who have been trained in self-administration will have access only to their individual drug supply. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure nursing staff had the necessary skills to administer a resident's medication and administer the right dose to a resident (Resident 24). Findings include:On 9/7/25 at 12:26 p.m., Qualified Medication Aide (QMA) 5 was setting up Resident 24's and Resident 23's medication at the same time. She indicated she could not find Resident 24's acetaminophen (a pain medication) medication and sent Licensed Practical Nurse (LPN) 4 to look for his medication in the medication room. LPN 4 came back with Resident 23's acetaminophen. The dosage was 325 milligram (mg). QMA 5 indicated they shared Resident 23's and 24's medications sometimes because the residents were married. QMA 5 was instructed that Resident 24's ordered acetaminophen dose was one 500 mg tablet three times daily and not 325 mg. QMA 5 indicated if she gave him two tablets that would be a dose of 650 mg and proceeded to administer Resident 24 one 325 mg tablet. This was short 175 mg for his ordered 500 mg tablet. On 9/11/25 at 1:00 p.m., the Regional Clinical Director (RCD) indicated she found the 325 mg acetaminophen in the cart for Resident 23 and removed it from use since Resident 23's dose ordered was 500 mg. The RCD indicated QMA 5 was counseled regarding incident. A policy titled, Medication Error Reporting, was provided by the Director of Nursing (DON) on 9/10/25 at 9:25 a.m. It indicated, .The facility will notify the appropriate personnel at the pharmacy when a medication error has occurred via phone call or email. 3.1-14(i)

Based on observations and interviews, the facility failed to date medications and remove expired medications from use for 1 of 2 medication carts and 1 of 2 medication rooms. Findings include:On 9/725 at 11:20 a.m., the 100 hall medication cart was observed. Inside the top drawer of cart eye drops were being stored with nitroglycerin, ear, and oral medications. Qualified Medication Aide (QMA) 8 indicated she would correct and store medications separately. The following medications were found without a date or were expired.a. Resident 2 had two bottles of fluticasone nasal sprays (used to treat allergies) without a date to indicate when they were opened. He had ear drop solution 6.5% with no date to indicate when opened on the bottle. He had an inhaler flutic/vilan 100-25 mcg with no date to indicate when it was opened.b. An ellipta inhaler was in the cart with no name or date on it.c. Resident 31 had three bottles of fluticasone without a date to indicate when they were opened.d. Resident 14 had two bottles of fluticasone with a date to indicate when they were opened.e. Resident 1 had a bottle of fluticasone with a date to indicate when it was opened.f. A bottle of fluticasone was in the cart without a name or date on the bottle.g. Resident 28 had a bottle of latanoprost (used to treat glaucoma) with a date to indicate when opened. It was sent from the pharmacy on 4/3/25. h. Resident 4 had a flutic/salm discus (used to treat asthma) without a date on the diskus.i. Resident 3 had an insulin pen of lantus expired on 9/4/25. On 9/7/25 at 11:40 a.m., QMA 8 indicated she would remove the items from the medication cart and reorder said medications. A policy titled, Medication Storage in the Facility, was provided by the Director of Nursing (DON) on 9/10/25 at 9:25 a.m. It indicated, .Eye drops, ointments, drops and inhalers are to be kept separate from other medications.Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled, or without secure closure will immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists. 3.1-25(j)3.1-25(m)3.1-25(n)

Based on interviews and record review, the facility failed to ensure accurate documentation related to wound care orders for a pressure ulcer and administration of a controlled substance for 1 of 19 Residents reviewed for accurate documentation (Resident 2). Findings include:1. On 9/9/25 at 12:06 p.m. Resident 2's medical record was reviewed. He was a long-term care Resident 2's diagnoses included, but were not limited to, acute and chronic respiratory failure, stage 4 pressure ulcer (a pressure wound over the tailbone, that involves full-thickness tissue loss, exposing muscle, tendon, or bone) to the sacral area, post traumatic stress disorder (PTSD), and anxiety. Resident 2's physician orders indicated Resident 2 had an order for Lorazepam 0.5 milligram (mg) oral tablets, give one tablet by mouth every 8 hours as needed (PRN) for anxiety. An order for Lorazepam 0.5 mg oral tablets, give 0.5mg by mouth every 8 hours PRN for anxiety. An order for Hydroxyzine 25 mg oral tablets, give 25 mg by mouth every 6 hours PRN for anxiety. None of these orders had a stop date. A medication review, dated 7/10/25, indicated Resident 2 had an order for Hydroxyzine 25 mg every 8 hours as needed for anxiety. The recommendation was to either discontinue the medication or add a stop date to the PRN for short-term use. Neither of the options were checked off and the only response was note written to physician under follow-through. Resident 2's Medication Administration Record (MAR) indicated on 9/3/25 the order that said Lorazepam 0.5 mg oral tablets, give 0.5 mg by mouth every 8 hours PRN for anxiety was marked as given and effective at 9:42 p.m. and the order that said Lorazepam 0.5 mg oral tablets, give one tablet by mouth every 8 hours as needed (PRN) for anxiety was marked as given and effective at 9:43 p.m. The MAR indicated on 9/9/25 the order that said Lorazepam 0.5 mg oral tablets, give 0.5 mg by mouth every 8 hours PRN for anxiety was marked as given and effective at 11:55 a.m. and again at 3:44 p.m., and the order that said Lorazepam 0.5 mg oral tablets, give one tablet by mouth every 8 hours as needed (PRN) for anxiety was marked as given and effective at 4:09 p.m. On 9/10/25 at 9:34 a.m. the narcotic book and the Lorazepam card were observed. All pills were accounted for and appropriately signed off in the narcotic book. During an interview on 9/10/25 at 9:15 a.m. the Director of Nursing (DON) indicated the Lorazepam orders for Resident 2 were duplicate orders. The DON indicated she talked to Licensed Practical Nurse (LPN) 12 who charted that she gave both ordered doses in the MAR and she indicated she did not give both doses, she clicked both on accident but did not give both. 2. On 9/9/25 at 12:06 p.m. Resident 2's medical record was reviewed. He was a long-term care Resident 2's diagnoses included, but were not limited to, acute and chronic respiratory failure, stage 4 pressure ulcer (a pressure wound over the tailbone, that involves full-thickness tissue loss, exposing muscle, tendon, or bone) to the sacral area, post traumatic stress disorder (PTSD), and anxiety. A physician order, dated 7/29/25, for wound care indicated staff should cleanse the sacral wound with normal saline, pat dry, apply Hydrofera blue (a non-cytotoxic antibacterial foam wound dressing made of polyvinyl alcohol (PVA) sponge containing methylene blue and gentian violet), skin prep the surrounding tissue and secure with a bordered foam dressing every 3 days and PRN for soilage. A Nurse Practitioner (NP) wound assessment report, dated 8/29/25, indicated the wound measured 7 centimeters (cm) long, 8 cm wide and 0.7cm deep. The report indicated the wound was 50% epithelial tissue (one of the four basic types of human tissue, covers body surfaces, lines cavities and organs, and forms glands) and 50% granular tissue (a type of new, soft connective tissue that forms in response to injury or inflammation). The report also indicated the wound edges were attached and it did not mention any undermining or tunneling. A weekly skin check, dated 9/4/25, indicated Resident 2 did not have a loss of skin integrity. A weekly wound evaluation, dated 9/5/25, indicated the current wound care orders as of 8/29/25 were cleanse with normal saline, pat dry, skin prep to surrounding tissue, apply Calcium Alginate with Silver (a highly absorbent wound dressing made from natural seaweed fibers (alginate) that also contains antimicrobial silver particles) to the wound bed, secure with an abdominal (ABD) pad and secure with tape. The record lacked documentation of a physician order for the recommended wound treatment. On 9/11/25 at 10:00 a.m. the DON provided an ER note, dated 9/5/25, that indicated the wound measured 8.3 cm long, 6 cm wide, and 0.5 cm deep. The note indicated the wound was between 25% and 50% granular tissue and between 25% and 50% slough (non-viable, yellow or white, devitalized tissue composed of fibrin, dead cells, proteins, and sometimes bacteria or biofilms). The note also indicated there was undermining that measured 0.4 cm deep from 3 o'clock to 5 o'clock and a second undermining that measured 0.5 cm deep from 6 o'clock to 7 o'clock. On 9/9/25 at 1:43 p.m. the DON indicated the wound nurse, which was the current ADON, would go around with the NP and the wound nurse was responsible for putting any new orders for wound treatments into the resident's medical record. On 9/11/2025 at 9:48 a.m. the DON indicated the ADON had just started in July, so she wasn't well versed on the process of putting in new orders when doing wound rounds with the NP. She indicated they did wound rounds every Friday with the wound NP. The ADON should have taken paper with her while they go around to take notes. Then the wound NP should tell them what she wants ordered, and then the NP would put in her note either that day or the following Monday. The DON indicated the ADON was told one thing about the orders and the NP put something else in her note. On 9/11/25 at 10:00 a.m. the DON provided a copy of a current facility policy titled, SWAT Program Skin, Weight, Assessment Team program, dated 10/9/23. This policy indicated, . System for providing care once wound is identified. upon receipt of the order- immediate transcription of the order onto MAR/TAR. On 9/10/25 at 2:30 p.m. a policy pertaining to accuracy of documentation was requested. No policy pertaining to documentation was provided at exit. 3.1-3(o)3.1-3(r)

Based on record review and interview, the facility failed to send adequate documentation with a resident to the hospital and failed to reconcile a resident's medications, who was discharging to his home for 2 of 3 residents reviewed for discharge (Resident 44 and Resident 46). Findings include:1. On 9/8/25 at 11:37 a.m., a record review was completed for Resident 46. He had the following diagnoses which included but were not limited to chronic respiratory failure, diabetes, neuropath (weakness, numbness, and pain from nerve damage, usually in the hands and feet), major depressive disorder, gastro-esophageal reflux disease (GERD) (a digestive disease in which stomach acid or bile irritates the food pipe lining), and anxiety disorder. Resident 46 was discharged home on 8/17/25. His record lacked documentation of his medications that were sent home with him, except hydrocodone (a pain medication) and hydroxyzine (an anti-itch medication). The medications lacking reconciliation were amitriptyline (an antidepressant), amlodipine (for high blood pressure), aripiprazole (for depression), ascorbic acid (vitamin C), atorvastatin (for high cholesterol), Plavix (for blood clots), docusate sodium (for constipation), ferrous sulfate (iron), Humalog (an insulin), insulin glargine (for diabetes), Jardiance (for diabetes), losartan (for hypertension), metformin (for diabetes), metoprolol (for high blood pressure), and oxybutynin (for overactive bladder), paroxetine (for depression), and tamsulosin (for enlarged prostate). On 9/11/25 at 10:35 a.m., the Regional Nurse Consultant (RNC) indicated the nurse sent Resident 46's medications home with him, but they could only find where the disposition of hydrocodone and hydroxyzine were documented. 2. On 9/8/25 at 12:12 p.m., a record review was completed for Resident 44. She had the following diagnoses which included but were not limited to cerebral infarction (a condition where blood flow to the brain is interrupted, leading to damage or death of brain cells), acute renal failure, cerebral edema ( a condition where excess fluid accumulates in the brain tissue, causing it to swell), subarachnoid hemorrhage (SAH) (a bleeding into the space between the brain and the thin membrane ([NAME] mater) that covers it), weakness, and GERD. Resident 44's record lacked a discharge summary to include pertinent information regarding resident's current health along with past health concerns, code status, and physician orders. On 12/10/25 at 10:32 a.m. the Regional Nurse Consultant (RNC) indicated Resident 44 was sent out with swelling to the right side of her head. She indicated a SBAR (Situation Background Assessment and Recommendation) was completed in the progress notes but she could not find any discharge information that was sent with the resident to the hospital. A policy titled, Guidelines for Discharge/Transfer, was provided by the Director of Nursing (DON) on 9/10/25 at 9:24 a.m. It indicated, .Types of discharges for reference: higher level of care (emergency or planned hospital transfer), completed transfer form in electronic health record (EHR)- EHR discharge/transfer form, send face sheet, send advanced directives, send MAR/TAR (Medication Administration Record/Treatment Administration Record, other pertinent information or required information as per state regulations. 3.1-12(a)(4)

Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) for types of medications used by the residents for 2 of 5 residents reviewed for MDS accuracy (Residents 51 and 41). Findings include:1. On 9/9/25 at 1:52 p.m., a record review was completed for Resident 51. She had the following diagnoses which included, but were not limited to, bipolar disorder (a mental illness that causes clear shifts in a person's mood, energy), allergies, constipation, pain, and anxiety. Resident 51 had an MDS dated [DATE]. Section N (Medications used) indicated she did not take an antianxiety medication. A physician order, dated 4/21/25, indicated Resident 51 took Ativan (an antianxiety medication) 0.5 mg (milligrams) two times daily. A care plan, dated 9/8/25, indicated she was at risk for increased anxiousness related diagnoses with need for anxiolytic (antianxiety). The goal indicated she would have no adverse reactions related to anxiolytic use. 2. On 9/9/25 at 1:45 p.m., a record review was completed for Resident 41. He had the following diagnoses which included, but were not limited to, generalized edema (swelling), gastro-esophageal reflux disease (GERD) (stomach reflux), weakness, repeated falls, and diabetes. Resident 41 had a MDS, dated [DATE], Section N indicated he did not take an anticoagulant (medications that prevent blood from clotting). It indicated he took an antiplatelet (medications that prevent platelets from clumping together and forming blood clots). A physician order, dated 5/9/24, indicated Resident 41took Eliquis (an anticoagulant) 2.5 mg two times daily for an antiplatelet. A care plan, dated 9/1/19, indicated he was at risk for bleeding related anticoagulant use. The goal was he would have no adverse reactions with the use of anticoagulants. An intervention indicated that staff would administer his medications as ordered. On 9/10/25 at 1:32 p.m., the Regional Nurse Consultant (RCS) indicated the MDS for both residents had been corrected. They did not have a policy for accuracy of assessments. They followed the RAI (Resident Assessment Instrument).

Based on interview and record review, the facility failed to follow safety guidelines and to provide adequate employee training resulting in a resident's wheelchair falling over during transport in a facility vehicle for 1 of 3 residents reviewed for accidents (Resident B). Findings include: On 7/30/25 at 3:20 p.m., Resident B was observed lying on the bed watching television. The bed was positioned against the wall lower to the floor and a small manual wheelchair was sitting beside the top of the bed. The resident indicated, the prior week while she was being driven to her dialysis appointment in the facility van, her wheelchair tipped over and she fell hitting her head on the floor. The van was being driven by a maintenance staff worker, not the facility's primary transportation driver. Resident B indicated she was not sure exactly what happened, but she did not think she had been properly secured in the van because when they turned a corner she fell. The resident indicated she had pain on one side of her body after the fall and was subsequently seen in the emergency room (ER) of a nearby hospital. Resident B's clinical record was reviewed on 7/30/25 at 2:00 p.m. Resident B who was admitted on [DATE] had diagnoses to include end stage renal disease (ESRD - kidney failure), difficulty walking, and dependence on renal dialysis.admission Minimum Data Set (MDS) assessments, completed on 7/26/25, assessed Resident B as being cognitively intact. The resident was dependent on staff for bed mobility, transfers in and out of bed, and transfers in and out of a car or van. The resident used a manual wheelchair for mobility. An incident report, dated 7/26/25 at 6:50 a.m., documented Resident B as having had a fall. Physician's orders for Resident B included, a. Dialysis weekly on Monday, Wednesday, and Friday.b. Apixaban (Eliquis - a blood thinner) 2.5 milligrams (mg) give 1 tablet by mouth daily.An electronic notification to providers, dated 7/26/25 at 6:50 a.m., indicated Resident B had fallen. An examination of the resident indicated she was currently taking an anticoagulant medication, was complaining of pain after the fall, and one pupil was restricted. The primary provider responded with a recommendation to send the resident to the ER for testing and x-rays. A nursing progress note, dated 7/26/25 at 8:36 a.m., indicated Resident B had an unwitnessed fall while being transported to dialysis. The resident's wheelchair fell backwards, and the resident fell flat on her back and head. The resident returned to the facility where she was assessed and found to have right pupil constriction and complaints of head and right arm pain. Resident B was sent out to the ER. An interdisciplinary team (IDT) progress note, dated 7/28/25 at 9:09 a.m., indicated Resident B had an unwitnessed fall during transport to a dialysis appointment. The resident fell backward in a wheelchair during transport, and Registered Nurse (RN) 11 who had been following the van pulled over and assessed the resident, who said she was sore. Upon return to the facility, Resident B complained of pain in her shoulder, and she was sent to the ER for evaluation. A local hospital report, dated 7/26/25, indicated Resident B who was taking Eliquis presented to the ER after a mechanical fall experience while on her way to dialysis. The resident was getting in the van and had a mechanical fall, and she stated she hit her head and her right arm. The resident complained of having a mild headache but severe right arm pain that was constant non-radiating and was worse with touch and movement. Computed tomography (CT) scans of the head, and x-rays of the right shoulder and right elbow were performed. A care plan written for Resident B after her fall on 7/26/25, indicated the resident was at risk of falls related to general weakness, and difficulty walking. Interventions included ensuring placement of seatbelts during transportation by facility staff and provide education to staff who transported the resident to outside appointments. A transportation van education sign-in sheet, dated 6/20/25, indicated 6 employees had been educated on the correct operation of a van lift, correct procedure for loading/unloading a resident on a lift, correct procedure for securing a resident with the proper tie downs, and manual operation of a van lift. Maintenance Worker 11 signed as having received the education. The facility lacked documentation the 6 employees who were providing resident transport with the facility van had been observed for competence, or that the employees had been re-educated regarding safety protocols after the incident that had occurred on the van 6/20/25.During an interview on 7/31/25 at 9:44 a.m., the Director of Nursing (DON) indicated Resident B had been admitted to the facility with orders for dialysis at a local dialysis center three times a week, and she was being transported in the facility van. On 7/26/25 while enroute to dialysis, Resident B's wheelchair tipped backwards, and the resident fell resulting in pain to her shoulder and head. Maintenance Worker 11 later indicated at the time of the incident, the front belt was off the wheelchair. The DON indicated, to her knowledge, there was nothing mechanically wrong with the van. During an interview on 7/31/25 at 10:10 a.m., the Administrator (ADM) indicated 2 months ago, an outside vendor had provided van safety education to the transportation drivers. On 7/26/25 Resident B fell on the facility bus when Maintenance Staff 11 failed to anchor her wheelchair properly on the front base of the wheelchair. Maintenance Worker 11 had attached straps to the front wheels of the wheelchair versus the front base, and the straps had come off while the van was moving down the road causing the resident's wheelchair to fall backwards. Maintenance Worker 11 had been trained on van safety last month to include how to secure a resident in the van. During an interview on 7/31/25 at 1:05 p.m., Maintenance Worker 11 indicated on 7/26/25 Resident B's wheelchair had tipped over causing the resident to fall while he was taking her to dialysis on the facility van. Maintenance Worker 11 indicated after turning a corner not far from the facility, he heard the resident yell she had fallen, and when he looked into the rearview mirror he could no longer see her sitting in her wheelchair behind him. Maintenance Worker 11 indicated he had not found out until after Resident B's fall that he had been hooking up resident wheelchairs in the van incorrectly. Maintenance Worker 11 indicated he and 5 others facility employees had been trained on van safety in June, but the group had been standing around the van in a group while the instructor demonstrated the correct procedure of hooking to the frame versus the wheels, and he had been unable to visualize the process while looking through the van windows. On 7/31/25 at 1:38pm the ADM provided a Safety During Transport - Securing Chair policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of this facility to secure resident wheelchair in transport vehicle to ensure resident safety during transport.9. Final check. a. Two [2] front straps 30 to 45-degree angles. Two [2] rear straps 30 to 45-degree angles.c. All straps are not attached to any adjustable or removable parts of the wheelchair. No straps are attached to the footrests, armrests, or wheels.This citation relates to Complaint 2573037.3.1-45(a)(1)3.1-45(a)(2)

Based on and interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for 5 of 12 residents reviewed for resident assessments (Residents 6, 34, 13, 43 and 29). Findings include: 1. On 9/10/24 at 11:16 a.m., a record review was completed for Resident 6. She had the following diagnoses which included, but were not limited to, End Stage Renal Disease (ESRD- disease and degeneration of the kidneys), type 2 diabetes (an inability for the body to produce/process blood sugar), and muscle weakness. She had a physician's order, dated 1/27/24, which indicated she may attend dialysis on Monday, Wednesday, and Friday at a specific center. She had a comprehensive care plan, dated 1/26/24, which indicated she had a diagnosis of ESRD and required dialysis treatment. A Minimum Data Set (MDS) assessment, dated 8/23/24, indicated Resident 6 had not recieved dialysis treatments. 2. On 9/10/24 at 11:35 a.m., a record review was completed for Resident 34. She had the following diagnoses which included, but were not limited to, heart failure, muscle weakness, schizophrenia unspecified, and psychosis (a set of symptoms that can cause a person to lose touch with reality, making it difficult to distinguish what is real and what is not). An undated comprehensive care plan indicated she qualified for classifcation of a Level II related to her diagnosis of schizophrenia, but did not require specialized services. A MDS assessment, dated 5/28/24, was not coded to accuratly reflect her Level II status. 3. On 9/10/24 at 11:05 a.m., a record review was completed for Resident 13. He had the following diagnoses which included but not limited to heart failure, sleep apnea, major depression, chronic kidney disease, and hyperlipidemia (high cholesterol). A MDS assessment, dated 8/19/24, was coded to indicated her recieved an anticoagulant medication. Resident 13's physician orders were reviewed and laked docuemntation that he recieved an anticoagulant medication. During an interview on 9/10/24 at 11:44 a.m., the Regional MDS Consultant (MDSC) indicated, the facility should follow the RAI (Rap Assessment Instrument) for information and guidance related to anticoagulant medication coding. Resident 13 recieved an antiplatlet medication which had been miscoded as an anticogulant. 37981 4. On 9/11/24 at 11:41 a.m., Resident 43's record was reviewed. His diagnoses included, but were not limited to, diabetes mellitus (blood sugar disorder), essential hypertension (high blood pressure), and cerebrovascular disease (conditions that affect blood flow to the brain). His quarterly MDS assessment, dated 8/7/24, indicated Resident 43 was on an anticoagulant. His physician orders, dated 7/20/24, indicated Resident 43 had an order for aspirin 81 mg, give 1 tablet one time a day related to cerebrovascular disease and essential hypertension. An anticoagulant was not observed. During an interview, on 9/12/24 at 9:45 a.m., the Director of Nursing (DON) indicated aspirin should not have been coded on the MDS (Minimum Data Set) as an anticoagulant and the MDS Coordinator (MDSC) should have followed the RAI (Resident Assessment Instrument) Manual. During an interview, on 9/12/24 at 10:18 a.m., the Regional MDS Consultant (RMDSC) indicated she went back to the MDS record and changed the aspirin use from anticoagulant to antiplatelet use. A review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17, dated October 2019, was completed. It indicated, .Anticoagulant .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period .Do not code antiplatelet medications such as aspirin .here 38768 5. On 9/10/24 at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making breathing more difficult), congestive heart failure, and lung cancer. She had a current and active physician order, initiated 7/5/24, to receive hospice services. A nursing progress note, dated 7/6/24 at 9:10 p.m., indicated, . Resident admitted to hospice during previous shift . A comprehensive admission minimum data set (MDS) assessment, dated 7/10/24, indicated Resident 29 did not receive hospice services. During an interview on 9/10/24 at 12:09 p.m., the Regional MDS Consultant, (MDSC) indicated Resident 29's admission MDS should have coded that she received Hospice services since the MDS was dated 5 days after her Hospice services began. At that time, the MDSC indicated, there was no MDS policy, but the facility followed the RAI (Resident Assessment Instrument) guidelines.

Based on observation, interview, and record review, the facility failed to ensure a resident who was at risk for developing pressure ulcers, received a pressure reducing device for her wheelchair for 1 of 2 residents reviewed for pressure ulcers (Resident 29). Findings include: On 9/9/24 at 10:10 a.m., Resident 29 was observed. She was seated in a wheelchair (WC) with her overbed table in front of her. She rested her head in her hand with her eyes closed. No Pressure reducing cushion was observed on her WC seat at that time. On 9/9/24 at 12:33 p.m., Resident 29 was observed. She remained seated in her WC, no pressure reducing cushion was observed, as lunch trays were delivered. On 9/9/24 at 1:23 p.m., Resident 29 was observed. She remained seated in her WC and no pressure reducing cushion was observed in place. On 9/10/24 at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making breathing more difficult), congestive heart failure, and lung cancer. A comprehensive admission Minimum Data Set (MDS) assessment, dated 7/10/24, indicated Resident 29 was at risk for the development of pressure ulcers and required a pressure reducing device for her chair. Resident 29 had an admission comprehensive care plan, dated 7/2024, which indicated, she was at risk for the development of pressure ulcer related to her diagnoses and required interventions which included but were not limited to, follow preventative measures as ordered. During an interview on 9/11/24 at 10:00 a.m., the Director of Nursing (DON) indicated Resident 29 had not come to the facility with a WC, but shortly after her admission to Hospice, she had been evaluated by therapy and was provided a WC with a pressure reducing cushion. The DON indicated Resident 29 should have the cushion on her WC seat and she would go look for it. On 9/11/24 at 10:30 a.m., the DON indicated nursing had not been able to locate Resident 29's cushion and she did not know how long Resident 29 had gone without it. On 9/11/24 at 10:30 a.m., the DON provided a copy of Resident 29's order invoice which indicated a 16-inch gel pressure reducing cushion had been provided. On 9/11/24 at 10:30 a.m., the DON provided a copy of current facility policy titled, S-W-A-T Program, Skin Weight Assessment Team Program Meeting Guidance, dated 10/9/23. The policy indicated, .it is the intent of the facility to assess the nutritional status as well as the skin condition status of each resident and to timely address any issues or any potential for issues related to weight and/or skin. The SWAT Team will monito residents who meet the criteria on a weekly basis to ensure that measures are in place to avoid weight loss in at risk for weight loss resident; as well as to avoid skin breakdown in residents at risk for skin breakdown- based on their medical assessments an overall health status . interventions decided upon by the team will be recorded on the individual resident monitoring and record form. The appropriate disciplines will address interventions requiring a physician's order, will have that order obtained. Any new intervention will be added to the resident's care plan 3.1-40(a)

Based on observation, record review, and interview, the facility failed to ensure a resident had a self-adminstration asessment for a medication (Ventolin) stored at bedside for 1 of 12 residents (Resident 34) reviewed for medications at bedside. Findings include: On 9/10/24 at 10:12 a.m., an inhaler of Ventolin (a bronchodilator) used to treat chronic obstructive pulmonary disease (COPD) was observed on Resident 34's bedside table. Resident 34 was not observed in her room. The medication was left unattended. On 9/10/24 11:28 a.m., a record review was completed for Resident 34. She had the following diagnoses which included but not limited to COPD, heart failure, dementia, and anxiety disorder. She had an order for Ventolin HFA inhalation aerosol solution 108 (90 base) mcg/act (micrograms/actuation) (albuterol sulfate) take two puffs inhale orally every four hours as needed for shortness of breath (SOB). Residnet 34's record lacked a medication self-administration assessment. On 9/10/24 at 11:00 a.m., during an interview with the Director of Nursing, she indicated the medication should not have been left in resident's room. A policy titled, Self-Administration of Medication by Residents with a date of March 2023, was provided by the Director of Nursing (DON) on 9/10/24 at 11:52 a.m. It indicated, An interdisciplinary team determines resident's ability to self-administer medications by means of a skill assessment as follows 3.1-45(a)

Based on record review and interview, the facility failed to assess on a quarterly basis to determine any improvement, decline or remained the same level with mobility and Range of Motion (ROM) for 2 of 3 residents reviewed (Resident 1 and 36). Findings include: 1. On 9/10/24 at 2:04 p.m., a record review was completed for Resident 1. He had the following diagnoses which included but not limited to type 2 diabetes, difficulty walking, heart failure, and history of falling. Resident 1 had undated care plans that indicated he required assistance with his ADLs related to a history of falls, weakness, and decreased mobility. He had an undated care plan that indicated he required a restorative program for Active Range of Motion (AROM) to restore or maintain his functional range of motion (the amount of movement a joint or body part can make, usually measured in degrees). Interventions included to evaluate and revise the program as needed and to notify nursing of decline or improvement for further evaluation, possible therapy and or MD (Medical Director) notification. He had an undated care plan indicating he required a restorative program for dressing/grooming to restore or maintain his ability to dress and undress, bathe, wash, and complete personal hygiene. Interventions included to evaluate and revise the program as needed and to notify the restorative nurse of decline or improvement for further evaluation, possible therapy or MD notification. His record lacked a comprehensive quarterly assessment to measure his extent of movement in his joints and the identification of limitations, along with any improvements, decline, or if he functionally remained at the same level of care. 2. On 9/11/24 at 11:43 a.m., a record review was completed for Resident 36. He had the following diagnoses which included but not limited to difficulty swallowing, difficult speaking, Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that damages the airways and makes it hard to breathe), essential hypertension, and high cholesterol. He had a care plan, dated 3/17/21, that indicated he required a restorative program for dressing/grooming to restore or maintain his ability to dress and undress, bathe, wash and complete personal hygiene tasks. Interventions included to provide the program as scheduled, evaluate and revise the program as needed, and notify the restorative nurse of decline or improvement for further evaluation, possible therapy or MD notification. His MDS, dated [DATE], indicated he did not receive the program as indicated. His record lacked a comprehensive quarterly assessment to measure his extent of movement in his joints and the identification of limitations, along with any improvements, decline, or if he functionally remained at the same level of care. During an interview with the Regional MDS Consultant on 9/12/24 at 10:44 a.m. She indicated therapy will evaluate and recommend residents to restorative. Certified Nursing Assistants (CNA) provide the restorative programs. They document in Point of Care (POC) but the facility failed to refresh and initiate (pull) into the POC in order for information to transfer to the MDS. They were supposed to do assessments on a quarterly basis. She indicated they were working on performing assessment and checking for minutes. During an interview with the Regional Nurse Consultant on 9/10/24 at 11:44 a.m., the Regional MDS Consultant indicated they followed the Resident Assessment Instrument (RAI) manual for policies pertaining to restorative programs. 3.1-42(a)(1) 3.1-42(a)(2)

Based on record review and interview, the facility failed to label tuberculosis testing serum appropriately for 1 of 2 medications rooms reviewed (100 hall). Findings include: On 9/9/24 at 10:38 a.m., a vial of tuberculin serum was observed undated and in the specimen refrigerator. LPN 21 removed the serum from the refrigerator. The freezer was approximately 2 inches deep with ice buildup in this refrigerator. On 9/10/24 at 10:40 a.m., during an interview with the Director of Nursing (DON), she indicated the serum should have been dated when it was opened. A policy titled, Tuberculosis Testing (Mantoux Test), dated March 2023, was provided by the Director of Nursing on 9/10/24 at 11:52 a.m. It indicated, .After a physician's order is secured, acquire the dose necessary from the vial located in the medication refrigerator. If opening a new vial, it must be initiated and dated, as it is only good for 30 days after opening the vial . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview and record review, the facility failed to ensure a resident received oxygen as ordered for 1 of 1 resident reviewed for Oxygen services (Resident 29). Findings include: On [DATE] at 10:10 a.m., Resident 29 was observed. She was seated in a wheelchair (WC) with her overbed table in front of her. She rested her head in her hand with her eyes closed. An oxygen (O2) concentrator was observed against the wall with tubing in a clear plastic bag. The Nasal Canula (NC) was not in place, and the concentrator was not turned on. On [DATE] at 12:33 p.m., Resident 29 was observed. She remained seated in her WC with her eyes closed. Her O2-concentrator remained off and no O2 was applied to Resident 29. On [DATE] at 1:23 p.m., Resident 29 was observed. She remained seated in her WC with her eyes closed. Her O2 was not in place, and the concentrator remained off. On [DATE] at 10:56 a.m., Resident 29 was observed in bed with her eyes closed. Her O2 was not in place, and the concentrator remained off. On [DATE] at 12:00 p.m., Resident 29 was observed. She remained in bed, but her eyes were open and she indicated she did not feel good. Resident 29 indicated she was uncomfortable, and needed her pants pulled up. She pulled her sheet down and revealed her pants which were pulled down to the middle of her thighs, she indicated the aide forgot to pull them up after she got changed. Resident 29 indicated she was in pain. On [DATE] at 12:02 p.m., Qualified Medication Aide (QMA) 23 was notified that Resident 29 was in pain and needed assistance to pull her pants up. QMA 23 pulled Resident 29's scheduled pain medication and entered her room within five minutes. QMA 23 attempted to help Resident 29 reposition to pull up her pants, but Resident 29 struggled to roll from side to side and quickly became out of breath with her excursion. Resident 29 became frustrated and asked QMA 23 to stop and just give her the medicine. Around that time, Registered Nurse (RN) 13 entered the room to assist QMA 23. RN 13 helped the resident put her hair in a ponytail and resituated her over-bed table within the resident's reach. When Resident 29 was comfortable, RN 13 and QMA 23 left her room, and neither offered to place the oxygen on her before they left. On [DATE] at 9:08 a.m., Resident 29 was observed in bed. Her eyes were open and she indicated she felt much better than she had the day before. Her O2 NC was observed on the floor. On [DATE] at 9:10 a.m., RN 13 indicated Resident 29 had previous orders for O2 to be applied to keep her oxygen saturation level above 90, but RN 13 believed that order had been changed to as needed, since Resident 29 was often noncompliant with wearing her O2. She did not like the way it felt in her nose, and she often pulled the tubing off herself. On [DATE] at 9:15 a.m., RN 13 entered Resident 29's room. She picked up the O2 canula from the floor and detached it from the concentrator. She tidied the room a little bit before she left and pleasantly engaged with Resident 29. Upon leaving Resident 29's room, RN 13 did not offer placing a new O2 NC. On [DATE] at 11:00 a.m., Resident 29's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of disease which affect lung tissue and capacity making breathing more difficult), congestive heart failure, and lung cancer. She had a current and active physician order to apply O2 via NC every shift at 3 Liters, to maintain oxygen saturations above 90. A comprehensive admission minimum data set (MDS) assessment, dated [DATE], indicated Resident 29 received oxygen services. Resident 29 had an admission comprehensive care plan, dated ,d+[DATE], which indicated she was at risk for complications with gas exchanges related to her diagnosis of lung cancer and that she received oxygen therapy. The care plan lacked revision to include details and/or interventions for her refusals to wear the O2 or noncompliance with oxygen therapy. The care plan lacked revision to include standing or as needed clarification of her physician's order for oxygen therapy. During an interview on [DATE] at 10:00 a.m., the Director of Nursing (DON) indicated, Resident 29 had an order for oxygen therapy to be applied every shift, but it should have been changed to as needed since she did often refuse or was noncompliant with wearing her NC. On [DATE] at 10:30 a.m., the DON provided a copy of current facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised [DATE]. The policy indicated, .the comprehensive care plan will further expand on the resident's risks, foals and interventions using the Person-Centered Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. These needs will be defined from observation, interviews, clinical medical record review with the resident, residents; family 3XXX,d+[DATE](a)(6)

Based on observation, interview, and record review the facility failed to ensure effective handwashing of staff delivering lunch trays for 2 of 4 residents observed for receiving lunch trays (Residents 42 and 43). Findings include: On 9/9/24 11:56 a.m., the Social Services Director (SSD) was observed removing Resident 42's lunch tray from the mobile kitchen cart and not using hand hygiene before entering and after leaving his room. A sign on his door indicated to stop because the resident required EBP. The sign indicated, .Everyone must: Clean their hands, including before entering and when leaving the room Then, without using hand hygiene, she returned to the mobile kitchen cart and removed and provided lunch for Resident 43. During an interview, on 9/9/24 at 11:59 a.m., the SSD indicated that she thought she had gelled her hands before entering and after leaving Resident 42 and Resident 43's room. During an interview, 9/9/24 at 12:00 p.m., the Assistant Director of Nursing (ADON) indicated the SSD should have used hand sanitizer before entering and leaving Resident 42 and Resident 43's room. During an interview, on 9/12/24 at 11:27 a.m., the Director of Nursing (DON) indicated Resident 42's roommate, Resident 43, had enhanced barrier precautions because he had a suprapubic catheter (urinary drainage system). On 9/11/24 at 11:46 a.m., Resident 43's record was reviewed. His physician order, dated 7/20/24, indicated, .Enhanced Barrier Precautions ever shift for catheter A current policy, titled, Guidelines for Enhanced Barrier Precautions - (EBP), An extension of Personal Protective Equipment - (PPE), dated December 2022, was provided by the DON, on 9/11/24 at 2:10 p.m. A review of the policy indicated, .Proper hand hygiene is a critical requirement in all aspects of resident care to include any precautions such as Universal/Standard/Contact/Droplet/Airborne as well as Enhanced (EBP) 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident's right for his medical record to be kept private and confidential when it was not discussed without the resident's permission for 1 of 3 residents reviewed for resident's rights (Resident H). Findings include: During an interview on 3/7/2024 at 10:06 a.m., Resident H's family indicated they had received clinical information from the Business Office Manager (BOM), regarding Resident H's medical condition, treatment, and services on several occasions, which included a private meeting outside of the facility property. Information provided by the BOM to Resident H's family included but was not limited to the following details: a. The facility had not provided Resident H with wound care and there were no Wound Care notes. b. The facility had not provided Resident H Physical Therapy (PT), as ordered, and there were no PT notes. c. The BOM filed reports/grievances with the Executive Director (ED) in regard to her opinion of a lack of care for Resident H and had not received a response from the ED. d. The BOM shared her opinion/assumption that Resident H had decreased mental capacity. e. The BOM indicated she overheard a telephone conversation, which occurred between a facility nurse and Resident H's dialysis center. f. The facility had not created a care plan for Resident H's wounds. During an interview on 3/7/24 at 9:40 a.m., the BOM indicated she had given permission for Resident H's family to use the above information she provided if they wanted to file a complaint regarding the resident's care. The BOM indicated she believed she was qualified to provide clinical information to Resident H's family due to her experience as a Certified Nursing Assistant (CNA). During an interview on 3/7/24 at 10:41 a.m., the Regional Nurse Consultant (RNC) indicated it was not within the scope of practice for a BOM to provide clinical information to a resident or family member. The RNC indicated the discussion of resident information outside of the facility premises would have been considered a HIPAA (Health Insurance Portability and Accountability Act) violation. The RNC indicated it would be against facility policy to provide clinical information to a family member if they were not the POA (Power of Attorney) for the resident. During an interview on 3/7/24 at 11:00 a.m., the Director of Nursing (DON) indicated only clinical staff were permitted to provide clinical information to the resident and/or the POA. The DON indicated health information was considered confidential and could only be provided to family members if the resident or POA provided prior approval for the information to be disseminated to family members. The DON indicated if information was shared without the resident or POA's permission, it was considered a HIPAA violation. On 3/7/24 at 1:00 p.m., Resident H's medical record was reviewed. He was a long-term care resident who had diagnoses which included, but were not limited to, End Stage Renal Disease (permanent kidney failure requiring dialysis), Type 2 Diabetes, and Diabetic Neuropathy (nerve damage resulting in pain or numbness). Resident H's most recent comprehensive Minimum Data Set (MDS) assessment was an admission MDS dated [DATE]. The MDS indicated Resident H was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating considered normal cognition. Resident H was listed as his own responsible party and did not have a POA. The record lacked documentation of a POA and/or Guardianship authority to determine who and/or when Resident H's medical record could be discussed. On 3/7/24 at 12:02 p.m., the (RNC) provided a copy of the current, but undated, facility resident guidelines titled, Your Rights and Protections as a Nursing Home Resident. The guidelines indicated, .As a nursing home resident, you have certain rights and protections under Federal and state law . You have the right to be informed, make your own decisions, and have your personal information kept private On 3/7/24 at 1:03 p.m., the ED provided a copy of the current, but undated, facility guidelines titled, HIPAA and HiTECH Privacy. The guidelines indicated, .There should be no conversations about a resident's . personal health or health information in areas where other residents may hear or where employees without need to know may have access . It is extremely important that you never share or improperly use information with anyone who is not on a need-to-know basis . This citation relates to Complaint IN00428989. 3.1-3(o)

Based on interview and record review, the facility failed to ensure compliance with Indiana Department of Environmental Management's (IDEM) requirement to submit documentation of a fully certified Water Distribution Manager to comply with the Safe Drinking Water Act. Further, the facility failed to ensure a Plan of Correction was submitted after an onsite inspected which resulted in deficient practice on [DATE]. These deficient practices had the potential to effect 43 of 43 residents who resided in the facility. Findings include: During an interview on [DATE] at 12:14 p.m., the Section Chief for the IDEM Drinking Water Field Inspection, (SC), indicated, IDEM did not have documentation to satisfy the requirement of a designated water safety operator. Additionally, an onsite inspection had been conducted on [DATE], and the facility failed to submit a formal Plan of Correction for the cited deficiencies at that time. On [DATE], a second letter of noncompliance was submitted which requested these requirements to be addressed. The SC submitted a copy of the letter of noncompliance for review. A Noncompliance Letter on IDEM letterhead, dated [DATE] indicated, On [DATE], representatives of IDEM, Office of Water Quality, conducted a second review of the [NAME] of Lebanon .a summary of the review is provided below: .according to our records . The [NAME] of Lebanon is without a certified operator in responsible charge . it also states that a written notice is to be submitted to the Commissioner no later than 30 days after the occurrence of a change in the person serving as the certified operator in responsible charge . On [DATE] at 1:55 p.m., the SC provided a copy of the first noncompliance letter dated [DATE], which stated the same information as above. Further, the SC submitted a summary of prior Sanitary Survey results, where were reviewed on [DATE] at 12:30 p.m. A Sanitation Survey was conducted on [DATE] which resulted in a System Management & Operation Deficiency, DSS FSO certification for [Maintenance Director] expired on [DATE] . [MD] needs to become DSS certified or have another person become certified as the Facility Specific Operator . During an interview on [DATE] at 1:30 p.m., the Maintenance Director indicated he believed he was DSS certified and provided a copy of his certificate. A copy of the Maintenance Director's DSS certificate was reviewed, although it was undated, an accompanying letter dated [DATE] indicated instruction for the DSS examination. A review of the Indiana State License and Certification website on [DATE] at 1:35 p.m., revealed the Maintenance Director's DSS certification was Inactive. A review of the IDEM website for Operator Requirement and Qualifications indicated, Once certified, an operator must get their required continuing education hours and renew their license(s) triennially (every three years). Secondly, the Sanitary Survey report submitted by the SC indicated, a Sanitation Survey was conducted on [DATE] and cited 7 deficiencies, with no resolved dates. During an interview on [DATE] at 1:37 p.m., the Maintenance Director indicated he was not responsible for writing or submitted plan or correction reports. That was his Regional Supervisor's responsibility. During an interview on [DATE] at 1:45 p.m., The Maintenance Director Regional Supervisor (RMD) indicated, he could not remember when or who he submitted a plan of correction to, but that he was sure it had been completed. On [DATE] at 2:00 p.m., the Maintenance Director provided a copy of his notes on the corrections that were made for the [DATE] sanitation survey. The report was 11 pages long and contained pictures of deficient equipment/areas. The MD indicated, next to the pictures were his handwritten notes of the corrections that had been completed. The report lacked documentation of who completed the repairs, and/or how the deficiency would be monitored/maintained as to not repeat the deficiency. The Maintenance Director and the RMD were unable to provide a copy of a formal plan of correction. On [DATE] at 2:30 p.m., the Maintenance Director provided a copy of current, but undated facility policy titled, Water Systems- Legionella Risk Prevention. The policy indicated, It is the policy of the facility to ensure that microbial growth is inhibited in the water system. The facility will provide a safe, sanitary and comfortable environment to include practices in place to help prevent the development and transmission of communicable disease and infection . If you qualify for a Water Management Program, make a building specific list (for the building for which the Water Management Program is being devised) taken from the Mater [NAME] as to areas/equipment that need to be monitored . program review needs to take place at least annually This federal/state tag relates to Complaint IN00412867. 3XXX,d+[DATE](b)

Based on observation, and interview, the facility failed to ensure medications were stored properly in 2 of 2 medication carts, and 2 of 2 treatment carts reviewed for medication storage (100 hallway, and 200 hallway). Findings include: During a random observation of the 100 hallway medication cart with Registered Nurse (RN) 9, on 7/10/23 at 10:09 a.m., the following was observed to be unbagged, not stored separately, or treatments in the medication cart among oral medications, a. Top right drawer was observed to be a catch-all of items to include, but were not limited to, a bottle of Johnson's baby shampoo without a resident label, 3 prefilled syringes of 0.9% sodium chloride injection with no resident label, an opened bottle of COVID -19 Ag reagent, 2 pill crushers soiled with unidentified white powder, AA batteries, [NAME] hand lotion, and 2 cigarette lighters. b. Bottom drawer had an opened tube of Biofreeze (topical analgesic) belonging to Resident 40, a glucagon pen (emergency injection to treat sever low hypoglycemia) with Resident 15's name on the outside of the box, and an opened bottle of Povidone iodine 10% with Resident 43's name written on the bottle without a resident specific label for directions, all stored among vital sign equipment of stethoscopes and blood pressure cuffs. c. Top left drawer was observed to have the following medication stored randomly to include Resident 5's opened and undated bottle of Azelastine (antihistamine) nasal spray 0.1 %, Resident 31's bottle of Azelastine 0.05% eye drops (antihistamine) opened and undated, Resident 16 Systane nighttime eye ointment (lubricant) 3.5 grams (gm) opened and undated, and Resident 32 a Symbicort 160/4.5 (corticosteroid) micrograms (mcg) 10.2 gm inhaler opened and undated. d. Bottom drawer contained a can of value scents citrus air freshener deodorizer opened and stored among medications to include Resident 5 a tube of triamcinolone cream (topical corticosteroid used to treat swelling and itching) 0.1% opened and undated, and a bottle of Azelastine 0.1% nasal spray opened and undated, and Resident 19 a tube of Diclofenac sodium topical gel (antifungal) 1% opened and undated. The 100 hallway medication room was observed with RN 9, the sink, counter, and floor were observed to be heavily soiled with unidentified substances, dirt, paper debris, lime build up in the sink and around the faucet, and when turned on the water sprayed out of the faucet to the left side onto the counter. There was no paper towel. On 7/10/23 at 10:28 a.m., the 100 hallway treatment cart was observed with RN 9, the following treatments were observed to be stored randomly together and unbagged, among 6 containers of wound cleaner and a can of aerosol sunscreen, a. Top drawer Resident 5, 2 bottles of Nystatin powder opened and undated, Resident 36 a bottle of Nystatin powder opened and undated, Resident 43 a bottle of Povidone iodine 10% with no resident specific label opened and undated, Resident 146 a bottle of Nystatin powder opened and undated, Resident 39 a tube of Biofreeze opened and undated, Resident 40 a tube of Aquaphor cream (moisturizes dry, chapped, or irritated skin) with no resident specific label opened and undated, Resident 26 a bottle of Nystatin powder opened and undated, and Resident 15 a bottle of Nystatin powder opened and undated, a bottle of selenium anti-dandruff shampoo opened and undated, and a bottle of renew skin repair without a resident specific label, and Resident 16 a bottle of baby shampoo with no resident specific label, and a tube of hydrophilic wound dressing (absorbs excess fluids from wounds while maintaining a moist healing environment) opened, undated, and no resident specific label. On 7/11/23 at 9:51 a.m., the 200 hallway treatment cart was observed with Licensed Practical Nurse (LPN) 28, the following treatments were observed to be stored randomly together and unbagged, a. Second drawer Resident 18 a bottle of Nystatin powder opened and undated, Resident 5 a bottle Ketoconazole 2% shampoo (antifungal) opened unbagged with red liquid leaking out of the lid and dried on the side of the bottle, and a container of c-bactra-nyst-znox 1:1:1 ointment (combination ointment used to treat fungal infections) not bagged and undated, Resident 33 a tube of Ketoconazole cream 2% opened and undated, Resident 12 a tube of Aquaphor ointment opened and undated, Resident 13 a container of Proctofoam 1% (rectal foam that helps relieve swelling and itching in the anal region) opened and undated, Resident 29 a tube of Diclofenac sodium topical gel 1% opened undated, Resident 1 a tube of Biofreeze 4% gel opened undated, Resident 2 a bottle of Ketoconazole shampoo 2% opened undated, Resident 3 a bottle of ammonium lactate 12% (lubricant) opened and undated with the cap not closed, Resident 9 a bottle of Nystatin powder opened and undated stored among the containers wound cleaners, and Resident 23 had 2 containers of Eucerin cream opened and undated. There was a tube of Dermaphor ointment (moisturizer to treat or prevent dry, rough, scaly, itch skin, and minor skin irritation) and tube of Venelex wound dressing ointment (topical wound dressing for management of chronic and acute wounds and ulcers) both opened unbagged with no resident specific label or name. b. Third drawer Resident 2 a tube of Biofreeze opened and undated, and Resident 33 a tube of Lidocaine 4% cream opened and undated. c. Fourth drawer Resident 24 Aquaphor ointment butt cream opened and undated stored among 11 tubes of house stock calmoseptine, and an opened tube of medihoney with no resident specific label stored with wound dressings. The 200 hallway medication refrigerated top shelf was observed to have the majority of the shelf covered in a dark dried unidentified substance with resident medications laying on top of it. Observation of the 200 hallway medication cart with LPN 28, a. Resident 14 a bottle of Latanoprost solution 0.005% eye drops (used to treat glaucoma) opened and undated, Resident 2 a Symbicort inhaler opened undated, and Resident 197 a tube of aspercreme 10% (topical analgesic) opened undated and not bagged stored among the oral medications. On 7/11/23 at 10:18 a.m., a second observation of the 100 hallway medication cart indicated concerns from the prior day of opened and unbagged treatments being stored in the medication cart among oral medications, and undated opened medications continued. On 7/11/23 at 10:52 a.m., a second observation of 100 hallway medication room. Sink and counter observed to be heavily soiled with unidentified substances, lime build up in sink and around faucet, water sprays to the left side when turned on and still no paper towel. The floor was littered with paper debris, heavily soiled with unidentified dark and red dried substances. The DON indicated it was the nurse's responsibility to clean up the medication room, or to monitor housekeeping so they could clean. During a random observation on the 100 hallway medication cart on 7/13/23 at 9:25 a.m., sitting halfway down the hallway in front of room [ROOM NUMBER]. On top of the medication cart was a cup of unidentified crushed medications, an inhaler, IV bag of clear medication, and a plastic water glass with pink liquid. The medication cart was unsupervised as LPN 14 was observed on another hallway taking a resident back to his room, and 2 unidentified resident were observed sitting near the cart conversing. At 9:36 a.m., LPN 14 was observed returning to the medication cart and administering the medications to Resident 32 at the end of the hallway. During an interview on 7/11/23 at 10:13 a.m., LPN 28 indicated, it was the responsibility of the nurse using the cart to maintain the carts in a neat and orderly manner, and date medications when opened. The contracted wound nurse used the treatment carts also, but it was still the nurses responsible for maintaining medication and treatment carts. During an interview on 7/14/23 at 9:25 a.m., the Director of Nursing (DON) indicated, being newer she was unsure of what continuing education the nurses and Qualified Medication Aides (QMA's) had received at the facility. There were do not crush lists provided inside the narcotic books on the medication carts for staff reference. Medication pharmacy labels may also state to not crush. DON indicated, ultimately it was her responsible for making sure the staff were educated and residents received their medications properly. The nurses were responsible for assuring the medication and treatment carts and medication rooms were clean, organized, and medications dated when opened, with management oversight. On 7/14/23 at 12:30 p.m., the Regional Nurse Consultant provided a Medication Storage in The Facility policy, dated May 2019, and indicated the policy was the one currently being used by the facility. The policy indicated, Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations .3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access: a. License Nurses, b. Consultant Pharmacist, c. Pharmacist Technician, d. Individual lawfully authorized to administer drugs, e. Consultant Nurses. 4. Drugs for internal use are kept separate from externally used medications. 5. Eye drops, ointments, drops, and inhalers to be kept separately from floor stock medications. 6. Medications labeled for individual residents are stored separately from floor stock medications. 7. External medications including ointments for skin irritations and medication for application to wounds should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such. 8. Potentially harmful substances [e.g. urine test reagent tablets, household poisons, cleaning supplies, disinfectants] are stored in a locked area separately from medications .15. Mediation storage areas are kept clean, well lit, and free of clutter .16. Medication and treatment carts are a property of the pharmacy; the facility is required to keep the carts clean and damage free . 3.1-25(j) 3.1-25(k) 3.1-25(m) 3.1-25(o)

Based on interview and record review, the facility failed to ensure allegations of verbal and mental abuse were thoroughly investigated resulting in psychosocial harm to 4 of 20 residents reviewed for allegations of verbal and mental abuse (Resident #13, #26, #28, #32). The immediate jeopardy began on 03/06/2015 when CNA #5 threatened to smother a resident with a pillow while he slept, the staff member was not removed, and the Administrator did not thoroughly investigate and/or report the incident to State agencies according to law. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 10//6/2015 at 8:21 a.m. The immediate jeopardy was removed on 10/8/15, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not immediate jeopardy. Findings include 1. During an interview on 9/23/2015 at 11:16 a.m., Resident #32 indicated Certified Nursing Assistant (CNA) #5 had been verbally abusive toward him in the past. He indicated CNA #5 told hem she was going to smother him with a pillow while he slept. The resident indicated he could not recall the date of the incident, but indicated he notified the Director of Nursing (DON) at the time of the incident. Resident #32's record was reviewed on 9/23/2015 at 12:00 p.m. A Minimum Data Set (MDS) assessment, dated 6/19/2015, indicated Resident #32 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an interview on 9/23/2015 at 12:02 p.m., the DON indicated the previous Administrator had been informed of CNA #5's threat to smother Resident #32 in his sleep. During an interview on 9/23/2015 at 2:29 p.m., the Administrator indicated she could not provide evidence the allegation had been reported to the required entities or an investigation of the allegation had been conducted for Resident #32's allegation of abuse by CNA #5. She indicated the allegation should have been reported and investigated. During an interview on 9/23/2015 at 2:57 p.m., the DON indicated the former facility Administrator had been the abuse point of contact and had not reported or thoroughly investigated Resident #32's allegation of abuse against CNA #5. During an interview on 10/6/15 at 8:45 a.m., the Administrator indicated staff was supposed to follow the abuse policy to the max. The Administrator stated, The person who was aware (of abuse) could be as guilty as the person who did the abuse if the allegation of abuse was not reported immediately. During an interview on 10/6/15 at 9:50 a.m., the Social Service Director (SSD) indicated she was aware Resident #32 made an allegation of CNA #5 threatening to smother him with a pillow. The SSD indicated she was not able to recall the exact date of the incident, but indicated it could have been in February or March, 2015. The SSD indicated the former Administrator and DON were aware of the incident and conducted an investigation. During an interview on 10/6/15 at 10:00 a.m., the Administrator indicated Resident #32 was discharged to his family's home on 10/5/15. During an interview on 10/6/15 at 10:00 a.m., the DON indicated the previous Administrator interviewed Resident #32 regarding CNA #5 threat to smother Resident #32 with a pillow. The DON indicated the former Administrator informed her the resident re-canted his story and indicated he and CNA #5 were joking with each other. The DON indicated she removed CNA #5 from providing care to Resident #32 after the allegation but the CNA was allowed to provide care to other residents. The DON indicated CNA assignment sheets indicated the residents who received care by each CNA for each shift. Incident reports were reviewed on 10/6/15 and indicated the facility did not report the allegation of CNA #5 threatening to smother Resident #32 with a pillow until 9/23/15 at 11:30 a.m. The incident report indicated, .9/23/2015 Description added---9/23/2015 During Annual Recertification Survey on this date (Resident #32 named) reported to the Surveyor during an interview; In November the CNA (CNA #5 named) told him she was going to smother him with a pillow .Follow up added -- 9/29/2015: The resident stated he thought the aide was hoping he would take her statement as a joke, but he felt it was a 'serious matter.' The resident stated the CNA's assignment was changed and she no longer provides care to him CNA assignment sheets were requested on 10/6/15 at 10: 00 a.m., and provided on 10/7/15 at 10:00 a.m. The assignment sheets indicated the last date CNA #5 provided care to Resident #32 was 3/6/15. Assignment sheets were not available for 3/10/15, but the CNA's time sheet indicated she worked during the evening shift on that date. A CNA assignment sheet, dated 3/15/15, indicated CNA #5 was assigned, but removed from care, to Resident #32. CNA's time card was reviewed on 10/6/15 at 3:50 p.m. and indicated the CNA's last day worked was 9/19/2015. 2. During an interview on 9/24/2015 at 9:24 a.m., Resident #13 indicated Certified Nursing Assistant (CNA) #5 was moody. The resident indicated CNA #5 told her she should move elsewhere if she didn't like how she provided care and indicated the CNA's comment made her feel like a lost cause. During an interview on 9/29/2015 at 11:10 a.m., Resident #13 indicated CNA #5 transferred her to her bed via a Hoyer lift (mechanical lift). Resident #13 indicated she had an incontinent bowel movement during the transfer and indicated CNA #5 sarcastically said, You just (s---) all over the floor. The resident indicated CNA #5 told her she could have controlled her elimination and indicated the CNA's comments made her feel horrible, disappointed, and bad about herself. During an interview on 9/28/2015 at 4:15 p.m., the Director of Nursing (DON) indicated the Activity Director (AD) recorded the minutes for the Resident Council Meeting on 9/15/15 and indicated Resident #13 reported the allegation during the Resident Council meeting. During an interview on 9/28/2015 at 4:22 p.m., the Activity Director indicated she had not recognized the allegations as abuse and had not immediately informed the Administrator. During an interview on 9/29/15 at 4:17 p.m., the Administrator indicated the facility became aware of the allegation of verbal abuse during the Hoyer transfer when it was discussed in the Resident Council meeting on 9/15/15. The Administrator indicated the Activity Director should have immediately informed her of the abuse allegations. The Administrator indicated the DON reviewed and signed the Resident Council minutes on 9/18/15 and should have immediately notified her after awareness of the allegation. During an interview on 10/6/15 at 8:35 a.m., Resident #13 indicated she was not able to recall the exact date CNA #5 yelled at her during the Hoyer transfer. The resident indicated it was sometime within a few weeks prior to the Resident Council meeting on 9/15/15. During an interview on 10/6/2015 at 10:00 a.m., the DON indicated CNA #5 was not assigned to care for Resident #13 after she became aware of the allegation of verbal abuse. The DON indicated CNA #5 was allowed to provide care to other residents until she was suspended on 9/20/15. During an interview on 10/6/15 at 11:27 a.m., the Administrator indicated the allegation of CNA #5 being verbally and mentally abusive to Resident #13 had not been reported to the State agency and indicated she planned to submit the report that day. During an interview on 10/6/15 at 5:00 p.m., the Administrator indicated the Resident Council meeting on 9/15/15 was conducted at 2:30 p.m. Resident #13's record was reviewed on 9/28/15 at 10:50 a.m. A Minimum Data Set (MDS) assessment, dated 8/20/15, indicated Resident #13 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident Council minutes, dated 9/15/15, were reviewed on 9/28/15 at 4:20 p.m. The minutes indicated, .(CNA #5 named) was lifting a resident (identified by the DON as Resident #13) by Hoyer when residents (sic) bowels released. States (CNA #5 named) told her she should have been able to hold it until she got in bed Reportable incidents were provided by the Administrator on 10/6/15 at 10:15 a.m. The incidents did not indicate the allegation of verbal abuse during the Hoyer transfer was reported timely to the State agency and did not indicate an investigation of the allegation was conducted. Schedules were reviewed for dates and times CNA #5 worked after the Activity Director and DON were aware of the abuse allegation. The schedules indicated CNA #5 worked during evening shifts on September 15, 16, 18, and 19, 2015. CNA assignment sheets were requested on 10/6/15 at 10:00 a.m. The documents were provided on 10/7/15 at 10:00 a.m. and indicated CNA #5 was assigned to offer snacks, provide showers, and put residents to bed on 9/15/15 (Tuesday) and 9/16/15 (Wednesday). The CNA assignment sheet indicated Resident #13 received evening showers on Mondays and Thursdays. CNA assignment sheets were not available for 9/18/5 and 9/19/15. A nurses' note, dated 9/19/15 at 9 p.m., indicated Resident #13 refused a shower on that date. 3. During an interview on 9/24/15 at 10:09 a.m., Resident #28 indicated Certified Nurse Aide (CNA) #5 verbally abused Resident #26 on Saturday, 09/19/2015, during the evening meal. Resident #28 stated, (CNA #5 named) jumped all over (Resident #26 named) and cursed. Resident #28 indicated CNA #5 yelled, You had me get this (s---) and now you are not going to eat it? What do you want me to do with the (s---)? Resident #28 indicated she reported the abuse to the Social Service Director (SSD) on 09/20/2015. During an interview on 9/24/15 at 10:25 a.m., Resident #26 indicated a CNA yelled at her during dinner over the weekend. She indicated she would not name the CNA because she did not want to get anyone in trouble. During an interview on 9/25/15 at 1:55 p.m., the SSD indicated she immediately notified the DON on 09/20/2015 of awareness of allegations of abuse occurring in the dining room and in the hallway on 09/19/15. She indicated she should have notified the Administrator, but didn't call her because it was the weekend. During an interview on 9/25/15 at 2:01 p.m., the Administrator indicated the DON left a voice message on 9/20/15 and indicated the DON informed her of the allegation of abuse occurring in the hallway on 09/19/2015 and indicated the DON suspended CNA #5 from work on 09/20/2015. During an interview on 9/28/15 at 10:09 a.m. and again on 10/6/15 at 9:45 a.m., CNA #6 indicated she heard CNA #5 talking loudly and inappropriately to cognitively impaired residents sometime in the past 6 months. The CNA indicated she realized CNA #5 was verbally abusive, but did not immediately report it to the Administrator. During an interview on 9/29/15 at 11:07 a.m., Resident #2 indicated she heard CNA #5 yelling at Resident #26 in the dining room on 9/19/2015 and indicated the CNA was chewing her out. She indicated it lasted a little while before it settled down. She indicated she wasn't sure what the yelling was about but stated, It wasn't right. The resident indicated she did not tell staff about the incident. During an interview on 10/6/15 at 9:50 a.m., the SSD indicated she was informed by Resident #28 on 9/20/15 of allegations CNA #5 yelled and cursed at Resident #26 during the evening meal in the dining room on 9/19/15. The SSD indicated she notified the DON on 9/20/15 of the allegation. During an interview on 10/6/15 at 10:00 a.m., the DON indicated she was unable to recall being notified of the allegation of verbal and mental abuse to Resident #26 that allegedly occurred during the evening meal in the dining room on 9/19/15. During an interview on 10/6/15 at 10:00 a.m., the Administrator indicated she had not been made aware of the allegation of verbal and mental abuse to Resident #26 during the evening meal in the dining room on 9/19/15. Resident #26's record was reviewed on 9/28/15 at 10:40 a.m. A Minimum Data Set (MDS) assessment, dated 6/26/15, indicated Resident #26 had moderate cognitive impairment with a Brief Interview for Mental Status score of 10 out of 15. Resident #28's record was reviewed on 9/28/15 at 10:33 a.m. A Minimum Data Set (MDS) assessment, dated 7/16/15, indicated Resident #28 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident #2's record was reviewed on 9/28/15 at 10:45 a.m. A Minimum Data Set (MDS) assessment, dated 8/26/15, indicated Resident #2 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Reportable incidents were reviewed on 10/6/15 at 10:15 a.m. and did not indicate the allegation of CNA #5 being verbally and mentally abusive to Resident #26 had been investigated and reported timely to the Administrator and State agencies in accordance with the law. 4. Resident #28 indicated residents were lined up in their wheel chairs in the hall after the evening meal on 09/19/2015. The resident indicated when she moved Resident #26's wheelchair so she could get to the entrance of her room, CNA #5 yelled and cursed at her. Resident #28 indicated she told the SSD about the incident on 9/20/2015. During an interview on 10/6/15 at 9:50 a.m., the SSD indicated she was informed by Resident #28 of allegations of verbal abuse to Resident #28 by CNA #5 in the hallway when she attempted to move Resident #26's wheelchair from the line outside the dining room. The SSD indicated she reported to allegation to the DON immediately after Resident #28 reported it to her and indicated she also notified the DON of the allegation of CNA #5 yelling and cursing at Resident #26 in the dining room on 9/19/15. During an interview on 10/6/15 at 10:00 a.m., the DON indicated CNA #5 was suspended from work on 9/20/15, immediately after she became aware of the allegation of CNA #5 yelling at Resident #28 when she attempted to move Resident #26's wheelchair. An incident report, dated 09/19/2019 at 7:01 p.m., was reviewed on 09/25/15 at 1:50 p.m. The report indicated, .9/21/15 Social Service Director was Manager on Duty for the week end of 9/19/15. (Resident #28 named) approached her on Sunday 9/20/15 and informed her of an incident that had happened on 9/19/15, Saturday around 7 pm. (Resident #28 named) stated another (Resident #26 named) was sitting in her wheelchair in the hall. (Resident #28 named) asked if she would like her to push her to her room and she replied yes. (CNA #5 named) saw this happening and according to (Resident #28 named), approached her and in a rude and hateful manner told her to STOP. That she had the resident where she wanted her, and that she was not being helpful at all! (Resident #28 named) released the wheel chair and walked to her room .Action Taken added--9/21/15 Social Service Designee interviewed (Resident #26 named) .The Director of Nursing then contacted (CNA #5 named) and explained the allegation that had been given to the Social Service Designee and per facility policy she was to be suspended pending a complete investigation of the allegation Resident #28's record was reviewed on 9/28/15 at 10:33 a.m. A Minimum Data Set (MDS) assessment, dated 7/16/15, indicated Resident #28 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A policy, dated 12/1999 and revised on 2/2015, titled Resident Mistreatment, Neglect, Abuse & Misappropriation of Property, was provided as a current policy by the Administrator on 9/25/15 at 2:45 p.m. The policy indicated, .Residents will be free from mistreatment, neglect, abuse, misappropriation of resident funds and property, verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal Abuse: Defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to, the following: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation . All reported incidents of alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported to the Administrator immediately, investigated and reported per state and federal law .Written results of investigations (including criminal, abuse, neglect, injuries of unknown etiology and misappropriation of resident property) are reported by the administrator to other officials in accordance with local, state, and federal law (including the state survey and certification agency, APS, etc.) within five (5) working days of the incidents The immediate jeopardy that began on 3/06/15 was removed on 10/8/15 when the facility in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of need for continued monitoring for abuse prevention and reporting. 3.1-28(d)

Based on interview and record review, the facility failed to implement their policies and procedures to thoroughly investigate abuse allegations and prohibit further verbal and mental abuse, resulting in psychosocial harm to 4 of 20 residents reviewed for allegations of verbal and mental abuse (Resident #13, #26, #28, #32). The immediate jeopardy began on 03/06/2015 when CNA #5 threatened to smother a resident with a pillow while he slept, the staff member was not removed, and the Administrator did not thoroughly investigate and/or report the incident to State agencies according to law. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 10//6/2015 at 8:21 a.m. The immediate jeopardy was removed on 10/8/15, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not immediate jeopardy. Findings include 1. During an interview on 9/23/2015 at 11:16 a.m., Resident #32 indicated Certified Nursing Assistant (CNA) #5 had been verbally abusive toward him in the past. He indicated CNA #5 told hem she was going to smother him with a pillow while he slept. The resident indicated he could not recall the date of the incident, but indicated he notified the Director of Nursing (DON) at the time of the incident. Resident #32's record was reviewed on 9/23/2015 at 12:00 p.m. A Minimum Data Set (MDS) assessment, dated 6/19/2015, indicated Resident #32 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an interview on 9/23/2015 at 12:02 p.m., the DON indicated the previous Administrator had been informed of CNA #5's threat to smother Resident #32 in his sleep. During an interview on 9/23/2015 at 2:29 p.m., the Administrator indicated she could not provide evidence the allegation had been reported to the required entities or an investigation of the allegation had been conducted for Resident #32's allegation of abuse by CNA #5. She indicated the allegation should have been reported and investigated. During an interview on 9/23/2015 at 2:57 p.m., the DON indicated the former facility Administrator had been the abuse point of contact and had not reported or thoroughly investigated Resident #32's allegation of abuse against CNA #5. During an interview on 10/6/15 at 8:45 a.m., the Administrator indicated staff was supposed to follow the abuse policy to the max. The Administrator stated, The person who was aware (of abuse) could be as guilty as the person who did the abuse if the allegation of abuse was not reported immediately. During an interview on 10/6/15 at 9:50 a.m., the Social Service Director (SSD) indicated she was aware Resident #32 made an allegation of CNA #5 threatening to smother him with a pillow. The SSD indicated she was not able to recall the exact date of the incident, but indicated it could have been in February or March, 2015. The SSD indicated the former Administrator and DON were aware of the incident and conducted an investigation. During an interview on 10/6/15 at 10:00 a.m., the Administrator indicated Resident #32 was discharged to his family's home on 10/5/15. During an interview on 10/6/15 at 10:00 a.m., the DON indicated the previous Administrator interviewed Resident #32 regarding CNA #5 threat to smother Resident #32 with a pillow. The DON indicated the former Administrator informed her the resident re-canted his story and indicated he and CNA #5 were joking with each other. The DON indicated she removed CNA #5 from providing care to Resident #32 after the allegation but the CNA was allowed to provide care to other residents. The DON indicated CNA assignment sheets indicated the residents who received care by each CNA for each shift. Incident reports were reviewed on 10/6/15 and indicated the facility did not report the allegation of CNA #5 threatening to smother Resident #32 with a pillow until 9/23/15 at 11:30 a.m. The incident report indicated, .9/23/2015 Description added---9/23/2015 During Annual Recertification Survey on this date (Resident #32 named) reported to the Surveyor during an interview; In November the CNA (CNA #5 named) told him she was going to smother him with a pillow .Follow up added -- 9/29/2015: The resident stated he thought the aide was hoping he would take her statement as a joke, but he felt it was a 'serious matter.' The resident stated the CNA's assignment was changed and she no longer provides care to him CNA assignment sheets were requested on 10/6/15 at 10: 00 a.m., and provided on 10/7/15 at 10:00 a.m. The assignment sheets indicated the last date CNA #5 provided care to Resident #32 was 3/6/15. Assignment sheets were not available for 3/10/15, but the CNA's time sheet indicated she worked during the evening shift on that date. A CNA assignment sheet, dated 3/15/15, indicated CNA #5 was assigned, but removed from care, to Resident #32. CNA's time card was reviewed on 10/6/15 at 3:50 p.m. and indicated the CNA's last day worked was 9/19/2015. 2. During an interview on 9/24/2015 at 9:24 a.m., Resident #13 indicated Certified Nursing Assistant (CNA) #5 was moody. The resident indicated CNA #5 told her she should move elsewhere if she didn't like how she provided care and indicated the CNA's comment made her feel like a lost cause. During an interview on 9/29/2015 at 11:10 a.m., Resident #13 indicated CNA #5 transferred her to her bed via a Hoyer lift (mechanical lift). Resident #13 indicated she had an incontinent bowel movement during the transfer and indicated CNA #5 sarcastically said, You just (s---) all over the floor. The resident indicated CNA #5 told her she could have controlled her elimination and indicated the CNA's comments made her feel horrible, disappointed, and bad about herself. During an interview on 9/28/2015 at 4:15 p.m., the Director of Nursing (DON) indicated the Activity Director (AD) recorded the minutes for the Resident Council Meeting on 9/15/15 and indicated Resident #13 reported the allegation during the Resident Council meeting. During an interview on 9/28/2015 at 4:22 p.m., the Activity Director indicated she had not recognized the allegations as abuse and had not immediately informed the Administrator. During an interview on 9/29/15 at 4:17 p.m., the Administrator indicated the facility became aware of the allegation of verbal abuse during the Hoyer transfer when it was discussed in the Resident Council meeting on 9/15/15. The Administrator indicated the Activity Director should have immediately informed her of the abuse allegations. The Administrator indicated the DON reviewed and signed the Resident Council minutes on 9/18/15 and should have immediately notified her after awareness of the allegation. During an interview on 10/6/15 at 8:35 a.m., Resident #13 indicated she was not able to recall the exact date CNA #5 yelled at her during the Hoyer transfer. The resident indicated it was sometime within a few weeks prior to the Resident Council meeting on 9/15/15. During an interview on 10/6/2015 at 10:00 a.m., the DON indicated CNA #5 was not assigned to care for Resident #13 after she became aware of the allegation of verbal abuse. The DON indicated CNA #5 was allowed to provide care to other residents until she was suspended on 9/20/15. During an interview on 10/6/15 at 11:27 a.m., the Administrator indicated the allegation of CNA #5 being verbally and mentally abusive to Resident #13 had not been reported to the State agency and indicated she planned to submit the report that day. During an interview on 10/6/15 at 5:00 p.m., the Administrator indicated the Resident Council meeting on 9/15/15 was conducted at 2:30 p.m. Resident #13's record was reviewed on 9/28/15 at 10:50 a.m. A Minimum Data Set (MDS) assessment, dated 8/20/15, indicated Resident #13 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident Council minutes, dated 9/15/15, were reviewed on 9/28/15 at 4:20 p.m. The minutes indicated, .(CNA #5 named) was lifting a resident (identified by the DON as Resident #13) by Hoyer when residents (sic) bowels released. States (CNA #5 named) told her she should have been able to hold it until she got in bed Reportable incidents were provided by the Administrator on 10/6/15 at 10:15 a.m. The incidents did not indicate the allegation of verbal abuse during the Hoyer transfer was reported timely to the State agency and did not indicate an investigation of the allegation was conducted. Schedules were reviewed for dates and times CNA #5 worked after the Activity Director and DON were aware of the abuse allegation. The schedules indicated CNA #5 worked during evening shifts on September 15, 16, 18, and 19, 2015. CNA assignment sheets were requested on 10/6/15 at 10:00 a.m. The documents were provided on 10/7/15 at 10:00 a.m. and indicated CNA #5 was assigned to offer snacks, provide showers, and put residents to bed on 9/15/15 (Tuesday) and 9/16/15 (Wednesday). The CNA assignment sheet indicated Resident #13 received evening showers on Mondays and Thursdays. CNA assignment sheets were not available for 9/18/5 and 9/19/15. A nurses' note, dated 9/19/15 at 9 p.m., indicated Resident #13 refused a shower on that date. 3. During an interview on 9/24/15 at 10:09 a.m., Resident #28 indicated Certified Nurse Aide (CNA) #5 verbally abused Resident #26 on Saturday, 09/19/2015, during the evening meal. Resident #28 stated, (CNA #5 named) jumped all over (Resident #26 named) and cursed. Resident #28 indicated CNA #5 yelled, You had me get this (s---) and now you are not going to eat it? What do you want me to do with the (s---)? Resident #28 indicated she reported the abuse to the Social Service Director (SSD) on 09/20/2015. During an interview on 9/24/15 at 10:25 a.m., Resident #26 indicated a CNA yelled at her during dinner over the weekend. She indicated she would not name the CNA because she did not want to get anyone in trouble. During an interview on 9/25/15 at 1:55 p.m., the SSD indicated she immediately notified the DON on 09/20/2015 of awareness of allegations of abuse occurring in the dining room and in the hallway on 09/19/15. She indicated she should have notified the Administrator, but didn't call her because it was the weekend. During an interview on 9/25/15 at 2:01 p.m., the Administrator indicated the DON left a voice message on 9/20/15 and indicated the DON informed her of the allegation of abuse occurring in the hallway on 09/19/2015 and indicated the DON suspended CNA #5 from work on 09/20/2015. During an interview on 9/28/15 at 10:09 a.m. and again on 10/6/15 at 9:45 a.m., CNA #6 indicated she heard CNA #5 talking loudly and inappropriately to cognitively impaired residents sometime in the past 6 months. The CNA indicated she realized CNA #5 was verbally abusive, but did not immediately report it to the Administrator. During an interview on 9/29/15 at 11:07 a.m., Resident #2 indicated she heard CNA #5 yelling at Resident #26 in the dining room on 9/19/2015 and indicated the CNA was chewing her out. She indicated it lasted a little while before it settled down. She indicated she wasn't sure what the yelling was about but stated, It wasn't right. The resident indicated she did not tell staff about the incident. During an interview on 10/6/15 at 9:50 a.m., the SSD indicated she was informed by Resident #28 on 9/20/15 of allegations CNA #5 yelled and cursed at Resident #26 during the evening meal in the dining room on 9/19/15. The SSD indicated she notified the DON on 9/20/15 of the allegation. During an interview on 10/6/15 at 10:00 a.m., the DON indicated she was unable to recall being notified of the allegation of verbal and mental abuse to Resident #26 that allegedly occurred during the evening meal in the dining room on 9/19/15. During an interview on 10/6/15 at 10:00 a.m., the Administrator indicated she had not been made aware of the allegation of verbal and mental abuse to Resident #26 during the evening meal in the dining room on 9/19/15. Resident #26's record was reviewed on 9/28/15 at 10:40 a.m. A Minimum Data Set (MDS) assessment, dated 6/26/15, indicated Resident #26 had moderate cognitive impairment with a Brief Interview for Mental Status score of 10 out of 15. Resident #28's record was reviewed on 9/28/15 at 10:33 a.m. A Minimum Data Set (MDS) assessment, dated 7/16/15, indicated Resident #28 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident #2's record was reviewed on 9/28/15 at 10:45 a.m. A Minimum Data Set (MDS) assessment, dated 8/26/15, indicated Resident #2 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Reportable incidents were reviewed on 10/6/15 at 10:15 a.m. and did not indicate the allegation of CNA #5 being verbally and mentally abusive to Resident #26 had been investigated and reported timely to the Administrator and State agencies in accordance with the law. 4. Resident #28 indicated residents were lined up in their wheel chairs in the hall after the evening meal on 09/19/2015. The resident indicated when she moved Resident #26's wheelchair so she could get to the entrance of her room, CNA #5 yelled and cursed at her. Resident #28 indicated she told the SSD about the incident on 9/20/2015. During an interview on 10/6/15 at 9:50 a.m., the SSD indicated she was informed by Resident #28 of allegations of verbal abuse to Resident #28 by CNA #5 in the hallway when she attempted to move Resident #26's wheelchair from the line outside the dining room. The SSD indicated she reported to allegation to the DON immediately after Resident #28 reported it to her and indicated she also notified the DON of the allegation of CNA #5 yelling and cursing at Resident #26 in the dining room on 9/19/15. During an interview on 10/6/15 at 10:00 a.m., the DON indicated CNA #5 was suspended from work on 9/20/15, immediately after she became aware of the allegation of CNA #5 yelling at Resident #28 when she attempted to move Resident #26's wheelchair. An incident report, dated 09/19/2019 at 7:01 p.m., was reviewed on 09/25/15 at 1:50 p.m. The report indicated, .9/21/15 Social Service Director was Manager on Duty for the week end of 9/19/15. (Resident #28 named) approached her on Sunday 9/20/15 and informed her of an incident that had happened on 9/19/15, Saturday around 7 pm. (Resident #28 named) stated another (Resident #26 named) was sitting in her wheelchair in the hall. (Resident #28 named) asked if she would like her to push her to her room and she replied yes. (CNA #5 named) saw this happening and according to (Resident #28 named), approached her and in a rude and hateful manner told her to STOP. That she had the resident where she wanted her, and that she was not being helpful at all! (Resident #28 named) released the wheel chair and walked to her room .Action Taken added--9/21/15 Social Service Designee interviewed (Resident #26 named) .The Director of Nursing then contacted (CNA #5 named) and explained the allegation that had been given to the Social Service Designee and per facility policy she was to be suspended pending a complete investigation of the allegation Resident #28's record was reviewed on 9/28/15 at 10:33 a.m. A Minimum Data Set (MDS) assessment, dated 7/16/15, indicated Resident #28 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A policy, dated 12/1999 and revised on 2/2015, titled Resident Mistreatment, Neglect, Abuse & Misappropriation of Property, was provided as a current policy by the Administrator on 9/25/15 at 2:45 p.m. The policy indicated, .Residents will be free from mistreatment, neglect, abuse, misappropriation of resident funds and property, verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal Abuse: Defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to, the following: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation . All reported incidents of alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported to the Administrator immediately, investigated and reported per state and federal law .Written results of investigations (including criminal, abuse, neglect, injuries of unknown etiology and misappropriation of resident property) are reported by the administrator to other officials in accordance with local, state, and federal law (including the state survey and certification agency, APS, etc.) within five (5) working days of the incidents The immediate jeopardy that began on 3/06/15 was removed on 10/8/15 when the facility in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of need for continued monitoring for abuse prevention and reporting. 3.1-28(a) 3.1-28(b)

Based on interview and record review, the facility failed to ensure residents were free from verbal and mental abuse when a Certified Nurse Aide (CNA) who verbally and mentally abused residents was not immediately removed from resident care, resulting in psychosocial harm to 4 of 20 residents reviewed for allegations of verbal and mental abuse (Resident #32, #26, #28, #13). The immediate jeopardy began on 03/06/2015 when CNA #5 threatened to smother a resident with a pillow while he slept, the staff member was not removed, and the Administrator did not thoroughly investigate and/or report the incident to State agencies according to law. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 10//6/2015 at 8:21 a.m. The immediate jeopardy was removed on 10/8/15, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include 1. During an interview on 9/23/2015 at 11:16 a.m., Resident #32 indicated Certified Nursing Assistant (CNA) #5 had been verbally abusive toward him in the past. He indicated CNA #5 told hem she was going to smother him with a pillow while he slept. The resident indicated he could not recall the date of the incident, but indicated he notified the Director of Nursing (DON) at the time of the incident. Resident #32's record was reviewed on 9/23/2015 at 12:00 p.m. A Minimum Data Set (MDS) assessment, dated 6/19/2015, indicated Resident #32 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an interview on 9/23/2015 at 12:02 p.m., the DON indicated the previous Administrator had been informed of CNA #5's threat to smother Resident #32 in his sleep. During an interview on 10/6/15 at 9:50 a.m., the Social Service Director (SSD) indicated she was aware Resident #32 made an allegation of CNA #5 threatening to smother him with a pillow. The SSD indicated she was not able to recall the exact date of the incident, but indicated it could have been in February or March, 2015. The SSD indicated the former Administrator and DON were aware of the incident and conducted an investigation. During an interview on 10/6/15 at 10:00 a.m., the DON indicated the previous Administrator interviewed Resident #32 regarding CNA #5 threat to smother Resident #32 with a pillow. The DON indicated the former Administrator informed her the resident re-canted his story and indicated he and CNA #5 were joking with each other. The DON indicated she removed CNA #5 from providing care to Resident #32 after the allegation but the CNA was allowed to provide care to other residents. The DON indicated CNA assignment sheets indicated the residents who received care by each CNA for each shift. CNA assignment sheets were requested on 10/6/15 at 10: 00 a.m., and provided on 10/7/15 at 10:00 a.m. The assignment sheets indicated the last date CNA #5 provided care to Resident #32 was 3/6/15. Assignment sheets were not available for 3/10/15, but the CNA's time sheet indicated she worked during the evening shift on that date. A CNA assignment sheet, dated 3/15/15, indicated CNA #5 was assigned, but removed from care, to Resident #32. CNA's time card was reviewed on 10/6/15 at 3:50 p.m. and indicated the CNA's last day worked was 9/19/2015. 2. During an interview on 9/24/2015 at 9:24 a.m., Resident #13 indicated Certified Nursing Assistant (CNA) #5 was moody. The resident indicated CNA #5 told her she should move elsewhere if she didn't like how she provided care and indicated the CNA's comment made her feel like a lost cause. During an interview on 9/29/2015 at 11:10 a.m., Resident #13 indicated CNA #5 transferred her to her bed via a Hoyer lift (mechanical lift). Resident #13 indicated she had an incontinent bowel movement during the transfer and indicated CNA #5 sarcastically said, You just (s---) all over the floor. The resident indicated CNA #5 told her she could have controlled her elimination and indicated the CNA's comments made her feel horrible, disappointed, and bad about herself. During an interview on 9/28/2015 at 4:15 p.m., the Director of Nursing (DON) indicated the Activity Director (AD) recorded the minutes for the Resident Council Meeting on 9/15/15 and indicated Resident #13 reported the allegation during the Resident Council meeting. During an interview on 9/28/2015 at 4:22 p.m., the Activity Director indicated she had not recognized the allegations as abuse and had not immediately informed the Administrator. During an interview on 9/29/15 at 4:17 p.m., the Administrator indicated the facility became aware of the allegation of verbal abuse during the Hoyer transfer when it was discussed in the Resident Council meeting on 9/15/15. The Administrator indicated the Activity Director should have immediately informed her of the abuse allegations. The Administrator indicated the DON reviewed and signed the Resident Council minutes on 9/18/15 and should have immediately notified her after awareness of the allegation. During an interview on 10/6/15 at 8:35 a.m., Resident #13 indicated she was not able to recall the exact date CNA #5 yelled at her during the Hoyer transfer. The resident indicated it was sometime within a few weeks prior to the Resident Council meeting on 9/15/15. During an interview on 10/6/2015 at 10:00 a.m., the DON indicated CNA #5 was not assigned to care for Resident #13 after she became aware of the allegation of verbal abuse. The DON indicated CNA #5 was allowed to provide care to other residents until she was suspended on 9/20/15. During an interview on 10/6/15 at 5:00 p.m., the Administrator indicated the Resident Council meeting on 9/15/15 was conducted at 2:30 p.m. Resident #13's record was reviewed on 9/28/15 at 10:50 a.m. A Minimum Data Set (MDS) assessment, dated 8/20/15, indicated Resident #13 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident Council minutes, dated 9/15/15, were reviewed on 9/28/15 at 4:20 p.m. The minutes indicated, .(CNA #5 named) was lifting a resident (identified by the DON as Resident #13) by Hoyer when residents (sic) bowels released. States (CNA #5 named) told her she should have been able to hold it until she got in bed Schedules were reviewed for dates and times CNA #5 worked after the Activity Director and DON were aware of the abuse allegation. The schedules indicated CNA #5 worked during evening shifts on September 15, 16, 18, and 19, 2015. CNA assignment sheets were requested on 10/6/15 at 10:00 a.m. The documents were provided on 10/7/15 at 10:00 a.m. and indicated CNA #5 was assigned to offer snacks, provide showers, and put residents to bed on 9/15/15 (Tuesday) and 9/16/15 (Wednesday). The CNA assignment sheet indicated Resident #13 received evening showers on Mondays and Thursdays. CNA assignment sheets were not available for 9/18/5 and 9/19/15. A nurses' note, dated 9/19/15 at 9 p.m., indicated Resident #13 refused a shower on that date. 3. During an interview on 9/24/15 at 10:09 a.m., Resident #28 indicated Certified Nurse Aide (CNA) #5 verbally abused Resident #26 on Saturday, 09/19/2015, during the evening meal. Resident #28 stated, (CNA #5 named) jumped all over (Resident #26 named) and cursed. Resident #28 indicated CNA #5 yelled, You had me get this (s---) and now you are not going to eat it? What do you want me to do with the (s---)? Resident #28 indicated she reported the abuse to the Social Service Director (SSD) on 09/20/2015. During an interview on 9/24/15 at 10:25 a.m., Resident #26 indicated a CNA yelled at her during dinner over the weekend. She indicated she would not name the CNA because she did not want to get anyone in trouble. During an interview on 9/28/15 at 10:09 a.m. and again on 10/6/15 at 9:45 a.m., CNA #6 indicated she heard CNA #5 talking loudly and inappropriately to cognitively impaired residents sometime in the past 6 months. The CNA indicated she realized CNA #5 was verbally abusive, but did not immediately report it to the Administrator. During an interview on 9/29/15 at 11:07 a.m., Resident #2 indicated she heard CNA #5 yelling at Resident #26 in the dining room on 9/19/2015 and indicated the CNA was chewing her out. She indicated it lasted a little while before it settled down. She indicated she wasn't sure what the yelling was about but stated, It wasn't right. The resident indicated she did not tell staff about the incident. During an interview on 10/6/15 at 9:50 a.m., the SSD indicated she was informed by Resident #28 on 9/20/15 of allegations CNA #5 yelled and cursed at Resident #26 during the evening meal in the dining room on 9/19/15. The SSD indicated she notified the DON on 9/20/15 of the allegation. Resident #26's record was reviewed on 9/28/15 at 10:40 a.m. A Minimum Data Set (MDS) assessment, dated 6/26/15, indicated Resident #26 had moderate cognitive impairment with a Brief Interview for Mental Status score of 10 out of 15. Resident #28's record was reviewed on 9/28/15 at 10:33 a.m. A Minimum Data Set (MDS) assessment, dated 7/16/15, indicated Resident #28 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident #2's record was reviewed on 9/28/15 at 10:45 a.m. A Minimum Data Set (MDS) assessment, dated 8/26/15, indicated Resident #2 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. 4. Resident #28 indicated residents were lined up in their wheel chairs in the hall after the evening meal on 09/19/2015. The resident indicated when she moved Resident #26's wheelchair so she could get to the entrance of her room, CNA #5 yelled and cursed at her. Resident #28 indicated she told the SSD about the incident on 9/20/2015. During an interview on 10/6/15 at 10:00 a.m., the DON indicated CNA #5 was suspended from work on 9/20/15, immediately after she became aware of the allegation of CNA #5 yelling at Resident #28 when she attempted to move Resident #26's wheelchair. Resident #28's record was reviewed on 9/28/15 at 10:33 a.m. A Minimum Data Set (MDS) assessment, dated 7/16/15, indicated Resident #28 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A policy, dated 12/1999 and revised on 2/2015, titled Resident Mistreatment, Neglect, Abuse & Misappropriation of Property, was provided as a current policy by the Administrator on 9/25/15 at 2:45 p.m. The policy indicated, .Residents will be free from mistreatment, neglect, abuse, misappropriation of resident funds and property, verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal Abuse: Defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples would include, but are not limited to, the following: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation . All reported incidents of alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported to the Administrator immediately, investigated and reported per state and federal law .Written results of investigations (including criminal, abuse, neglect, injuries of unknown etiology and misappropriation of resident property) are reported by the administrator to other officials in accordance with local, state, and federal law (including the state survey and certification agency, APS, etc.) within five (5) working days of the incidents The immediate jeopardy that began on 3/06/15 was removed on 10/8/15 when the facility in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of need for continued monitoring for abuse prevention and reporting. 3.1-27(a)(1) 3.1-27(b)

Based on observation, record review and interview, the facility failed to ensure 1 of 3 sampled residents received appropriate physician services related to rapid response to laboratory testing which indicated an active infection. This delay contributed in the resident developing urosepsis and hospitalization . (Resident W) Findings include: Review of Resident W's clinical record was completed on 10/8/2010 at 2:20 p.m. It indicated Resident W had been hospitalized ,[DATE] to 10/4/2010 with urosepsis and pneumonia. Resident W's [DIAGNOSES REDACTED]. The 7/23/2010 annual RAI (Resident Assessment Instrument) indicated he was fully alert and oriented, but required total staff assistance for all aspects of his care. He had a [MEDICAL CONDITION] and a suprapubic Foley catheter. A urology consultation, dated 8/30/2010, indicated Resident W's urine was clear at that time, but a nursing note on 9/8/2010 at 9:40 p.m., indicated the catheter was draining "lt (light) red urine." A phone order, dated 9/9/2010, indicated "abdominal pain & blood in urine. UA (urinalysis)" This lab report was available for review in the record. The urinalysis was dated 9/9/2010 and indicated a urinary tract infection [MEDICAL CONDITION] existed at that time: urine leukocytes-500 (normal negative) urine [MEDICATION NAME]- positive (normal negative) urine [MEDICATION NAME]- 5 (normal negative) urine blood-250 (normal negative) Subsequently a culture and sensitivity was performed and dated as reported 9/12/2010. It showed two pathogens were cultured out of this specimen, Proteus mirabilis and Escherichia coli, both over 100,000 cfu/ml. The sensitivity chart indicated they were treatable with most antibiotics. During a previous survey visit on 9/13/10 at 4:30 p.m., an observation was made of the attending physician (Dr. Z) becoming agitated while reviewing Resident W's chart at the unit desk, as evidenced by: raised voice, angry facial expression, thumping the chart, pointing to a report and demanding to know who had ordered this and why. "I know I didn't order this. Who did? I don't order these. Who would do this?...." Interview of RN #2 at the time indicated Dr. Z was questioning the urinalysis and culture on Resident W. Continued record review 10/8/10 indicated Dr. Z's progress note of 9/13/10 did not mention the urinalysis, the culture, or the reported hematuria. Even though these tests clearly identified a UTI and causative pathogens, the M.D. addressed only Resident W's complaints of abdominal pain. No treatment was ordered for the UTI. The nursing note of 9/14/10 at 12:40 a.m., indicated Resident W "...c/o complained of nausea. Face flushed et warm to touch. T (temperature) 101.6 F (Fahrenheit) axillary (taken under the arm). MD office notified. New orders received for Tylenol 325 mg. (milligrams) 2 tabs orally q 4 h prn (every 4 hours as needed) pain/fever et [MEDICATION NAME] suppository 1 X only (once) for nausea. His fever was at 103 axillary at 1:15 a.m. 9/14/10. "cool cloth placed to forehead." His fever was 103.2 F at 2 a.m. He complained, "I hurt all over." Resident W's temperatures continued to be elevated and rise at times over the next three days: 9/15/10 1:15 a.m. 102.5 9/15/10 2:30 a.m. 100.4 axillary 9/15/10 10 a.m. 99.1 axillary 9/15/10 11:10 p.m. 102.8 axillary 9/16/10 2:40 a.m. 102 axillary 9/16/10 5 a.m. 101.4 axillary 9/17/10 5 a.m. 101.8 9/17/10 8 a.m. 103 axillary Dr. Z was notified of elevated temperatures on 9/16/10 at 9 a.m. She then ordered some blood tests and another urinalysis and culture/sensitivity to be done. There was no reference to the urinalysis and culture/sensitivity already completed and in the chart. She ordered an antibiotic to be started after the specimens were obtained. The nursing note 9/17/10 at 8 a.m., indicated, "ax 103. lungs congested all lobes--not alert at this time--unable to swallow food at breakfast. wet cough noted. Dr (Z) notified. order to send to ER for eval...." Review of the emergency room documentation was completed on 10/8/10 at 12:15 p.m. It indicated Resident W was received unconscious. He was transferred directly to the intensive care unit and diagnosed with [REDACTED]. Interview with the Administrator and the Director of Nursing on 10/8/10 at 5 p.m., indicated Dr. Z had been very angry over the first urinalysis and culture and did not accept the Director of Nursing's explanation it had been a "nursing measure." The M.D. had "ignored" those reports already showing the urinary tract infection and then re-ordered them on 9/16/10 after the resident was acutely ill. The Director of Nursing indicated Dr. Z didn't like to do cultures, "she doesn't believe in them." That was why the nurses had been hesitant to call her about the elevated temperatures. This federal tag relates to complaint number IN 559. 3.1-22(c)(1) 3.1-22(c)(2)