Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen. 38 of 39 residents who riside in the facility eat food prepared in the kitchen. Findings include: During an observation on 09/30/24 at 09:22 AM, [NAME] 2 pulled the grease traps under the first set of burners. There were 2 layers of foil present. On the top layer of foil was burnt noodles, carrots, and other unidentifiable debris as well as other odd, shaped discolorations on top of each other. The oven under the first set of burners did not close fully. The walk in cooler had debris of various sizes and substance; cardboard, plastic, and paper were identified under the racks. There was a pipe coming from the top of the walk in freezer wrapped in black tape, at an elbow of the pipe was a square plastic container with green markings of 1 cup, 2 cups, 3 cups, and 4 cups underneath. There was liquid inside the container. The liquid was clear and frozen. There was a frozen substance coming out the left side of the container. The walk in freezer did not have a thermometer present on the inside. Within the kitchen there were 3 red buckets of sanitation solution. Dietary Aide 3 assisted in testing a bucket for correct strength. When Dietary Aide 3 removed strip he immediately indicated the strip was very light. The strip indicated a strength of 25 per Dietary Aide 3. He indicated the solution was weak as noted by the light color on the strip. During an interview on 09/30/24 at 09:22 AM, [NAME] 2 indicated the Dietary Manager (DM) was not in. [NAME] 2 indicated the oven was still operable and a work order was placed to fix the door to the oven. [NAME] 2 was unsure when the work order was placed. [NAME] 2 indicated to determine the temperature, the staff just guess. [NAME] 2 proceeded to show documentation of a recorded temperature for the deep freeze on 9/30/24. [NAME] 2 indicated there was not a thermometer present when the temperature was recorded as Zero. During an interview on 09/30/24 at 09:52 AM, Dietary Aide 3 was unable to determine where to get the information for a correct concentration. Records were reviewed 10/1/24 at 8:26AM, findings as follows: A work order for the right oven door was created on 8/4/24, then updated on 8/23/24. A comment on the document indicated hinges were worn out and parts needed to be located. The work order indicated the vendor would call when parts are found. In the comments section, a note indicated professional food service had been called on 9/30/24, the service would be sending out mobile service as soon as today to make correction to door on stove. The log for 3-Compartment Sink, dated August 2024, had an area for test strip PPM, wash temp, and rinse temperature. The log was blank for the effective or the expected numbers. The weekly cleaning task list contained: delime dishwasher, wipe down counter and drawers, clean coffee pots, clean hood filters, change aluminum foil in stove, clean stove burners, wipe down plate warmers, wipe down steam table, and wipe down all stainless steel appliances. At the bottom of the sheet were the directions: All cleaning jobs need to be done by the following Sunday. No monthly or daily cleaning lists were provided. During a continuous observation on 10/01/24 from 10:26 AM to 11:20 AM, A red bucket was tested slightly darker than 100. During the observation, the DM washed her hands 3 times. The first time she washed her hands was for 7 seconds. The second time was for 7 second seconds. The third time was for 7 seconds. The DM indicated the amount of time to wash hands was 20 seconds minimum. During an interview, on 10/01/24 at 11:20 AM, the DM indicated the sanitation buckets were to test between 100 and 200. The DM further indicated the sanitation requirements were at the top of the recording page where staff were expected to record the bucket sanitation. During an interview on, 10/2/24 at 11:06AM, the Maintenance Director indicated the pipe in the walk in freezer was cracked at the top at a joint. They were unsure where it was cracked and when they noticed it leaking, they wrapped it in heat tape and put a container under to catch the leak until it could be properly fixed. A policy titled, Cleaning and Sanitizing Equipment dated 1/23 was provided 10/1/24 at 8:26AM by the Administrator. The policy indicated dietary staff will maintain cleaning and sanitizing solution I clean receptacles and at proper concentration . A policy titled; Cleaning Schedules dated 01/12 was provided 10/1/24 at 8:26AM by the Administrator. The dietary staff will maintain the sanitation of the dietary department through compliance with a written, comprehensive cleaning schedule . 3.1-21(j)(2)(3)

Based on observation, interview, and record review the facility failed to ensure a nurse was appointed as charge nurse each shift. 41 residents resided in the facility. Findings include: In an observation on 11/12/23 at 11:04AM, a staffing sheet dated 11/10/23 was posted with an indicated census of 41. There was no indication the charge nurse was listed on the posting. There was no place on posting for a charge nurse to be indicated for any shift. In an interview, on 11/12/23 at 11:19AM, RN 8 (Registered Nurse) indicated there was no charge nurse. RN 8 indicated neither he nor the other nurse on duty were in charge, but both were RNs and equally trained. RN 8 indicated he was fairly sure the census posted on Friday, dated11/10/23 was still correct. In an interview on 11/12/23 at 11:24AM, RN 9 indicated she and the other RN on duty were of equal rank and neither were in charge. She indicated the DON (Director of Nursing) was notified and would be in within an hour. During an observation on 11/12/23 at 11:28AM, a staffing sheet was observed posted without a census indicated. The staffing sheet did not indicate the charge nurse. The staffing sheet did not have a place for a charge nurse to be indicated for any shift. During an observation on 11/13/23 at 9:19AM, a staffing sheet was observed posted with a census of 38 indicated. The staffing sheet did not indicate the charge nurse. The staffing sheet did not have a place for a charge nurse to be indicated for any shift. In an interview on 11/14/23 at 1:15 PM, the DON indicated she was in charge when she was in the building. The DON indicated when she was not in the building each nurse oversaw their assigned halls. The DON indicated when a family member or other staff member had any concerns, they were to call her directly. In an interview on 11/14/23 at 2:21PM, the DON indicated the facility did not have a policy regarding having an assigned charge nurse. A review of daily nursing assignments for the dates; 11/8/23, 11/9/23, 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/14/23, and 11/15/23; did not indicate a charge nurse was assigned on any shifts. 3.1-17(2)

Based on observation, interview, and record review the facility failed to ensure a consistently functioning call light system for 2 of 10 residents reviewed (Resident B and Resident C). Findings include: 1) During an interview and observation with Resident B, on 10/19/23 at 11:16 AM, she indicated that she waited long periods of time for her light to be answered and at times questioned if her call light worked at all. Resident B pushed her call light as requested. RN 1 (Registered Nurse) came into the room to administer noon medications approximately 10 minutes later. RN 1 indicated Resident B's call light was not on. The RN attempted to activate the call light. The RN indicated there was on as there was no way to tell if the call light was on. RN 1 indicated the call light system worked in waves with a transmitter located at the nurse's station. RN 1 explained when a resident pushes the light there was no audible or visual indication inside or directly outside of the resident room. The system required someone to be at the desk to see where the signal was coming from. RN 1 went to change the batteries to the call light. The RN 1 was able to understand Resident B had no way to know if the call light was functional. RN 1 was asked to ensure the call light in the bathroom was operating properly. The bathroom call light was operable as evidenced by a CNA responding promptly. Resident B's record review on 10/19/23 at 4:15 PM indicated her current comprehensive MDS (Minimum Data Set) assessment section C BIMS (Brief Interview of Mental Status) score was 15. A score of 15 indicated no cognitive decline. Section G of MDS for functional status indicated Resident B requires a one person staff assistance in mobility for transfers, toileting, locomotion, bathing, and position changes. Resident B used a wheelchair for mobility on and off the unit. Resident B's diagnoses included chronic obstructive pulmonary disease, heart disease, osteoarthritis, and muscle weakness. 2) An interview on 10/19/23 at 346 PM Resident C indicated her call light does not work. In an observation at the same time. Resident C activated her call light, but there was no indication at the Nurse's desk the call light had been activated. Resident C's record review began on 10/19/23 at 4:22 PM indicated her current comprehensive MDS (Minimum Data Set) assessment section C BIMS (Brief Interview of Mental Status) score was 15. A score of 15 indicated no cognitive decline. Section G of MDS for functional status indicated Resident C requires supervision for activities of daily living. Resident C's diagnoses included malignant neoplasm of lung, obstructive pulmonary disease, and age-related physical debility. A record review of facility grievances over the past 6 months, on 10/19/23 at 10:43 AM, indicated 3 grievances regarding call lights. One on 5/15/23 that replacement batteries were ordered, and call light was functioning. This room was checked, and call light was functioning. A grievance on 6/13/23 regarding Resident B's call light not being answered. Grievance indicated the battery was replaced and the call light was checked for functioning. A grievance on 10/2/23 a resident call light not being answered, and she missed an activity. During an interview the resident indicated her call light was functioning properly. During an interview with Maintenance Director, on 10/19/23 at 3:23 PM, indicated he randomly checked 2 or 3 rooms of each hallway weekly to determine if the call light system was functioning. The maintenance director was able to provide a weekly grid from 5/26/23 to 10/16/23. He indicated the 300 hall was closed due to remodel and the 400 hall had its own systems. He indicated the system the facility was using at time of survey was temporary and the remodel included a new call light system. The Maintenance Director indicated he had only replaced two batteries on call lights. The maintenance director did not have an exact date of how long the batteries should last or how long each were in use at time of survey. During an interview with the DON (Director of Nursing) on 10/19/23 she indicated they began using silver bells on or around 2/22/23 for a couple of weeks until the temporary system arrived and was fully available and operational. A policy and procedure was provided by DON, on 10/19/23 at 406 PM, titled Call Lights effective revised dated 8/2022. The policy stated purpose: To respond to residents' requests and needs in a timely and courteous manner. No policy regarding call light function was available for review. This citation is related to complaint IN00418275 3.1-19(u)

Based on interview and record review the facility failed to ensure food temperatures were monitored and documented for every meal. 39 of 39 residents residing in the facility received food from the kitchen. Findings Include: In an interview on 1/24/23 at 9:39 AM, Resident I, identified by the facility as interviewable, indicated the meals provided by the kitchen were not hot half the time. In an interview on 1/24/23 at 11:41 AM, Resident B, identified by the facility as interviewable, indicated the majority of the time the meals were not hot. In an interview on 1/24/23 at 11:49 AM, Resident E, identified by the facility as interviewable, indicated the meals were usually warm but not hot. In an interivew on 1/24/23 at 11:58 AM, Resident F, identified by the facility as interviewable, indicated the meals were often lukewarm or cold. In an interview on 1/24/23 at 12:15 PM, Resident G, identified by the facility as interviewable, indicated the meals provided by the kitchen were lukewarm, never hot, but could be warmer. In an interview on 1/24/23 at 12:42 PM, Resident J, identified by the facility as interviewable, indicated the meals were not very good as they were often lukewarm. In an interview on 1/24/23 at 10:21 AM, Dietary 2 indicated he took food temperatures prior to the food being served. They indicated 39 of 39 residents residing in the facility received food from the kitchen. Temperature logs, dated 1/1/23-1/23/23, were provided by the Dietary Manager on 1/24/23 at 11:06 AM. The logs indicated there were no food temperatures recorded for: 1/1/23: breakfast and lunch 1/2/23: lunch 1/3/23: lunch 1/4/23: breakfast and lunch 1/5/23: lunch 1/6/23: breakfast and lunch 1/9/23: breakfast and lunch 1/10/23: breakfast and lunch 1/11/23: breakfast and lunch 1/12/23: breakfast and lunch 1/13/23: breakfast and lunch 1/17/23: breakfast and lunch 1/18/23: breakfast and lunch 1/20/23: breakfast and lunch In an interview on 1/24/23 at 11:06 AM, the Dietary Manager indicated food temperatures should be taken and recorded for each meal. In an interview on 1/24/23 at 12:03 PM, Qualified Medication Assistant (QMA) 5 indicated residents complained about cold food daily. QMA 5 indicated she offerred to heat up the residents food or an alternative item from the kitchen. A current policy, dated 12/2022, was provided by the Director of Nursing Services on 1/24/23 at 2:29 PM. The policy indicated: Temperatures should be monitored and recorded on the weekly temperature record prior to the start of and throughout meal service to ensure adequate holding temperatures are maintained. This Federal citation is related to complaint IN00399520. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure smoking assessments were completed for 1 of 2 residents reviewed. (Resident 10) Findings included: During an observation on 12/12/22 at 9:34 AM, Resident 10 was observed smoking with other residents in the designated smoking area outside the facility. Resident 10 was wearing a protective apron and staff was assisting with smoking materials. During an observation on 12/12/22 at 1:36 PM, Resident 10 was observed smoking with other residents in the designated smoking area outside the facility. Resident 10 was wearing a protective apron and staff was assisting with smoking materials. During an observation on 12/14/22 at 9:49 AM, Resident 10 was observed smoking with other residents in the designated smoking area outside the facility. Resident 10 was wearing a protective apron and staff was assisting with smoking materials. Resident 10's record was reviewed on 12/12/22 at 11:38 AM. Diagnoses included major depressive disorder, recurrent, severe with psychotic symptoms, cognitive social or emotional deficit following cerebral infarction, other cerebral infarction due to occlusion or stenosis of small artery, polyneuropathy in diseases classified elsewhere, anxiety disorder, unspecified. A Minimum Data Set (MDS) assessment, dated 10/18/22, indicated Resident 10 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). A facility nursing admission/readmission evaluation, dated 3/25/22, indicated, under the smoking evaluation, Resident 10 did not smoke. A physician progress note, dated 4/14/22, indicated Resident 10 was a current daily smoker. Resident 10 had smoked 1 pack of cigarettes per day for 46 years. A supervised smoking policy/contract, dated 4/11/22, was signed by Resident 10. The policy/contract included rules to be followed by the resident who wished to smoke, the designated smoking times, the facility's right to implement a behavioral contract, monitor, document all smoking related behaviors and the facility's rights when a resident violated the smoking policy. The policy/contract did not include an assessment of a resident that wished to smoke. A supervised smoking policy/contract, dated 10/22/22, was signed by Resident 10. The policy/contract included rules to be followed by the resident who wished to smoke, the designated smoking times, the facility's right to implement a behavioral contract, monitor, document all smoking related behaviors and the facility's rights when a resident violated the smoking policy. The smoking policy/contract did not include an assessment of a resident that wished to smoke. An independent activity tracking log for Resident 10, dated November 2022, was provided by the Director of Nursing on 12/13/22 at 11:07 AM. The log indicated Resident 10 smoked on November 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 21, 22, 23, 25, 26, 28, 29, and 30. An independent activity tracking log for Resident 10, dated December 2022, was provided by the Director of Nursing on 12/13/22 at 11:07 AM. The log indicated Resident 10 smoked on December 1, 2, 3, 5, 6, 7, 8, 9, 10, and 12. A care plan, initiated on 12/13/22, indicated Resident 10's desire to use tobacco products. The goals indicated Resident 10 would adhere to the facility's smoking policy and would not have any injuries related to smoking through the next review. The interventions indicated the facility was to complete smoking assessments as indicated. No care plan was in place for smoking prior to 12/13/22. No smoking assessments were in Resident 10's record. In an interview on 12/12/22 at 12:06 PM, RN 2 indicated an admission assessment, completed by a nurse, included a smoking assessment. RN 2 indicated social services might, also, do an assessment. In an interview on 12/12/22 at 1:50 PM, the Social Service Director (SSD) indicated an initial smoking assessment was to be done by nursing and quarterly assessments were to be done by the SSD. In an interview on 12/13/22 at 9:37 AM, the Director of Nursing (DON) indicated a resident's smoking status was assessed by a nurse in the admission/readmission assessment. If the response indicated the resident was a smoker, additional questions would populate to be answered. The DON indicated quarterly smoking assessments were to be done by the SSD. The DON indicated a resident's desire to smoke did not require a physician's order but absolutely needed to be care planned. In an interview on 12/13/22 10:11AM, the Regional Director indicated a care plan should be completed if a resident desired to smoke. The Regional Director indicated when a resident signed the facility smoking policy/contract, it indicated the resident was assessed for smoking. No resident assessment questions were found within the facility smoking policy/contract. A current policy, titled Smoking Policy, dated 12/2022, indicated under Procedure: .3. Assessments of residents a. Each resident who smokes must have a smoking assessment completed upon admission, quarterly and with significant change in condition by Social Services or designee. b. Smoking assessment will determine the amount of supervision required for each resident. Supervision requirements will be care planned and communicated to staff monitoring smoking

Based on interview and record review the facility failed to ensure a medication prescribed had an appropriate diagnosis for 1 of 5 residents reviewed. (Resident 134). Findings include: In an interview on 12/12/22 at 9:26AM, Resident 134 indicated she took medications but was unsure for what purpose. Resident 134's record review began on 12/12/22 at 2:18PM, indicated Resident 134 had the following diagnoses: displaced fracture of right clavicle, pneumonia, chronic lung disease, recurrent and persistent hematuria, hyperglycemia, A fib, acute and chronic respiratory failure, major depressive disorder recurrent, anxiety disorder, coronary artery bypass, and burn of 2nd degree to thigh. Resident 134's diagnoses list did not include a history of migraines or a seizure disorder. An admission MDS (minimum data set) assessment section I (active diagnosis), completed on 12/1/22 indicated diagnoses were: fracture, A fib, pneumonia, anxiety disorder, depression, chronic lung disease, respiratory failure, recurrent hematuria, hyperglycemia, burn, and atherosclerosis. The MDS did not indicate a diagnosis of seizure or migraine. Resident 134's current care plan did not indicate a problem area of seizures or migraines. Resident 134 had an order for Topiramate Tab 200mg to be given by mouth twice a day for seizures started on 11/23/22. Resident 134's medication administration record (MAR) dated December 2022 indicated the medication was documented as given twice a day on December 1st through December 11th. In an interview on 12/13/22 at 8:29AM, the DON indicated Resident 134 was taking Topiramate for migraines. The DON indicated the diagnosis was entered incorrectly in system. The DON indicated for admissions a nurse was to put the orders in and a second nurse then was to verify the physician orders were correct. The DON indicated there was no diagnosis of migraine or treatment plan for migraines in Resident 134's record. On 12/13/22 at 2:40PM the current facility policy was reviewed. A policy titled, Physician Services/Orders effective 09/30/2022, provided by DON 12/13/22 at 2:30PM, indicated 3. The physician will perform pertinent, timely medical assessments, prescribe an appropriate medical regimen 3.1-48(a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure insulin was dated when opened for 3 residents, in 1 of 2 medication storage carts observed. (Resident 14, Resident 12, and Resident 1). Findings include: During an observation, on 12/13/22 at 8:02AM with QMA 3, 3 insulin pens and a bottle of insulin without an open date were observed. In an interview with QMA 3, she indicated all meds should be labeled with an open date when they are first opened. QMA 3 indicated insulin is considered opened when it is taken from the refrigerator and put into the cart. QMA 3 was unable to determine when the 4 containers of insulin were put into the cart. In an interview, on 12/13/22 at 9:06AM the DON indicated all medications should be labeled with a pharmacy label and should have an open date. 1) Resident 14's record review began on 12/13/22 at 9:22AM. The record indicated diagnoses included type 2 diabetes mellitus with diabetic neuropathy. Resident 14 had a physician's order for Lantus SoloStar solution pen injector, (an insulin) give 55 units twice daily. In the 400 hall med cart Resident 14's insulin pen was observed with approximately 160units remaining and no open date was found. Resident 14's medication administration record dated December 2022 indicated documentation insulin utilizing the pen was given twice a day from December 1st through December 12th. 2) Resident 12's record review began on 12/12/22 at 10:54AM. The record indicated diagnoses included type 2 diabetes without complications. Resident 12 had physician orders for Insulin Degludec solution injection 20units daily and Insulin Lispro solution per sliding scale. In the 400 hall cart Resident 12's Degludec insulin pen was observed without an open date and with approximately 20 units remaining. Resident 12's lispro (insulin) was observed in cart without an open date. Resident 12's medication administration record for December 2022 indicated documentation insulin Lispro was administered: December 1st at 8:00PM December 3 at 11:30am and 8PM December 4 at 11:30AM, 4:30PM, and 8PM December 5 at 4:30PM December 6 at 8PM December 7 at 4:30PM and 8PM December 8 at 4:30PM December 9 at 4:30PM December 10 at 11:30AM December 12 at 4:30PM and 8PM Resident 12's medication administration record for December 2022, indicated documentation of administration of Deglu[DATE]units daily in am for December 1st-14th. 3) Resident 1's record review began on 12/13/22 at 9:30AM. The record indicated diagnoses included type 2 diabetes mellitus without complications. Resident 1 had a physician's order for Insulin Lispro per sliding scale. In the 400-hall med cart Resident 1's insulin was observed without an no open date. Resident 1's medication administration record for December 2022 indicated documentation Resident 1 was administered Lispro at 8PM on December 1, 3, 4, 5, 6, 8, 9, 10, 11, and 12th. On 12/15/22 at 11:16AM the current facility policy was reviewed. A policy titled, Medication Receipt, Labeling, and Destruction Policy and Procedure effective 8/29/2022, provided by the Regional Nurse Constultant on 12/15/22 at 11:08AM, indicated 3. Items such as insulin, eye drops,, etc, will be dated when opened . 3.1-25(k)(6)

Based on interview and record review the facility failed to protect the resident's right to be free from abuse for 1 of 5 residents reviewed for abuse (Resident B) Findings include: An incident report, dated 10/7/22, was provided by the Administrator on 11/22/22 at 2:48 PM. The report indicated on 10/7/22 a third party had notified the facility that a former resident had alleged an incident of sexual assault. The report indicated the resident no longer resided in the facility and the Certified Nursing Assistant (CNA) no longer was employed by the facility. The resident did not have any grievances regarding the CNA alleged and the facility was unable to substanitate the allegation of abuse. A statement was provided by the Administrator on 11/22/22 at 2:48 PM. The statement indicated on 9/16/22 the Administrator was notified of an inappropriate interaction between a facility employee and a facility resident: Resident B and CNA 2. The statement indicated both individuals are alert and orientated x4 and highly aware of what they say and do and what is acceptable behavior and what is not, any inappropriate actvity between residents and employees are not acceptable and a violation of company policies. Other corporate individuals were notified of report and company [NAME] President of Human Resources was dispatched to the facility to facilitate investigation. The statement indicated the Administrator was present during the interview with CNA 2 and CNA 2 denied any inappropriate interactions with any resident, by self or other employees. HR 3 indicated the facililty had received reports of inappropriate interactions, then CNA 2 decided to resign her position. The report also indicated Resident B was interviewed and denied having any inappropriate interaction with any staff member while at the facility. In a confidential interivew on 11/22/22, an employee indicated CNA 2 had told another staff member about her sexual relationship with Resident B. The staff member then reported the allegation to the Administrator. In an interview on 11/22/22 at 2:48 PM, the Administrator indicated on 9/16/22 an employee reported Resident B and CNA 2 were in a sexual relationship. The Administrator indicated he interviewed CNA 2 and Resident B on 9/16/22 and both parties denied the relationship. The Administrator indicated CNA 2 resigned during the interview. The Adminsitrator indicated at a later date, the facility had found information posted on social media accounts by Resident B that he was in a relationship with CNA 2. The Administrator indicated on 10/5/22 the police department indicated Resident B had filed charges of sexual assault against CNA 2. The Administrator indicated there was no other documentation he could provide at the time. In an interview on 11/22/22 at 3:26 PM, Police Officer 5 indicated Resident B had called on 10/2/22 and filed charges against CNA 2 regarding sexual assualt. Police Officer 5 indicated the investigation was still pending and he was unable to give any other information at the time. The Surveyor attempted to call Resident B on 11/22/22 at 3:24 PM, but Resident B's phone went straight to voicemail and the voicemail was full. Resident B's record review was conducted on 11/22/22 at 3 PM. Diagnoses included: unspecified injury of unspecificed level of lumbar spinal cord sequla, parkinson's disease, post traumatic stress disorder and depression. A quarterly Minimum Data Set (MDS) assessment, dated 7/15/22 indicated Resident B had a Brief Interview of Mental Status (BIMS) of 13/15 (cognitively intact). Progress notes were reviewed between 9/1/22 and 9/22/22, no notes indicated any allegation, distress or behaviors were exhibited from Resident B at the time. A policy, dated 9/2022, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines, was provided by the Administrator on 11/22/22 at 3:58 PM. The policy indicated abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Abuse 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. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical hamr pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abus including abuse facilitated or enabled through the use of technology. Willfull, as used means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .sexual abuse: is nonconsensual sexual contact of any type with a resident. This Federal Citation is related to Complaint IN00393506 3.1-27(a)(1)

Based on interview and record review the facility to ensure an allegation of abuse was reported to the Indiana Department of Health within 24 hours of the allegation. (Resident B) Findings include: An incident report, dated 10/7/22, was provided by the Administrator on 11/22/22 at 2:48 PM. The report indicated on 10/7/22 a third party had notified the facility a former resident had alleged an incident of sexual assault. A statement was provided by the Administrator on 11/22/22 at 2:48 PM. The statement indicated on 9/16/22 the Administrator was notified of an inappropriate interaction between a facility employee and a facility resident. In an interview on 11/22/22 at 2:48 PM, the Administrator indicated on 9/16/22 an employee reported Resident B and CNA 2 were in a sexual relationship. The Administrator indicated he interviewed CNA 2 and Resident B on 9/16/22 and both parties denied the relationship. The Administrator indicated on 10/5/22 the police department indicated Resident B had filed charges of sexual assault against CNA 2. The Administrator also indicated he had not reported the allegation to the Indiana Department of Health until 10/7/22. A policy, dated 9/2022, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines, was provided by the Administrator on 11/22/22 at 3:58 PM. The policy indicated reporting/response: ii: ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. This Federal Finding relates to Complaint IN00393506 3.1-28(c)