Based on observation, record review, and interview, the facility failed to develop a care plan for a resident with broken and missing teeth for 1 of 1 residents reviewed for dental care. (Resident 82) Finding includes: On 3/11/24 at 10:22 a.m., observed Resident 82 sitting in her wheelchair in her room. Observed Resident 82's top front teeth to be missing and front bottom teeth observed to be broken. During an interview at that time, Resident 82 indicated her teeth are falling out. On 3/12/24 at 9:30 a.m., the clinical record of Resident 82 was reviewed. The diagnosis included, but was not limited to, malnutrition. An admission Minimum Data Set (MDS) assessment, dated 1/9/24, indicated Resident 82 had .d. Obvious or likely cavity or broken natural teeth. The clinical record lacked a person centered care plan with dental services to be provided for Resident 82. A Physicians order with a start date of 12/27/23 with no end date, indicated .Dental .to evaluate and treat as indicated. During an interview on 3/13/24 at 8:33 a.m., the Director of Nursing indicated Resident 82's clinical record lacked a person centered care plan for dental services. A dental care plan should have been developed after the admission MDS assessment. On 3/13/24 at 10:25 a.m., the Director of Nursing provided a policy titled Dental Services, dated 11/1/23, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy explanation and compliance guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment process, and are addressed in each resident's plan of care. 2. Residents and/or resident representatives, during the admission process, are notified of dental services available under the State plan . 3.1-35(a)

Based on interview and record review, the facility failed to ensure student Nurse Aides (Nursing Assistant in training) were certified within the 120 day guideline of nurse aide training for 3 of 5 nurse aide records reviewed. (NA 2, NA 3, NA 4) Findings include: 1. On 3/14/24 at 11:33 a.m., the education and training record for Nurse Aide (NA) 2 was reviewed. NA 2's date of hire was 6/5/23. NA 2 began Certified Nursing Assistant (CNA) training on 6/5/23. NA 2 completed the class on 6/23/23. NA 2's student record lacked a Certification from the Indiana Department of Health, verifying Certified Nursing Assistant status. On 3/15/23 at 9:45 a.m., the Nurse Educator provided a documentation indicating NA 2's first day to work on the floor after completion of the program was 6/27/23. On 3/11/24 at 9:33 a.m., the Director of Nursing (DON) provided a current as worked schedule. The schedule indicated NA 2 continued to work for the facility as an NA. 2. On 3/14/24 at 10:00 a.m., the education and training record for Nurse Aide 3 was reviewed. NA 3 had a start date of 6/5/23. NA 3 began Certified Nursing Assistant (CNA) training on 10/9/23. NA 3 completed the class on 10/27/23. NA 3's student record lacked a Certification from the Indiana Department of Health verifying Certified Nursing Assistant status. On 3/15/23 at 9:45 a.m., the Nurse Educator provided documentation indicating NA 3's first day to work on the floor, after completion of the program, was 6/27/23. NA 3 continued to work the floor providing care to the residents. On 3/11/24 at 9:33 a.m., the DON provided a current as worked schedule. The schedule indicated NA 3 continued to work as an NA. 3. On 3/14/24 at 10:00 am., the education and training record for Nurse Aide (NA) 4 was reviewed. NA 4 had a start date of 9/5/22. NA 4 began Certified Nursing Assistant training on 10/9/23. NA 4 competed the class on 10/27/23. NA 4's student record lacked a Certification from the Indiana Department of Health, verifying Certified Nursing Assistant status. On 3/15/23 at 9:45 a.m., the Nurse Educator provided documentation indicating NA 4's first day to work on the floor, after completion of the program, was 10/30/23. NA 4 continued to work the floor providing care to the residents. On 3/11/24 at 9:33 a.m., the DON provided a current as worked schedule. The schedule indicated NA 4 continued to work as an NA on 3/12/24. During an interview on 3/11/24 at 10:00 a.m., the Education Coordinator indicated the NAs were working with a Certified Nursing Assistant on the floor in the Certified Nursing Assistant (CNA) capacity. During an interview on 3/15/24 at 8:35 a.m., the Education Coordinator indicated the test provider sent the students a link to schedule the test to be certified as a CNA. It was up to the students to respond to the link and were to set up a time to test. The Education Coordinator indicated the students had put it off and had to be reminded several times. The NA's should be certified within 120 days of completing the class. On 3/15/24 at 8:49 a.m., the Director of Nursing provided a job description for Nursing Assistant in training, dated May 2009, and indicated it was the current job description. The job description indicated The primary purpose of this position is providing indirect daily care, safety and comfort of the residents while enrolled in a training program or obtaining nursing certification.Graduating CNA students, not yet certified, may also work 120 days while awaiting their Indiana certification. On 3/15/24 at 8:49 a.m., the Director of Nursing provided a policy titled Certified Nursing Assistant, dated May 2009, and indicated it was the current policy being used by the facility. A review of the policy indicated Must possess specific educational and experience such as: .Graduating CNA students, not yet certified may also work for 120 days while awaiting their Indiana certification. 3.1-14(b)(2)(A)

Based on interview and record review, the facility failed to complete a gradual dose reduction (GDR) for a psychotropic (a medication relating to or denoting drugs that affect a person's mental state) medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 63) Finding includes: On 3/11/24 at 11:00 a.m., Resident 63's clinical record was reviewed. The diagnosis included, but was not limited to, unspecified schizophrenia (a severe, lifelong brain disorder that causes people to interpret reality abnormally). The Quarterly MDS (Minimum Data Set) assessment, dated 12/14/23, indicated Resident 63 had moderate cognitive impairment. The Care Plan included, but was not limited to: Resident 63 has a risk for side effects related to the use of antipsychotic/antianxiety medications, initiated on 1/22/21 and current through 3/17/24. The Physician's Orders included, but were not limited to: Olanzapine (an antipsychotic medication) 5 mg (milligrams) give a half tablet at bedtime for schizophrenia, initiated on 2/19/24 with no end date noted. A Pharmacy Recommendation Report, dated 1/11/24, included, but was not limited to: Gradual dose reduction due at this time for relevant medication olanzapine 5 mg HS (at hour of sleep or at bedtime) for schizophrenia. Recommend reduction to olanzapine 2.5 mg HS and monitor for increase in symptoms related to schizophrenia. The physician marked agree in response and stated, Agree to GDR [gradual dose reduction] Zyprexa [olanzapine] to 2.5 mg, PO [by mouth], QHS [every night at hour of sleep] for schizophrenia. It was signed and dated by the physician on 1/18/24. A Pharmacy Recommendation Report, dated 2/15/24, included, but was not limited to: Gradual dose reduction due at this time for relevant medication olanzapine 5 mg HS for schizophrenia. Per previous recommendation signed and dated 1/18/24, provider agreed to decrease olanzapine. No new order entered in PCC [Point Click Care, a software program used for the tracking and administration of medications, care, and treatment for residents in the facility]. Recommend decrease olanzapine per provider order. The physician marked other in response and stated, Already at current dose of 2.5 mg. It was signed and dated by the physician on 2/19/24. The EMAR (electronic medication administration record) included, but was not limited to: Resident 63's olanzapine order indicated daily administration for the dates of January 18th through the 31st of 2024, resident received olanzapine 5 mg daily at bedtime for each of the 14 days. Resident 63's olanzapine order indicated daily administration for the dates of February 1st through the 18th of 2024, resident received olanzapine 5 mg daily at bedtime for each of the 18 days. During an interview on 3/13/24 at 9:45 a.m., the DON (Director of Nursing) indicated Resident 63's olanzapine order should have been reduced from the 5 mg to the 2.5 mg dose on 1/18/24 when it was signed by the physician. On 3/13/24 at 11:30 a.m., the DON provided a policy titled Following Medication-Physician Orders/Parameters, dated March of 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated instructions on administering medications in a safe and effective manner following physician orders and the review of the 6 rights of medications which includes the right dosage of medications. 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed ensure residents were treated with dignity for 1 of 32 residents reviewed. Staff failed to acknowledge a resident while providing care and failed to inform the resident of the placement of the call light. (Resident 165) Finding includes: On 1/24/23 at 9:05 a.m., Resident 165 was observed in her room. Resident 165 was sitting in her wheel chair that was in between the bed and the wall. Resident 165's call light was observed attached to the bed and behind the resident and out of the residents view. During an interview at that time, Resident 165 indicated she was not sure where her call light was. Resident 165 was observed to look for the call light. The call light was observed to be out of the residents reach. During an interview on 1/24/23 at 9:11 a.m., Nurses Aide (NA) 3 indicated Resident 165 should have had her call light in reach. Observed NA 3 provide the call light to the resident. NA 3 placed the call light on the bed on the right side of the wheel chair. No interaction by NA 3 to the resident was observed. NA 3 was not observed to communicate to the resident where the call light was placed. During an interview on 1/24/23, at 9:20 a.m., Resident 165 indicated she did not know where NA 3 had placed the call light. Resident 165 was observed looking for the call light on the left side of the wheel chair. The clinical record for Resident 165 was reviewed on 1/24/23 at 10:00 a.m. The diagnoses included, but were not limited to, unsteadiness on feet and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment, dated 1/20/23, indicated Resident 165 was cognitively intact. A Plan of Care History, dated January 2023, indicated Resident 165 required one person physical assist for all Activities of Daily Living. During an interview on 1/27/23 at 8:45 a.m., the Director of Nursing (DON) indicated the call light should have been in reach. The DON also indicated NA 3 should have addressed the resident by name and communicated the placement of the call light. On 1/27/23 at 9:17 a.m., the DON provided a policy titled Resident Rights, undated, and indicated it was the current policy being used by the facility. A review of the policy indicated, Basic rights: You have the right to be treated with respect and dignity in recognition of your individuality and preferences. 3.1-3(a)

Based on observation, record review, and interview, the facility failed to ensure a call light was in the reach of a resident for 1 of 32 residents reviewed. (Resident 165) Finding includes: On 1/24/23 at 9:05 a.m., Resident 165 was observed in her room. Resident 165 was in her wheel chair watching television. The wheel chair was in between the bed and the wall. Resident 165's call light was observed attached to the bed and behind the resident and out of the residents view. During an interview at that time, Resident 165 indicated she was not sure where her call light was. Resident 165 was observed to look for the call light. The call light was observed to be out of the residents reach. During an interview on 1/24/23 at 9:11 a.m., Nurses Aide (NA) 3 indicated Resident 165 should have had her call light in reach. Observed NA 3 provide the call light to the resident. NA 3 placed the call light on the bed on the right side of the wheel chair. No interaction by the NA to the resident was observed. NA 3 was not observed to communicate to the resident where the call light was placed. During an interview, on 1/24/23 at 9:20 a.m., Resident 165 indicated she did not know where NA 3 had placed the call light. At that time, Resident 165 was observed looking for the call light on the left side of the wheel chair. The clinical record for Resident 165 was reviewed on 1/24/23 at 10:00 a.m. The diagnoses included, but were not limited to, unsteadiness on feet and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment, dated 1/20/23, indicated Resident 165 was cognitively intact. A Plan of Care History, dated January 2023, indicated Resident 165 required one person physical assist for all Activities of Daily Living. During an interview, on 1/27/23 at 8:45 a.m., the Director of Nursing (DON) indicated the call light should have been in reach for Resident 165. The DON also indicated NA 3 should have communicated the placement of the call light. On 1/27/23 at 9:17 a.m., the DON provided a policy titled Resident Call System, dated October 2022, and indicated it was the current policy being used by the facility. A review of the policy indicated, All residents will be instructed in the use of the call light system .The call light should be within reach of the resident. 3.1-3(v)(1)

Based on observation, record review, and interview, the facility failed implement infection control practices to prevent the spread of infections for 2 of 4 observations of resident care. Handwashing was not complete. (LPN 5, CNA 4) Findings include: 1. During an observation of wound care on 1/24/23 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 was observed to perform hand hygiene for 10 seconds before completing a treatment order for Resident 165's pressure ulcer. Licensed Practical Nurse (LPN) 5 was observed to perform hand hygiene for 10 seconds after completing the treatment. During an interview on 1/26/23 at 9:55 a.m., the Infection Preventionist (IP) indicated LPN 5 should have washed her hands for at least 20 seconds before and after wound care. 2. During a catheter care observation, on 1/25/23 at 11:20 a.m., observed Certified Nursing Assistant (CNA) 4 perform hand hygiene for 10 seconds prior to providing catheter care for Resident 107. Observed CNA 4 perform hand hygiene for 10 seconds after the providing catheter care for Resident 107. During an interview on 1/26/23 at 9:55 a.m., the IP indicated CNA 4 should have washed her hands for a at least 20 seconds before and after catheter care. The IP provided a document, titled Hand Hygiene: and indicated it was the current procedure used by the facility. The procedure indicated, Why, How and When, dated June 2021, indicated Duration of the entire procedure: 20-30 seconds. On 1/26/23 at 12:15 p.m., the IP provided a policy titled, Catheter Use and Care, dated July, 2018, and indicated it was the current policy being used by the facility. A review of the policy indicated Procedure: Perform hand hygiene and put on clean gloves. On 1/26/23 at 12:15 p.m., the IP provided a policy titled, Hand Washing, revised 6/2021, and indicated it was the current policy being used by the facility. A review of the policy indicated Policy: to ensure proper hand washing before and after procedures and/or resident care to prevent the spread of infection. Procedure: Refer to who Hand Hygiene: why, how and when of the patient safety packet. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a staff member working as the Director of Dining and Nutrition Services (Dietary Manager) had a valid and active CDM (Certified Dietary Manager) certification. This had the potential to affect 110 of 110 residents residing in the facility who received food from the kitchen. Finding includes: On 1/27/23 at 8:30 a.m., the personnel file for the Director of Dining and Nutrition Services (Dietary Manager) was reviewed. The following documents were reviewed: -The Director of Dining and Nutrition Services job description indicated, .has the authority and responsibility for assuring that established policies are carried out .regulatory compliant .the Department shall be directed on a full time basis by an individual who, by education or specialized training and experience .assuring that State/Federal regulations, specific to dining and nutrition, are met .managing food production and service, using safe, sanitary and efficient principles .managing and directing all employees of the Dining and Nutrition Services department, including hiring, training, and evaluation .must meet .criteria as defined by federal regulation .a certified dietary manager or certified food service manager . The document was signed by the staff member on 9/5/21. -The Job Description Performance Management System (JDPMS) Signature Sheet indicated, Director of Dining and Nutrition Services .I have read and received a copy of the Job Description and Performance Management System for the position . The document was signed by the staff member on 9/5/21. The record lacked supporting documentation that the Director of Dining and Nutrition Services had successfully completed and received the required Certified Dietary Manager certification. The record also lacked supporting documentation that at least two years of working experience as a Dietary Manager had been fulfilled. During an interview on 1/27/23 at 8:42 a.m., the Administrator (ADM) indicated the Director of Dining and Nutrition Services was hired in 2016 as a cook. In September of 2021, the staff member was promoted to the Director of Dining and Nutrition Services position. On 1/27/23, the staff member enrolled and had not yet begun the Become a Certified Dietary Manager online course. The ADM indicated the Registered Dietician visited the facility weekly on Mondays. During an interview on 1/27/23 at 1:48 p.m., the Director of Dining and Nutrition Services indicated he was hired at the facility in 2016 as a cook and was promoted on 9/5/21 to the Director of Dining and Nutrition Services position. He enrolled into the Certified Dietary Manager online course today (1/27/23). He indicated, previously the staff member just hadn't had time to enroll in the course. The Director of Dining and Nutrition Service job responsibilities included all aspects of the kitchen, food service, and staff supervision to ensure all regulations were met. During an interview on 1/27/23 at 1:52 p.m., the ADM indicated the facility lacked a policy regarding the Director of Dining and Nutrition Services job specific education or certification requirements. The lack of a Certified Dietary Manager resulted in a lack of direct dietary staff supervision. Cross reference F812. On 1/25/23 at 3:30 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .the person-in-charge shall demonstrate this knowledge .having a certified food employee who has shown proficiency of required information through passing a test that is of an accredited program .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to wear effectively keep their hair from contacting .exposed food . 3.1-20(c)

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner during 4 of 4 observations where staff's hair was uncovered potentially affecting 110 of 110 residents residing in the facility who received food from the kitchen. (Cook 2, [NAME] 6) Findings includes: 1. During the initial kitchen tour, on 1/23/23 from 9:00 a.m. to 9:25 a.m., observed [NAME] 2 walking through out the kitchen area where the noon meal was being prepared. [NAME] 2 was observed labeling food containers for the noon meal. [NAME] 2 had multiple loose hairs, approximately 4 inches in length, hanging below the neckline that were observed to not be covered. 2. During a follow-up kitchen tour, on 1/23/23 from 11:10 a.m. to 11:30 a.m., observed [NAME] 2 walking through out the kitchen area where the noon meal was being prepared and observed walking near the steamtable where the noon meal foods were being held. [NAME] 2 was observed making a lettuce and tomato sandwich for a resident. [NAME] 2 had multiple loose hairs, approximately 4 inches in length, hanging below the neckline that were observed to not be covered. 3. During a follow-up kitchen tour, on 1/23/23 from 12:35 p.m. to 12:49 p.m., observed [NAME] 2 standing at the steamtable plating the resident's noon meal. [NAME] 2 had multiple loose hairs, approximately 4 inches in length, hanging below the neckline that were observed to not be covered. 4. During a follow-up kitchen tour, on 1/27/23 from 1:30 p.m. to 1:40 p.m., observed [NAME] 6 at the food preparation table preparing stuffing for the evening meal. [NAME] 6 was wearing a white hair net that covered the hair located above the ears to the top of her head. The hair located from the ears to the neckline was observed to not be covered. [NAME] 6 had multiple loose hairs, approximately 4 inches in length, that hung below the neckline that were observed to not be covered. During an interview on 1/23/23 at 9:15 a.m., the Administrator indicated the current facility census was 110. During an interview on 1/23/23 at 12:55 p.m., the Assistant Dietary Manager indicated all staff hair was to be covered while in the kitchen. All residents residing in the facility received food from the kitchen. On 1/26/23 at 8:55 a.m., the Administrator provided a copy of the Personal Hygiene and Jewelry policy, dated June 2021, and indicated it was the current policy in use by the facility. A review of the policy indicated, .employees of the Dining and Nutrition Services Department will be expected to maintain proper personal hygiene, in compliance with the state sanitation code and follow the facility uniform policy when on duty .all employees .must wear hair restraints (hairnet, hat .) when they are in the department to prevent hair from contacting exposed food . On 1/25/23 at 3:30 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints such as .hair coverings or nets .that are designed and worn to wear effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)