Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a treatment not implemented timely for 1 of 3 residents reviewed for pressure ulcers. (Resident 30) Finding includes: On 1/24/25 at 1:38 p.m., the resident's left foot DTI (deep tissue injury) was observed with LPN 1. There was a small circular dark purple area about 1 cm (centimeter) x 1 cm to the bottom lateral side of the foot. The resident's record was reviewed on 1/23/25 at 1:08 p.m. Diagnoses included, but were not limited to, hypertension, cerebral infarction, and Alzheimer's disease. The admission Minimum Data Set (MDS) assessment, dated 11/29/24, indicated the resident was cognitively impaired and had a current unhealed pressure ulcer/DTI. A Care Plan, updated 12/2/24, indicated the resident had a DTI to his left lateral foot. The interventions included to treat per Physician's order. A Progress Note, dated 11/22/24 at 1:42 p.m., indicated the resident was a new admission to the facility. A dark brownish purple area was noted to his left foot. The admission Observation, dated 11/22/24, indicated the resident had a pressure ulcer injury to the left foot outer aspect. It was brownish purple in color and measured at 0.8 cm x 3 cm. A Progress Note, dated 11/26/24 at 6:22 p.m., indicated a dry red maroon discoloration was observed to the resident's left outer foot. The edges were starting to lift. A new order was received for skin prep daily. A Physician's Order, dated 11/26/24, indicated to apply skin prep to the left outer plantar DTI daily. The Treatment Administration Record (TAR), dated 11/2024, lacked any treatment to the left lateral foot from 11/22/24, when the area was first noted, through 11/26/24. The skin prep treatment was first documented as completed on 11/27/24. During an interview on 1/23/25 at 2:15 p.m., the Director of Nursing (DON) indicated they should have put a treatment in place when they had identified the DTI upon admission. A facility policy, titled Skin Condition and Pressure Ulcer Assessment, indicated, .7. At the earliest sign of a pressure or other type of ulcer, or skin tear, resident, legal representative, and attending physician will be notified. The Director of Nursing will be notified daily using 24-hour condition report. The size and description will also be described in the nursing notes and a pressure or non-pressure event will be completed in the EMR . 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident 52) Finding includes: On 1/21/25 at 11:23 a.m., Resident 52 was observed lying in bed. Her wheelchair was at her bedside. There were no anti-rollback bars noted to her wheelchair. On 1/22/25 at 2:53 p.m., Resident 52 was observed seated in her wheelchair in the hall near the Nurse's Station. There were no anti-rollback bars noted to her wheelchair. On 1/23/25 at 9:56 a.m., Resident 52 was observed seated in her wheelchair at the Nurse's Station. There were no anti-rollback bars noted to her wheelchair. The record for Resident 52 was reviewed on 1/22/25 at 1:14 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. She had one fall with no injury since the prior assessment and required partial to moderate staff assistance with bed mobility. A Care Plan, updated 12/31/24, indicated the resident was at risk for falls due to weakness and impaired mobility. An intervention, dated 11/26/24, indicated anti-roll back bars to wheelchair. A Progress Note, dated 11/25/24 at 11:44 a.m., indicated the resident was found sitting on the floor in the dining room. She was assisted back to her wheelchair by staff. The cameras were reviewed, and she had scraped her back and head on the table when she fell. An IDT (interdisciplinary team) note, dated 11/26/24 at 9:58 a.m., indicated the team had reviewed the resident's fall and anti-rollback bars had been applied to her wheelchair for safety. During an interview on 1/23/25 at 10:46 a.m., the Director of Nursing (DON) indicated there should have been anti-rollback bars on the resident's wheelchair. A facility policy, titled Fall Prevention, indicated, .The Interdisciplinary Team will use their initial assessment to determine how to provide the safest environment for each patient. Safety interventions will be initiated as needed for each patient .II. Fall risk interventions include: .F. Implement patient targeted interventions to reduce risk . 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration for 1 of 2 residents reviewed for respiratory care. (Resident 4) Finding includes: On 1/21/25 at 2:36 p.m., Resident 4 was observed seated in his wheelchair in the hallway outside his room. He had no oxygen in place. On 1/22/25 at 2:52 p.m., Resident 4 was observed seated in his wheelchair in the hallway outside his room. He had no oxygen in place. On 1/23/25 at 9:55 a.m., Resident 4 was observed seated in his wheelchair in the therapy room. He had no oxygen in place. Record review for Resident 4 was completed on 1/22/25 at 1:17 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic respiratory failure, and type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment, dated 1/7/25, indicated the resident was cognitively impaired and received oxygen therapy. A Care Plan, updated 1/7/25, indicated the resident had heart failure and chronic respiratory failure with a history of a pulmonary nodule. The interventions included to administer oxygen as ordered and as needed. A Care Plan, updated 1/7/25, indicated the resident was at risk for respiratory distress related to respiratory failure and hypoxia. The interventions included to administer oxygen as ordered. The Physician's Order Summary, dated 1/2025, indicated an order for oxygen 2-4 L (liters) per nasal cannula every shift. There were no other instructions or parameters listed. A Progress Note, dated 1/6/25 at 8:52 p.m., indicated the resident had a diagnosis of chronic respiratory failure with hypoxia and had an order for oxygen 2-4 L, which he refused during the day and sometimes at night. A Progress Note, dated 1/7/25 at 7:14 p.m., indicated the resident had a diagnosis of chronic respiratory failure and was oxygen dependent during the night only. The Medication Administration Record (MAR), dated 1/2025, indicated the oxygen had been signed off as administered every shift. An oxygen saturation was documented every shift, but the rate of oxygen administered was not documented. There were not any documented refusals. During an interview on 1/23/25 at 11:13 a.m., the Director of Nursing indicated she had updated the Physician, and the oxygen orders were now PRN (as needed). A facility policy, titled Oxygen Therapy, indicated, .12. Turn on liter flow to the ordered rate .18. Record oxygen therapy on the treatment or special record and nursing notes if PRN. Include type of catheter, liter flow, and response to treatment . 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to attempt alternative measures and assess the necessity for bed rails for 1 of 1 resident reviewed for bed rails. (Resident 52) Finding includes: On 1/21/25 at 11:23 a.m., Resident 52 was observed lying in bed. There were half length side rails to the top of the bed on both sides. On 1/21/25 at 1:41 p.m., Resident 52 was observed lying in bed. There were half length side rails to the top of the bed on both sides. The record for Resident 52 was reviewed on 1/22/25 at 1:14 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. She required partial to moderate staff assistance with bed mobility, was receiving hospice services, and bed rails were not used as a physical restraint. A Care Plan, updated 12/31/24, indicated the resident was at risk for falls due to weakness and impaired mobility. An intervention, dated 11/26/24, indicated to provide with safety device or appliance as needed. The Physician's Order Summary, dated 1/2025, lacked any orders for side rails. There was a lack of any evaluation or assessment completed for the use of side rails. During an interview on 1/23/25 at 11:13 a.m., the Director of Nursing (DON) indicated she was unable to find any assessment for the side rails but would have one completed now. She was unsure if any other interventions had been attempted prior to the side rails. On 1/24/25, the DON provided a Side Rail Assessment, dated 1/23/25. The bilateral top half side rails were to be used when in bed for assistance with transfers and bed mobility. A facility policy, titled Side Rails, indicated, .2. An assessment will be performed to determine if full length side rails are needed to treat medical symptoms. Use of full side rails require a Physician's Order. A one half side rail will be used in accordance with assessed need and resident desires . 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents were treated with dignity, related to urinary drainage bags not covered, for 2 or 4 residents reviewed for dignity. (Residents C and D) Findings include: 1. Resident C was observed on 10/18/24 at 4:19 a.m., 4:34 a.m., and 5:49 a.m. lying in bed. The urinary drainage bag was attached to the side of the bed closest to the door. The urinary drainage bag was uncovered with urine present and visible in the bag. Resident C's record was reviewed on 10/18/24 at 1:31 p.m. The diagnoses included, but were not limited to, cerebral palsy and moderate intellectual disabilities. A Quarterly Minimum Data Set (MDS) assessment, dated 9/29/24, indicated a moderately impaired cognitive status, was dependent for activities of daily living, and had an indwelling urinary catheter. 2. Resident D was observed asleep in bed at 4:30 a.m. The urinary catheter drainage bag was attached to the bed frame on the side of the bed and was uncovered with urine present and visible in the bag. During an observation on 10/18/24 at 4:52 a.m., Resident D was awake and sitting on the side of the bed. The urinary drainage bag remained attached and uncovered on the side of the bed. There was urine present and visible in the bag. CNA 1 entered the room and asked the resident if he would like to get out of bed or lie back down. Resident D opted to get up for the day. After morning care had been completed by CNA 1, She placed the urinary drainage bag under the wheelchair seat next to the urinary drainage bag cover and assisted the resident to the common area across from the Nurses' Station. During an interview on 10/18/24 at 5:15 a.m., LPN 2 indicated the urinary drainage bag was to be placed in the urinary drainage bag cover. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An admission MDS assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. An indwelling urinary catheter was present. A facility urinary catheter care policy, dated January 2013 and received from the Director of Nursing as current, indicated catheter covers/dignity bags were to be used to preserve the resident's dignity and privacy. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with activities of daily living (ADL's) received oral care and assistance with placement of eyeglasses for 2 of 3 residents reviewed for ADL's. (Residents B and D) Findings include: 1. During an observation on 10/18/24 at 6:30 a.m., CNA 3 and CNA 4 entered Resident B's room. CNA 3 washed the resident's face and checked to ensure she had not been incontinent of urine or bowel. A mechanical lift was used to transfer the resident from the bed to the Broda Chair (reclining chair). Her hair was brushed and the glasses were cleaned and applied. Oral care had not been completed. Resident B's record was reviewed on 10/18/24 at 9:07 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. An Annual Minimum Data Set (MDS) assessment, dated 10/8/24, indicated long and short term memory problems and was dependent on staff for hygiene and oral hygiene. A Care Plan, dated 10/9/24, indicated a deficit in self care. The interventions indicated the staff were to assist with oral care twice daily. 2. During an observation on 10/18/24 at 4:52 a.m., CNA 1 provided morning care to Resident D. The resident's face and underarms were washed and incontinent care had been provided. He was dressed in clean clothing and assisted out to the common area by CNA 1. Oral care had not been completed and eyeglasses were not placed on the resident. The resident was observed with natural bottom teeth. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An admission MDS assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. The vision was adequate with corrective lenses. The Resident Care Card, identified as current by CNA 1 on 10/18/24 at 5:15 a.m., indicated the resident was to wear glasses. A Care Plan, dated 9/20/24, indicated a deficit in self-care. The interventions indicated assistance would be provided for oral care for his upper denture and lower natural teeth twice a day and as needed. During an interview on 10/18/24 at 10:36 a.m., the Director of Nursing indicated oral care was to be provided daily with morning care. During an interview on 10/18/24 at 3:29 p.m., CNA 5 indicated the resident would sometimes refuse to wear his glasses. An undated oral hygiene policy, received from the Director of Nursing as current on 10/18/24 at 1:17 p.m., indicated oral hygiene was to be completed for the teeth, gums, and mouth. Oral hygiene was an essential part of the morning and evening care. An undated morning care policy, received from the Director of Nursing as current on 10/18/24 at 1:17 p.m., indicated the resident was to be assisted with oral hygiene and eyeglasses were to be cleaned and placed on the resident. This citation relates to Complaint IN00444647. 3.1-38(a)(3) 3.1-38(a)(3)(C)

Based on observation, record review, and interview, the facility failed to ensure a resident with a urinary catheter and history of urinary tract infections received proper care and services related to improper placement of the urinary catheter drainage bag and tubing, catheter care not completed, and the outlet tube was not disinfected after emptying the urinary drainage bag, for 1 of 2 residents reviewed for urinary catheters. (Resident D) Finding includes: During an observation on 10/18/24 at 4:52 a.m., Resident D was awake and sitting on the side of the bed. CNA 1 entered the room and asked the resident if he would like to get out of bed or lie back down. Resident D opted to get up for the day. The urinary drainage bag on the side of the bed contained a large amount of clear yellow urine. CNA 1 unattached the urinary drainage bag from the side of the bed and placed the bag on the floor. She changed the resident's pants and each time after threading the catheter through the leg of the pants, the drainage bag was placed on the floor. The urinary drainage bag laid on the floor throughout the morning care and CNA 1 had stepped over the urinary drainage bag on the floor several times during the morning care. The catheter tubing was also on the floor and the resident was observed rolling the tubing with his foot. CNA 1 then placed the plastic urine measuring container on the floor and opened the outlet tube and drained the urine from the bag. After 850 cubic centimeters of urine was drained, the outlet tubing was clamped and returned to the holder on the drainage bag without being disinfected. The resident stood up on the side of the bed. The brief was soiled with bowel movement. CNA 1 washed the buttocks and placed a clean incontinent brief on the resident and completed dressing the lower part of his body. The urinary catheter was not washed. The resident was then assisted to the wheelchair. CNA 1 placed the urinary drainage bag under the wheelchair seat. The catheter tubing was on the floor. At the time of the observation, CNA 1 indicated she was unsure if the catheter tubing could be touching the floor and stated, it usually is. She then assisted the resident in the wheelchair to the Nurses' Station, with the catheter tubing still on the floor. During an interview on 10/18/24 at 5:15 a.m., LPN 2 indicated the catheter tubing was not to be touching the floor. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An admission Minimum Data Set assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. An indwelling urinary catheter was present. A Care Plan, dated 9/20/24, indicated a there was a risk for infections related to an indwelling catheter. The interventions indicated, the urinary drainage bag was to be stored in a protective bag, the drainage system was not to touch the floor, and catheter care was to be completed every shift and as needed. A facility urinary catheter care policy, dated January 2013 and received from the Director of Nursing as current, indicated the urinary drainage bags and tubing were to be positioned to prevent touching of the floor. The outlet tubes were to be disinfected with an antiseptic after emptying the drainage tube. The resident was to receive perineal and catheter care with soap and water at least twice daily. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (CNA 1 and CNA 6) when providing care to residents (Residents D and C) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control. Findings include: 1. During an observation on 10/18/24 at 4:52 a.m., CNA 1 entered Resident D's room and prepared to start the morning care without any PPE being worn. CNA 1 was stopped before care was started. CNA 1 indicated if the resident was on EBP, there was usually a cart outside of the room. She acknowledged a sign above the bed, which indicated the resident was on EBP. CNA 1 then donned the PPE and began the morning care. Resident D's record was reviewed on 10/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, dementia, history of urinary tract infections, and urinary retention. An admission Minimum Data Set (MDS) assessment, dated 9/27/24, indicated a moderately impaired cognitive status, supervision was required for oral hygiene and hygiene and moderate assistance was required for bathing. An indwelling urinary catheter was present. A Care Plan, dated 10/4/24, indicated EBP was required. The interventions included PPE would be used when care was provided. A sign would be placed outside the door that indicated EBP was required. The staff were to wear gown and gloves while care was provided and a face shield was to be worn if needed. A Physician's Order, dated 10/1/24, indicated enhanced barrier precautions were ordered. 2. During an observation on 10/18/24 at 5:49 a.m., CNA 6 prepared to complete morning care for Resident C without any PPE being worn. CNA 6 was stopped prior to the start of the care. She acknowledged a sign on the wall above the bed that indicated the resident was on EBP. She then donned a gown and gloves. Resident C's record was reviewed on 10/18/24 at 1:31 p.m. The diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities. A Quarterly MDS assessment, dated 9/292/4, indicated a moderately impaired cognitive status, was dependent for all activities of daily living, and an indwelling catheter was present. A Care Plan, dated 10/4/24, indicated EBP was required. The interventions included PPE would be used when care was provided. A sign would be placed outside the door that indicated EBP was required. The staff were to wear gown and gloves while care was provided and a face shield was to be worn if needed. A Physician's Order, dated 10/1/24, indicated enhanced barrier precautions were ordered. During an interview on 10/18/24 at 2:20 p.m., the Director of Nursing indicated the signs for EBP had been moved to above the residents' beds to make it a little more confidential. A facility EBP policy, dated August 2024, and received from the Director of Nursing as current, indicated EBP was to be used during high contact activities, which included hygiene and bathing activities. EBP was to be used if the resident had an indwelling device, which included indwelling urinary catheters. Gowns and gloves would be available near or outside the resident's room. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure a care plan was reviewed and revised to include changes related to splint use for a resident with contractures for 1 of 16 resident care plans reviewed. (Resident 35) Finding includes: On 1/8/24 at 9:54 a.m., Resident 35 was observed in his bed. Both hands were contracted at the wrist (a fixed tightening of muscles that prevents normal movement of associated body part) and there were no splints in place. A sign above the bed indicated to place splints on both hands/arms in the morning and after dinner for 2-3 hours, unless he asked for them off. On 1/9/24 at 8:50 a.m. and 2:14 p.m., 1/10/24 at 8:32 a.m. and 9:58 a.m., the resident was observed without splints on his hands. The resident's record was reviewed on 1/10/24 at 8:40 a.m. Diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities and contracture of muscle multiple sites. The Quarterly Minimum Data Set assessment, dated 9/20/23, indicated the resident was cognitively intact, and was dependent on staff assistance for all ADLs (activities of daily living). The current ADL Functional Status/ Rehabilitation Potential Care Plan indicated the resident had self care deficit related to impaired mobility and impaired cognitive abilities and weakness secondary to cerebral palsy with multiple contractures. Interventions included, but were not limited to, assist with repositioning and bed mobility, and assist with eating and drinking fluids. There was no intervention related to assisting with splint application. During an interview with RN 1 on 1/10/24 at 9:58 a.m., she indicated she was not aware if the resident wore splints. During an interview with Occupational Therapy Assistant 1 at that same time, she indicated the resident was supposed to wear the splints for 2-3 hours a day unless he declined. During an interview with the Director of Nursing on 1/10/24 at 10:09 a.m., she indicated Physician's Orders would be updated to include the splints and the care plan would be updated. 3.1-35(e)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of monitoring and assessments of skin discolorations for 1 of 1 residents reviewed for non-pressure skin conditions. (Resident 43) Finding includes: On 1/9/24 at 8:52 a.m., Resident 43 was lying in bed. There were 2 dark red/purple discolorations observed to her left forearm and 1 dark red/purple discoloration observed to her left wrist. On 1/10/24 at 1:10 p.m., Resident 43 was observed lying in bed. The same discolorations were still observed. Record review for Resident 43 was completed on 1/10/24 at 1:14 p.m. Diagnoses included, but were not limited to, dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/23/23, indicated the resident was cognitively impaired. The resident was an extensive 2+ assist for bed mobility, transfer and toilet use. She was an extensive 1 person assist for locomotion, dressing and personal hygiene. She was on hospice care. A Care Plan, dated 10/7/22 and revised 11/22/23, indicated the resident was receiving antiplatelet therapy and was at an increased risk for bruising or bleeding. An intervention included to observe for signs of abnormal bleeding which included bruising. They were to document abnormal findings and notify the MD and hospice. A Progress Note, dated 1/11/24 at 2:29 a.m., indicated a skin assessment was completed. No new areas were observed. The record lacked any documentation the discolorations had been assessed or were being monitored. During an interview on 1/11/23 at 9:21 a.m., the Director of Nursing (DON) indicated she was unable to find any documentation the resident's discolorations were assessed and monitored. She would have the nurse measure them and she would investigate them. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to a hand splint not in place as recommended and no Physician's order for splints for 1 of 1 residents reviewed for positioning and mobility. (Resident 35) Finding includes: On 1/8/24 at 9:54 a.m., Resident 35 was observed in his bed. Both hands were contracted at the wrist (a fixed tightening of muscles that prevents normal movement of associated body part) and there were no splints in place. A sign above the bed indicated to place splints on both hands/arms in the morning and after dinner for 2-3 hours, unless he asked for them off. On 1/9/24 at 8:50 a.m. and 2:14 p.m., 1/10/24 at 8:32 a.m. and 9:58 a.m., the resident was observed without splints on his hands. The resident's record was reviewed on 1/10/24 at 8:40 a.m. Diagnoses included, but were not limited to, cerebral palsy, moderate intellectual disabilities and contracture of muscle multiple sites. The Quarterly Minimum Data Set assessment, dated 9/20/23, indicated the resident was cognitively intact, and was dependent on staff assistance for all ADLs (activities of daily living). There was no Physician's Order in place for the use of splints. There was no documentation on the Treatment Administration Record when or if the splints were applied or removed. During an interview with RN 1 on 1/10/24 at 9:58 a.m., she indicated she was not aware if the resident wore splints. During an interview with Occupational Therapy Assistant 1 at that time, she indicated the resident was supposed to wear the splints for 2-3 hours a day unless he declined. During an interview with the Director of Nursing on 1/10/24 at 10:09 a.m., she indicated Physician's Orders would be updated to include the splints and the care plan would be updated. 3.1-42(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 1 residents reviewed for pain. (Resident 19) Finding includes: During an interview with a family member of the resident on 1/10/24 at 9:02 a.m., he indicated she would frequently complain of pain to her knees. On 1/10/24 at 1:20 p.m., Resident 19 was heard moaning in her room from the hall. The resident was observed lying in her bed, she was grimacing and indicated she was having pain. She was unable to state where the pain was but indicated she needed help. RN 1 indicated at that time, the resident would do that frequently and that was normal for her, she received scheduled pain medication. She indicated she would see if there was something else she could have. The resident's record was reviewed on 1/10/24 at 11:05 a.m. Diagnoses included, but were not limited to, dementia, osteoarthritis, cerebral vascular accident and depression. The resident also received hospice services. The Quarterly Minimum Data Set assessment, dated 8/30/23, indicated the resident had severe cognitive impairment, and had frequent pain for which she received scheduled medication. The scheduled Quarterly Pain Assessment due in November had not been completed. A Physician's Order, dated 6/10/23, indicated the resident received morphine sulfate (an opioid pain medication) 5 milligrams (mg)/0.25 milliliters twice daily for pain. The resident could also have the medication every 2 hours as needed for pain. A Physician's Order, dated 6/10/23, indicated the resident could have acetaminophen suppository, 650 mg every 6 hours as needed for pain. There was no order for oral acetaminophen. The current Pain Care Plan indicated the resident was at risk for pain related to osteoarthritis and chronic pain. Interventions included, but were not limited to, administer medications as ordered, observe for non-verbal signs of pain such as facial grimacing and crying, and offer non-pharmacological interventions such as back rub, warm blanket and position change. The January 2024 Medication Administration Record (MAR) indicated the resident had not received any as needed morphine sulfate or the acetaminophen suppository for pain. There was no indication any non-pharmacological interventions had been attempted to manage pain. During an interview with the Director of Nursing on 1/10/24 at 12:54 p.m., she indicated she had competed the Quarterly Pain Assessment that was due in November. She also indicated non-pharmacological interventions would be added to the MAR. 3.1-37(a)

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to hospice prescribing antibiotics for a urinary tract infection without a urinalysis and culture completed for 1 of 3 residents reviewed for antibiotic use. (Resident 43) Finding includes: Record review for Resident 43 was completed on 1/10/24 at 1:14 p.m. Diagnoses included, but were not limited to, dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/23/23, indicated the resident was cognitively impaired. The resident was an extensive 2+ assist for toilet use. She was on hospice care and received an antibiotic. A Physician's Order, dated 8/22/23-9/1/23 and again on 9/13/23-9/22/13, was for Cipro (antibiotic) 500 mg (milligrams) twice a day. A Physician's Order, dated 10/14/23, was for ceftriaxone (antibiotic) 1 gram injection 1 time only. A Physician's Order, dated 10/14/23-10/20/23, was for Augmentin (antibiotic) 500-125 mg twice a day. Review of the August, September and October 2023 Medication Administration Records (MARs) indicated the resident had received the antibiotics. The Revised McGeer Criteria for Infection Surveillance Checklist, dated 8/22/23, indicated the resident had a UTI (urinary tract infection). The resident had confusion and foul urine odor. The UTI criteria was not met for an antibiotic. The Revised McGeer Criteria for Infection Surveillance Checklist, dated 9/13/23, indicated the resident had a UTI. The resident had a fever. The UTI criteria was not met for an antibiotic. The Revised McGeer Criteria for Infection Surveillance Checklist, dated 10/13/23, indicated the resident had a UTI. The resident had confusion. The UTI criteria was not met for an antibiotic. There was no documentation to indicate a urinalysis had been completed on any of the above dates to indicate a UTI. There was no documentation to indicate the resident received the antibiotics for a true infection. During an interview on 1/11/24 at 12:56 p.m., the Director of Nursing (DON) indicated the resident had received antibiotics during August, September and October 2023 for a UTI. The resident had not met the criteria for an antibiotic. She had spoken to hospice and told them they cannot put residents on antibiotics unless they meet the criteria for a true infection.

Based on observation, record review, and interview, the facility failed to ensure resident equipment was safe and functional related to torn and ripped armrests on a resident's wheelchair for 1 of 1 random observations of resident equipment. (Resident 108) Finding includes: On 1/9/24 at 9:48 a.m., Resident 108 was observed seated in her wheelchair. The armrests on both sides were ripped and torn. On 1/10/24 at 8:32 a.m., the resident was seated in the dining room, the arm rests on her wheelchair were ripped and torn. The resident's record was reviewed on 1/10/24 at 11:05 a.m. Diagnoses included, but were not limited to, dementia, osteoarthritis, cerebral vascular accident and depression. The resident also received hospice services. The Quarterly Minimum Data Set assessment, dated 8/30/23, indicated the resident had severe cognitive impairment, and had frequent pain which she received scheduled medication for. During an interview with Occupational Therapy Assistant 1 on 1/11/24 at 9:05 a.m., she indicated she had not previously noticed the torn armrests, but had notified maintenance they needed to be fixed that morning. During an interview with the Director of Nursing on 1/11/24 at 1:30 p.m., she indicated nursing or maintenance would normally identify a problem with a wheelchair. 3.1-19(e)

Based on record review and interviews, the facility failed to protect the resident's right to be free from verbal and physical abuse by a staff member for 1 of 5 residents reviewed for abuse. (Resident B, CNA 2). Finding includes: Record review for Resident B was completed on 11/29/22 at 1:02 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, Parkinson's disease, depression, dementia, and mood disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 8/31/22, indicated the resident was cognitively impaired. The resident was an extensive 2+ person assist for bed mobility, dressing, toilet use, and personal hygiene. The resident had no behaviors, rejection of care or indicators of psychosis. A Care Plan, dated 12/12/18 and revised 9/2/22, indicated the resident can become physically abusive during episodes of rejection of care. Interventions included to project a caring concerned attitude, encourage participation in care, and to re-approach later and possibly with alternate caregiver. An Indiana Department of Health Reportable Incident indicated the following occurred on 9/27/22 at 5:01 p.m.: - Brief Description of Incident: On 9/28/22, it was reported to the DON (Director of Nursing) that CNA 2 was inappropriately verbally abusive with Resident B. Reported that the staff member called her a bitch and told her she wished she wasn't a resident so she could hit her. - Type of Injury: On 9/28/22, upon assessment the resident had a bruise on her left hand. The bruise was dark purple in color and about the size of a silver dollar. The resident was able to move her left hand well and no swelling noted. The resident could become combative with care and had a history of swinging her arms and at times hitting the sides of the bed. - Immediate Action Taken: On 9/28/22, the staff member was placed on immediate suspension and taken off the schedule pending further investigation. Statements would be obtained. - Preventive Measures Taken: On 9/28/22, reviewed in-service training on Abuse would be completed by the Administrator and DON. - Follow up added: On 9/30/22 indicated, after investigation and obtained statements the allegation had been partially substantiated. Staff member had been counseled. She would receive re-education on proper approaches to residents. She would be taken off twelve hour night shifts and placed on 2-10 p.m., shifts for better observations of her behaviors and would be monitored by the DON. She understood that any further inappropriate verbal altercations would result in termination of her position. -Follow up added: On 10/10/22, the CNA had resigned from her position effective 10/10/22. Facility investigation witness statements indicated the following: - CNA 1 wrote a statement on 9/27/22 that indicated she had witnessed Resident B being verbally and physically abused by CNA 2 on several occasions. She would slam Resident B's arms and legs down and pin them there. She would act like she was going to spit in Resident B's face. She called the resident a b**** and told her she wished she wasn't a resident so she could hit her back. - LPN 1 indicated she had heard CNA 2 talk to residents disrespectfully in a rude tone. She had heard her tell a resident to not hit her. She was the same way to staff members when they would ask her certain questions or requested help with another resident. - CNA 2 wrote a statement on 9/28/22 that indicated CNA 1 was verbally abusive to residents as well. She would cuss towards residents and walk away from residents when they needed care. She had caught CNA 1 on many occasions. She indicated when she finished helping another resident get back to bed, she went in and helped CNA 1 hold Resident B while the resident was being combative. She did not spit on her whatsoever. She had never told a resident to shut up. She would ask them to quiet down and see what they needed. There were no other written statements from any other staff members about the incident. There were no interviews with any residents regarding abuse or care from staff members. CNA 2 was not removed from the schedule until the following day when the DON began the investigation. A Progress Note, dated 9/28/22 at 9:59 a.m., indicated a bruise was observed on the resident's left hand between the thumb and index finger that measure 6 cm (centimeters) x 6 cm. The bruise was dark red and purple. Also, a bruise was observed on her left forearm that measured 1.5 cm x 1.5 cm that was purple/yellow. It was unknown when or how the bruises occurred. A telephone interview with CNA 1 was completed on 11/30/22 at 11:40 a.m. The CNA indicated during her shift, she and CNA 2 went in to check on Resident B. The resident was calm. The resident needed her brief changed. She then started to do incontinence care. As soon as the resident saw CNA 2, she became combative and was swinging at them. She was already doing incontinence care on the resident, so CNA 2 grabbed the resident's arms and held them down at the hand/wrist area and forearm. The resident then started kicking, so CNA 2 then slammed her legs down on the bed. CNA 2 then grabbed her arms again. The resident was making a spitting noise at them but not actually spitting. CNA 2 then leaned into the resident's face and acted like she was going to spit in her face. CNA 2 then called the resident a b**** and said she wished she wasn't a resident so she could punch her in the face. CNA 1 indicated she was shocked by what was happening so she just hurried up and got the incontinence care done and then went to go tell someone. She indicated the DON was already gone for the day so she went and told the SSD (Social Services Director). She indicated she gave her statement to the SSD and then the SSD put the note underneath the DON's door. She indicated the DON called her in the next day for her statement. She did not recall what other staff was working at the facility that evening. Interview with the DON on 11/29/22 at 2:11 p.m., indicated the statement from CNA 1 and LPN 1 was the first time they had ever told her anything related to CNA 2. She indicated when she came to work in the morning, she found the note from CNA 1 that was placed underneath her door. She indicated she did not interview any residents about abuse or about care from staff. She did not recall all the staff who had worked that night. She had asked some nurses about CNA 2. LPN 1 had said she had witnessed CNA 2 speaking harshly to residents in the past. LPN 1 did not work on the evening of the incident. She indicated the incident was partially substantiated related to CNA 2 being verbally inappropriate. CNA 2 admitted to her that at times she was short with residents and would tell them to be quiet. She could not determine where CNA 2 was holding the resident during the incident and assumed she was holding the residents hand. Interview with the SSD on 11/30/22 at 12:52 p.m., indicated CNA 1 came to her and told her the allegations related to CNA 2 and Resident B. She immediately went to the DON and reported it. She was unable to recall dates and didn't document anything. She indicated this was not the first report they had about CNA 2. Another resident had complained about care from CNA 2 previously and that incident's allegations were not treated as abuse. She indicated she did not do abuse interviews when allegations occur as the DON handled them. She remembered physically handing the DON the statement from CNA 1 and told the DON they needed to do something about it. She did not slide the statement underneath the DON's door. Follow up interview with the DON on 11/30/22 at 1:09 p.m., indicated she did not remember who told her about the incident. She believed it was when she got the note under her door the next morning when she came into work. She could not find any other witness statements that had been completed about the incident. Another incident with CNA 2 was reported from a different resident on 9/13/22. Cross reference F609 and F610. A facility policy titled, Resident Abuse and received as current from the facility on 11/28/22, indicated, .B. Abuse in any form will be clearly defined throughout the facility. Abuse shall broadly be considered the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, or deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psycho social well-being. More specifically, abuse shall be further delineated to include: 1. Verbal abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to a Resident or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability .3. Physical abuse - hitting, slapping, pinching, kicking or similar physical behaviors. It shall also include controlling behavior through corporal punishment This Federal tag relates to Complaint IN00391645. 3.1-27(a)(1) 3.1-27(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident 3 was completed on 11/30/22 at 9:31 a.m. Diagnoses included, but were not limited to, fracture of left fibula, type 2 diabetes mellitus, and osteoarthritis. The Significant Change MDS (Minimum Data Set) assessment, dated 10/5/22, indicated the resident was cognitively impaired and had a fall with a fracture in the past 6 months. A Progress Note, dated 9/16/22 at 3:55 p.m., indicated the resident was pulling her roommate in their wheelchair backwards into their room, tripped over the bedside table, lost her balance, and fell. Her left ankle was swollen and painful. The resident was sent to the Emergency Room. A Progress Note, dated 9/16/22 at 11:06 p.m., indicated the emergency room called the facility and reported there were no fractures, but the resident was being admitted to the hospital with a urinary tract infection. The resident was readmitted to the facility on [DATE]. A Progress Note, dated 9/19/22 at 11:44 a.m., indicated the Interdisciplinary team had reviewed the resident's fall from 9/16/22 and therapy was to screen the resident. A Progress Note, dated 9/20/22 at 11:18 a.m., indicated therapy had completed a screen as a result of the resident's fall on 9/16/22. The resident was showing increased difficulty with transfers, ambulation, and functional activities. She was complaining of pain and had decreased balance and weakness. Physical therapy services were recommended. A Progress Note, dated 9/21/22 at 3:23 a.m., indicated the resident was complaining of discomfort to both knees and her left ankle. A pain-relieving ointment was administered. A Progress Note, dated 9/22/22 at 3:07 p.m., indicated the therapy department had reported the resident was having increased difficulty weight bearing to the left lower extremity due to complaints of pain that seems to be worsening every day. The Physician was notified. On 9/23/22 a Physician's Order was received for x-rays of the left hip, left knee, and left ankle and the x-rays were completed. A Progress Note, dated 9/24/22 at 9:02 a.m., indicated the radiology reports had been received and the resident had a nondisplaced proximal fibula fracture. An Indiana Department of Health (IDOH) Reportable Incident, dated 9/25/22, indicated the resident had fallen on 9/16/22 and was sent to the emergency room with left ankle swelling and pain. X-rays had been completed and there were no fractures. The resident was admitted to the hospital with a urinary tract infection and returned to the facility on 9/18/22. Therapy screened the resident and found increased difficulty with transfers and ambulation due to complaints of pain. The hospital discharge paperwork was then reviewed, and it was discovered the hospital had x-rayed the incorrect (right) leg and ankle. The Physician was notified and ordered x-rays of the left leg and ankle. Those results indicated a left proximal fibula fracture. Interview with the Director of Nursing (DON) on 12/1/22 at 2:03 p.m., indicated the Quality Assurance (QA) Nurse and the MDS Coordinator were in charge of reviewing any hospital paperwork when a resident was admitted or re-admitted to the facility. Sometimes lab or radiology results may have been missing and staff would just receive in verbal report from the hospital that the results were negative. This x-ray discrepancy was found after staff had done a deeper dive into the paperwork when the resident had continued to complain of left ankle pain, 5 days after returning to the facility. Staff should have followed up with the hospital paperwork and radiology results sooner. 3.1-37(a) Based on observation, record review and interview, the facility failed to ensure Physician's orders were in place related to compression stockings for a resident with edema for 1 of 1 residents reviewed for edema (Resident 97) and failed to ensure follow up with hospital paperwork following a fall for 1 of 3 residents reviewed for falls. (Resident 3) Findings include: 1. On 11/28/22 at 11:18 a.m., Resident 97 was observed seated in her room. Both of her legs were swollen and she was wearing ankle socks. On 11/30/22 at 12:41 p.m., the resident was seated in her room. She had ace bandages wrapped on both legs. She indicated her legs were very swollen, and she had never worn compression stockings prior. The resident's record was reviewed on 11/30/22 at 8:53 a.m. The resident was admitted on [DATE]. Diagnoses included, but was not limited to, chronic kidney disease stage 4 and Diabetes Mellitus. The admission Minimum Data Set assessment, dated 11/24/22, indicated the resident was cognitively intact and needed extensive assistance for dressing. A Physician's Order, dated 11/18/22, indicated the resident was to wear light compression stockings daily for edema (swelling), to be put on in the morning and removed at night. The November Treatment Administration Record (TAR) did not have the order for compression stockings to be put on and taken off. Interview with the Director of Nursing, on 11/30/22 at 1:09 p.m., indicated the Physician had put the order for compression stocking in and had entered it incorrectly, so the order never transferred to the TAR . She indicated it had been corrected and she would educate the providers.

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to lack of a treatment in place for a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 35) Finding includes: On 12/1/22 at 11:37 a.m., Resident 35 was observed being assisted to use the restroom by 2 CNAs. The resident had an area observed to her coccyx. The area was a white/gray bubbled area approximately the size of a pea. The area did not appear to be open. Record review for Resident 35 was completed on 11/29/22 at 11:32 a.m. Diagnoses included, but were not limited to, anemia, hypertension, dementia, diabetes mellitus, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/22, indicated the resident was cognitively impaired. The resident required an extensive 2+ person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident did not have any pressure ulcers. A Care Plan, dated 11/22/22, indicated the resident had an open area on her coccyx. An intervention included treatment as ordered. An Event, dated 11/22/22, indicated: - open are on coccyx, wound area was white/waxy - measured: 1 cm (centimeters) x 0.4 cm - wound area treatment orders: NA - preventative measures that have been put in place: none needed A Progress Note, dated 11/29/22 at 9:25 a.m., indicated the open area on the coccyx with white slough (dead tissue) measured 1 cm x 0.4 cm x 0.1 cm. The area was cleansed, in house barrier cream applied. There was no documentation to indicate a treatment order had been put in place for the resident's pressure ulcer on her coccyx. Interview with the Director of Nursing on 12/1/22 at 1:13 p.m., indicated they did not have a treatment order in for the resident's wound but should have had one. 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure water temperatures were within normal limits for 1 of 16 rooms reviewed for accidents/ hazards. (room [ROOM NUMBER]) Finding includes: On 11/28/22 at 9:44 a.m. the water temperature in room [ROOM NUMBER] was checked and noted to be very hot to touch. At 10:15 a.m., the Maintenance Director checked the temperature and it was 137 degrees Fahrenheit. Interview with the Maintenance Director at that time indicated the water temperature was too hot, and should be between 110-120 degrees. He indicated he would go check the boiler at that time. His usual protocol was to check the temperature of one room per week. The current policy, Water temperature testing policy and procedures, indicated, .The water supply temperatures are done on a weekly basis .and to maintain an acceptable temperature range (110-120 F +/-) degrees. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure a resident was free from significant medication errors related to the incorrect administration of insulin for 1 of 3 residents observed during medication pass. (Resident 8) Finding includes: During a medication administration observation on 11/30/22 at 11:17 a.m. LPN 2 prepared Resident 8's insulin. She took the Humalog (insulin lispro) insulin pen out of the cart, cleaned the hub with an alcohol prep pad, and attached the needle. She then dialed the pen to 15 units and entered the resident's room. She cleaned the resident's right abdomen with an alcohol prep pad and injected the insulin. She had not primed the insulin pen or performed an air shot prior to administering the insulin. Interview with LPN 2 on 11/30/22 at 11:25 a.m., indicated she had not primed the insulin pen prior to administering the resident's insulin. She only primed the insulin pen with 2 units when it was new and first opened. Interview with the Director of Nursing (DON) on 11/30/22 at 1:09 p.m., indicated the insulin pen should have been primed prior to administration. A Facility policy, titled Injectable Medication Administration, received as current, indicated .M. Insulin Pen Technique .2) Prime (per manufacturers recommendation) prior to each injection . Manufacturer's instructions for the Humalog insulin pen, dated 4/2020, indicated, .Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 6 to 8 . 3.1-48(c)(2)

Based on record review and interview, the facility failed to promote antibiotic stewardship related to unnecessary antibiotic use for 1 of 3 residents reviewed for antibiotic use. (Resident 47) Finding includes: The Antibiotic Stewardship program was reviewed on 12/1/22 at 9:12 a.m. Three residents were reviewed for urinary tract infections (UTIs). On 10/16/22, Resident 47 was started on an antibiotic, Cefdinir 300 milligrams, for three days for a suspected UTI and given a urinalysis (lab test to identify UTI). On 10/17/22, the urinalysis came back as negative; the resident did not have an infection. The Physician was notified and there were no new orders. The resident completed the course of antibiotics. The October 2022 Infection Tracking Log indicated there were no additional criteria to support the antibiotic use and criteria had not been met. Interview with the Director of Nursing on 12/1/11 at 11:35 a.m., indicated she was aware of the excessive amount of antibiotics in the facility, especially related to UTIs. She was in the process of educating the Physicians and nurses regarding unnecessary antibiotic use, and it was a work in progress. The current policy, Antimicrobial Stewardship Policy and Procedure Purpose, indicated, .Provide educational material and/ or in-services to medical staff and other professionals on new antimicrobials and/ or guidelines as appropriate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A Concern/Grievance Form, dated 10/14/22, indicated Resident D had reported to the DON that the CNAs who put him to bed on 10/13/22 threw him into bed after getting him out of his wheelchair. The CNAs had not changed his clothes or checked his brief. The grievance form indicated, the resolution of the resident's concern was the CNA who had been assigned to the resident was verbally counseled on safe transfers and instructed to ask for assistance if needed. There was lack of documentation that the resident's concern had been reported to the Indiana Department of Health as an allegation of abuse/neglect and that a thorough investigation had been completed. Interview with the DON on 12/1/22 at 2:03 p.m., indicated she had not felt like the resident's allegations met the criteria for abuse. She had spoken with the CNA, and she indicated the allegations had not occurred, so she verbally counseled the CNA on transfers. She had not reported the allegations to IDOH and had not completed any further investigation. A facility policy titled, Resident Abuse and received as current from the facility on 11/28/22, indicated, .Reporting .B. The report of alleged mistreatment, neglect or abuse must be reported to the Administrator or his/her designee IMMEDIATELY. C. The Administrator or his/her designee will notify the following persons immediately, by phone and in writing, of the alleged mistreatment, neglect, or abuse: 1. State Licensing and Certification Agency; ISDH This Federal tag relates to Complaint IN00391645. 3.1-28(c) 3.1-28(e) 3. An Indiana Department of Health Reportable Incident indicated the following occurred on 9/27/22 at 5:01 p.m.: - Brief Description of Incident: On 9/28/22, it was reported to the DON (Director of Nursing) that CNA 2 was inappropriately verbally abusive with Resident B. Reported that the staff member called her a bitch and told her she wished she wasn't a resident so she could hit her. - Type of Injury: On 9/28/22, upon assessment the resident had a bruise on her left hand. The bruise was dark purple in color and about the size of a silver dollar. The resident was able to move her left hand well and no swelling noted. The resident could become combative with care and had a history of swinging her arms and at times hitting the sides of the bed. -Immediate Action Taken: On 9/28/22, the staff member was placed on immediate suspension and taken off the schedule pending further investigation. Statements would be obtained. - Preventive Measures Taken: On 9/28/22, reviewed in-service training on Abuse would be completed by the Administrator and DON. - Follow up added: On 9/30/22 indicated, after investigation and obtained statements the allegation had been partially substantiated. Staff member had been counseled. She would receive re-education on proper approaches to residents. She would be taken off twelve hour night shifts and placed on 2-10 p.m., shifts for better observations of her behaviors and would be monitored by the DON. She understood that any further inappropriate verbal altercations would result in termination of her position. - Follow up added: On 10/10/22, the CNA had resigned from her position effective 10/10/22. Interview with the DON (Director of Nursing) on 11/29/22 at 2:11 p.m. and again on 11/30/22 at 1:09 p.m., indicated she did not remember who told her about the incident. She was not informed of the incident until the next morning after the incident had occurred. Staff should have reported the incident to her immediately and also reported any other incidents they had witnessed with CNA 2. Based on record review and interview, the facility failed to ensure allegations of abuse were reported immediately to the the facility Administration and the State Survey Agency for 4 of 5 abuse allegations reviewed. (Residents C, E, B and D) Findings include: 1. Resident C's record was reviewed on 11/29/22 at 10:54 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (one sided weakness and paralysis). The Quarterly Minimum Data Set (MDS) assessment, dated 9/7/22, indicated she was cognitively intact, and required extensive staff assistance for bed mobility and transfers A Concern/ Grievance Form, dated 8/2/22, indicated the resident's roommate had reported CNA 4 had cared for the resident on 7/31/22. She was making pee-ew noises because the resident had been incontinent of bowel. She threw the resident into bed like you would throw a 5 lb bag of potatoes, and pulled her up in bed forcefully. There was no documentation indicating the event had been reported to the State Survey Agency. Interview with the Director of Nursing (DON) on 9/29/22 at 1:10 p.m., indicated she had not reported the incident as she didn't feel it met the criteria of an allegation of abuse. 2. Resident E's record was reviewed on 11/30/22 at 11:43 a.m. the resident was admitted on [DATE]. Diagnoses include, but were not limited to, Bipolar disorder and Diabetes Mellitus. The Significant Change MDS assessment, dated 11/23/22, indicated the resident was cognitively intact and needed limited assistance with toileting. A Concern/ Grievance Form, dated 9/13/22, indicated on 9/12/22, CNA 2 was very rough with her during care. The resident had requested the CNA stop caring for her and leave her room, the CNA then made a comment about the resident being rude. The resident did not want the CNA to care for her any more. The was no documentation the event had been reported to the State Survey Agency. Interview with the Director of Nursing (DON) on 9/29/22 at 1:10 p.m., indicated she had not reported the incident as she didn't feel it met the criteria of an allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A Concern/Grievance Form, dated 10/14/22, indicated Resident D had reported to the DON that the CNAs that put him to bed on 10/13/22 threw him into bed after getting him out of his wheelchair. The CNAs had not changed his clothes or checked his brief. The grievance form indicated, the resolution of the resident's concern was the CNA who had been assigned to the resident was verbally counseled on safe transfers and instructed to ask for assistance if needed. There was a lack of documentation that the resident's concern had been reported to the Indiana Department of Health as an allegation of abuse/neglect and a thorough investigation had been completed. Interview with the DON on 12/1/22 at 2:03 p.m., indicated she had not felt like the resident's allegations met the criteria for abuse. She had spoken with the CNA, and she indicated the allegations had not occurred, so she verbally counseled the CNA on transfers. She had not reported the allegations to IDOH and had not completed any further investigation. A facility policy titled, Resident Abuse and received as current from the facility on 11/28/22, indicated, .Investigation: .B. The investigation shall consist of the following, as they relate to the reported incident: .3. Interview and obtain signed statements from any witnesses to the incident; .6. Interview with staff members (on shift) having contact with Resident during the period of the alleged incident; 7. Interviews with the Resident's roommate (when appropriate), family members, and visitors, if necessary, to complete investigation; 8. Interviews with other Residents to which the accused employee provides care or services; and 9. A review of circumstances surrounding the incident . This Federal tag relates to Complaint IN00391645. 3.1-28(d) 3. An Indiana Department of Health Reportable Incident indicated the following occurred on 9/27/22 at 5:01 p.m.: - Brief Description of Incident: On 9/28/22, it was reported to the DON (Director of Nursing) that CNA 2 was inappropriately verbally abusive with Resident B. Reported that the staff member called her a b**** and told her she wished she wasn't a resident so she could hit her. - Type of Injury: On 9/28/22, upon assessment the resident had a bruise on her left hand. The bruise was dark purple in color and about the size of a silver dollar. The resident was able to move her left hand well and no swelling noted. The resident could become combative with care and had a history of swinging her arms and at times hitting the sides of the bed. - Immediate Action Taken: On 9/28/22, the staff member was placed on immediate suspension and taken off the schedule pending further investigation. Statements would be obtained. - Preventive Measures Taken: On 9/28/22, reviewed in-service training on Abuse would be completed by the Administrator and DON. - Follow up added: On 9/30/22, after investigation and obtained statements the allegation had been partially substantiated. Staff member had been counseled. She would receive re-education on proper approaches to residents. She would be taken off twelve hour night shifts and placed on 2-10 p.m., shifts for better observations of her behaviors and would be monitored by the DON. She understood that any further inappropriate verbal altercations would result in termination of her position. - Follow up added: On 10/10/22, the CNA had resigned from her position effective 10/10/22. Facility investigation witness statements indicated the following: - CNA 1 wrote a statement on 9/27/22 that indicated she had witnessed Resident B being verbally and physically abused by CNA 2 on several occasions. She would slam Resident B's arms and legs down and pin them there. She would act like she was going to spit in Resident B's face. She called the resident a b**** and told her she wished she wasn't a resident so she could hit her back. - LPN 1 indicated she has heard CNA 2 talk to residents disrespectfully in a rude tone. She had heard her tell a resident to not hit her. She was the same way to staff members when they would ask her certain questions or to help with another resident. - CNA 2 wrote a statement on 9/28/22 that indicated CNA 1 was verbally abusive to residents as well. She would cuss towards residents and walk away from residents when they needed care. She had caught CNA 1 on many occasions. She indicated when she finished helping another resident get back to bed she went in and helped CNA 1 hold Resident B while the resident was being combative. She did not spit on her whatsoever. She never told a resident to shut up. She would ask them to quiet down and see what they needed. There were no other written statements from any other staff members about the incident. There were no interviews with any residents regarding abuse or care from staff members. CNA 2 was not removed from the schedule until the following day when the DON began the investigation. Interview with DON (Director of Nursing) on 11/29/22 at 2:11 p.m. and again on 11/30/22 at 1:09 p.m., indicated she did not interview any residents about abuse or care from staff. She was unsure which nurse worked on the evening of the incident and did not interview any other staff who had worked that evening. Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated and measures were taken to prevent further abuse while the investigation was in progress for 4 of 5 abuse allegations reviewed. (Residents C, E, B and D) Findings include: 1. Resident C's record was reviewed on 11/29/22 at 10:54 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (one sided weakness and paralysis). The Quarterly Minimum Data Set (MDS) assessment, dated 9/7/22, indicated she was cognitively intact, and required extensive staff assistance for bed mobility and transfers A Concern/ Grievance Form, dated 8/2/22, indicated the resident's roommate had reported CNA 4 had cared for the resident on 7/31/22. She was making pee-ew noises because the resident had been incontinent of bowel. She threw the resident into bed like you would throw a 5 lb bag of potatoes, and pulled her up in bed forcefully. The roommate and resident had initially told the nurse working the night of 7/31/22 about the event and assumed it would be reported; it had not been. The event had not been addressed by the Director of Nursing (DON) until 8/4/22, 2 days after it was initially reported. The DON spoke to the resident, who confirmed that the event had occurred. The staff member was verbally counseled and was not to care for the resident any longer. There was no documentation any additional residents or staff had been interviewed regarding the incident. Interview with the DON on 9/29/22 at 1:10 p.m., indicated the CNA had not been suspended during the investigation. She did not feel the allegation met the criteria of abuse. 2. Resident E's record was reviewed on 11/30/22 at 11:43 a.m. the resident was admitted on [DATE]. Diagnoses include, but were not limited to, Bipolar disorder and Diabetes Mellitus. The Significant Change MDS assessment, dated 11/23/22, indicated the resident was cognitively intact and needed limited assistance with toileting. A Concern/ Grievance Form, dated 9/13/22, indicated on 9/12/22 CNA 2 was very rough with her during care. The resident had requested the CNA stop caring for her and leave her room, the CNA then made a comment about the resident being rude. The resident did not want the CNA to care for her anymore. The incident was addressed by the DON on 9/15/22. The CNA was verbally counseled on proper resident care. There was no evidence any other residents or staff had been interviewed about the event. Interview with the Director of Nursing (DON) on 9/29/22 at 1:10 p.m., indicated the CNA had not been suspended that time. She had been counseled on resident care. She did not feel the allegations met the criteria of abuse.

Based on record review, and interview, the facility failed to report and investigate abuse allegations, which also been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process as evidenced by the number of deficiencies cited involving abuse, abuse reporting and abuse investigations. This deficient practice had the potential to affect 44 of 44 residents residing in the facility. Findings include: Interview with the Administrator on 12/2/22 at 2:37 p.m., indicated the Quality Assessment and Assurance (QAA) Committee met at least quarterly and the committee consisted of the Administrator, Director of Nursing, department heads and therapy. The Pharmacy and Medical Director attended when available. The Quality Assurance and Performance Improvement (QAPI) plan requested at the Entrance Conference, was provided during the survey by the Administrator. The plan indicated the QAPI Committee will review the plan annually and make necessary revisions. The plan indicated how the facility should conduct clinical and non-clinical performance improvement projects (PIP) as part of the QAPI program and implementing the QAPI program planning and processes. 1. The following deficiencies were cited on this survey at an isolated scope with potential for more than minimal harm and had been cited previously as follows: - F600 Abuse was previously cited on Complaint surveys, dated 9/15/20 and 12/6/21. - F609 Abuse reporting was previously cited on a Complaint survey, dated 12/6/21. - F610 Abuse investigating was previously cited on the Recertification survey, dated 8/26/21, and a Complaint survey, dated 12/6/21. During this survey, the residents reviewed for abuse did not have allegations reported and thoroughly investigated. Cross reference F600, F609, F610. Interview with the Administrator on 12/2/22 at 2:37 p.m., indicated he was aware of the abuse allegation related to CNA 2. He was unaware of the other allegations from residents. They should have put a plan in place to make sure the grievances received from residents were looked at as abuse allegations when appropriate. 2. The following deficiency was cited on this survey at widespread with potential for more than minimal harm and had been cited previously as follows: - F880 Infection Control was previously cited on Recertification surveys dated 7/11/18, 6/21/19 & 8/26/21, and Complaint surveys dated 10/3/20, 12/16/21 & 7/19/22. During this survey, the facility failed to maintain a complete infection control program and failed to ensure staff followed appropriate protocols for hand hygiene. Cross reference F880. There was no evidence the facility had identified, developed, or implemented action plans and/or continued to monitor any corrective actions taken when these deficiencies were cited previously. 3.1-52(b)(2)

3. On 11/30/22 at 11:17 a.m., LPN 2 was observed preparing Resident 8's insulin. She took the Humalog (insulin lispro) insulin pen out of the cart, cleaned the hub with an alcohol prep pad, and attached the needle. She then dialed the pen to 15 units and entered the resident's room. She cleaned the resident's right abdomen with an alcohol prep pad and injected the insulin. She had not washed her hands or donned gloves prior to administering the injection. Interview with LPN 2 on 11/30/22 at 11:25 a.m., indicated she had not worn gloves when administering the insulin. She was unsure of the facility's policy regarding glove use and injections. Interview with the Director of Nursing (DON) on 11/30/22 at 1:09 p.m., indicated she had already spoken with LPN 2 and she should have worn gloves while administering the injection. A Facility policy, titled Injectable Medication Administration, received as current, indicated .Procedure .Sanitize hands with approved sanitizer .put on gloves .inject medication .remove and discard gloves. Clean hands by washing or using sanitizer . 3.1-18(b) Based on observation, record review and interview, the facility failed to maintain a complete infection control program which ensured ongoing monitoring of patterns and trends of infections. This had the potential to affect all 44 residents who resided in the facility. They also failed to ensure proper hand hygiene was used during wound care for 1 of 2 residents reviewed for pressure ulcers and during a random observation of medication administration (Residents C and 8) Findings include: 1. The Infection Control Program was reviewed on 12/1/22 at 9:12 a.m. The October 2022 Infection Control Log and Grid, indicated there were 11 cases of urinary tract infections (UTI) that month. There was a facility map that was color coded for types of infections. There were four rooms in a row, Rooms 10, 12,14 and 16, for which residents had UTI's in addition to others in the facility. The last inservice related to UTI's was in February 2022. Interview with the Director of Nursing, on 12/1/22 at 11:35 a.m., indicated the map was color coded for her own reference to be able to identify if there was a pattern or trend occurring. She indicated there was no policy regarding how many infections in an area would be a pattern or trend, but there should be. If necessary she would inservice the staff. She indicated UTI's were a big problem in the facility, and that she should do another inservice related to UTI's. The current policy, Infection Report and Surveillance Procedures, indicated, .1. Investigate source/ cause of infection. The investigation may require direct observations .review of policies and procedures, observation of employee performance, assessment of use and effectiveness of equipment and supplies 2. On 12/1/22 at 9:25 a.m., LPN 3 was observed providing wound care to Resident C. The LPN had supplies gathered and gloves on. The resident was positioned to her left side so the wound to her coccyx was accessible. The LPN removed the old dressing with her gloved hand, she then washed the wound with normal saline and a washcloth using the same gloved hands. She then removed gloves, donned a new pair without washing or sanitizing hands, and applied betadine and gauze to the wound. She removed gloves again and donned another pair without washing hands and applied an island dressing over the wound. Interview with the LPN after the wound treatment, indicated she was aware she should have washed her hands between glove changes but forgot.