Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 22 residents reviewed for resident call light access. (Resident 12) Finding includes: On 4/22/25 at 9:18 a.m., Resident 12 was observed sitting up in bed. The over-the-bed table was in front of the resident. Resident 12's call light was observed hanging from the headboard behind the resident's left shoulder. The call light was out of sight and out of reach of Resident 12. During an interview at that time, Resident 12 indicated she did not know where her call light was. Resident 12 indicated the call light was not always accessible to her when she was in bed. During an interview on 4/22/25 at 9:25 a.m., Qualified Medication Aide (QMA) 3 indicated call lights were to be within the resident's reach. During an interview on 4/22/25 at 9:45 a.m., the Assistant Director of Nursing indicated call lights were to be kept within the resident's reach. On 4/22/25 at 9:55 a.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, repeated falls, diabetes, and chronic kidney disease. The Annual Minimum Data Set (MDS) assessment, dated 3/25/25, indicated Resident 12 was moderately cognitively impaired, required substantial assistance with transfers, and had a history of falls. Resident 12's care plan, revised on 3/25/25, indicated the resident was at risk of falls. The interventions, included but was not limited to, keep call light within reach. On 4/24/25 at 9:45 a.m., the Director of Nursing provided a copy of the Resident Rights policy, dated June 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .communities are committed to protecting and promoting the rights of the residents .equal access to quality care .receive care in accordance with personal preference . 3.1-3(v)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were labeled with an open date for 1 of 4 medication carts observed. An insulin pen was not labeled with an open date. (Renaissance 2 Medication Cart) Finding includes: On 4/22/25 at 8:30 a.m., the Renaissance 2 Medication Cart was observed. An opened Insulin Flex Pen 100 units/ml (milliliter) lacked labeling indicating the date the insulin pen was opened or to whom it was prescribed. LPN 2 indicated there was no label on the insulin and confirmed at that time that the 300-unit flex pen had 100 units remaining. During an interview on 4/22/25 at 9:48 a.m., the Corporate Nurse indicated the open date should have been on the insulin pen. On 4/22/25 at 1:10 p.m., the Corporate Nurse provided a policy titled, Section D, Drug Storage from Life Span Policy and procedure [NAME], undated, and indicated it was the current policy being used by the facility. A review of the policy indicated .Refrigerator Storage, 7, Insulin and PPD (TB) vaccine and other multi-dose vials requiring refrigeration need to be dated when opened. All vials should be discarded 28 days of the open date . 3.1-25(j)

Based on observation, interview, and record review, the facility failed to follow the plan of care for 1 of 4 residents reviewed for medication administration. Physician's orders were not followed. (Resident B) Finding includes: During an observation on 7/6/23 at 8:55 a.m., Registered Nurse (RN) 3 was observed preparing Resident B's medications with the DON present. When RN 3 got to the order for the dabigatran etexilate (Pradaxa) medication, RN 3 indicated that the medication was not available and that it had been reordered from the pharmacy. Neither staff member knew the generic name for the medication. During an interview on 7/6/23 at 1:57 p.m., the Administrator and the DON indicated that the medication had not been recognized by the generic name by staff administering medications and staff were unaware it was in the medication cart. They indicated Resident B had received it intermittently and should have received it twice daily as ordered. During an observation with the Administrator on 7/6/23 at 3:15 p.m., Resident B's dabigatran etexilate (Pradaxa) medication was observed in the bottom drawer of the medication cart containing Resident B's other medications. The label indicated that the pharmacy had sent the medication to the facility on 6/27/23. On 7/7/23 at 9:15 a.m., Resident B's clinical record was reviewed. Resident B's diagnoses included, but were not limited to, paroxysmal atrial fibrillation (a rapid, erratic heart rate that starts and stops on its own), chronic diastolic congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), chronic kidney disease, and the presence of a cardiac pacemaker. Physician orders included, and were not limited to: - Dabigatran etexilate (Pradaxa, a blood thinner or anticoagulant medication) capsule; 75 mg (milligrams) 1 capsule, oral twice a day for paroxysmal atrial fibrillation with a start date of 6/26/23 and no stop date noted. Resident B's electronic medication administration record (eMAR) from 6/26/23 through 7/6/23 was reviewed and indicated that the following: - On 6/27/23 for the Upon Rising (7:00 a.m. - 11:00 a.m.) dose, the medication was marked as not administered; the reason was On Hold and the comment was awaiting pharmacy. - On 6/27/23 for the Before Bedtime (6:00 p.m. - 10:00 p.m.) dose, the medication was marked as not administered; the reason was Other, and the comment was pending pharm. - On 6/28/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Other, and the comment was waiting on rx [prescription]. - On 6/29/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable, and the comment was pharmacy notified, waiting on delivery. - On 6/30/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable, and the comment was pharmacy has been notified. - On 7/1/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable. The entry lacked an associated comment. - On 7/2/23 for the Upon Rising dose, the medication was marked as not administered; the reason was On Hold and the comment was awaiting arrival. - On 7/3/23 for the Upon Rising dose, the medication was marked as not administered; the reason was On Hold and the comment was awaiting pharmacy. - On 7/5/23 for the Upon Rising dose, the medication was marked as not administered; the reason was Drug/Item Unavailable, and the reason was medication reordered. - On 7/5/23 for the Before Bedtime dose, the medication was marked as not administered; the reason was Drug/Item Unavailable. The entry lacked an associated comment. On 7/10/23 at 8:50 a.m., the DON provided a copy of the Protocol for Following Physician Orders, dated for 4/3/17, and indicated it was the policy currently in use by the facility. A review of the policy indicated under the procedure portion, All licensed staff will verify and follow physician orders as written. If for any reason, the physician order cannot be followed, the professional will contact the physician for further instructions. This Federal tag relates to Complaint IN00412739. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure foods were served in a sanitary and safe manner for 2 of 3 kitchen observations. Staff hair was not covered while in the kitchen food preparation area. (Cook 2, Dietary Manager) Findings include: 1. During a follow-up kitchen observation on 7/5/23 from 11:30 a.m. to 11:50 a.m., the following was observed: a. [NAME] 2 was observed walking through out the kitchen area where the noon meal was being prepared and was observed near the steam table and near the food carts where the noon meal was being held. [NAME] 2 was observed to have multiple hairs in front of both ears, approximately 2 inches in length, and multiple hairs, approximately one inch in length above and below the neckline, that were observed to not be covered. b. The DM (Dietary Manager) was observed walking through out the kitchen area where the noon meal was being prepared and was observed near the steam table and near the food carts where the noon meal was being held. The DM was observed to have multiple hairs, approximately 2 inches in length at and above the neckline, that were observed to not be covered. 2. During a follow-up kitchen observation on 7/5/23 from 12:50 p.m. to 12:55 p.m., the following was observed: a. [NAME] 2 was observed walking through out the kitchen area near the steam table where the noon meal was being held. [NAME] 2 was observed to have multiple hairs in front of both ears, approximately 2 inches in length, and multiple hairs, approximately one inch in length, above and below the neckline, that were observed to not be covered. b. The DM was observed walking through out the kitchen and near the steam table where the noon meal was being held. The DM was observed to have multiple hairs, approximately 2 inches in length, at and above the neckline, that were observed to not be covered. On 7/7/23 at 8:00 a.m., the Activity Director provided a copy of the 4/27/23 Resident Council Minutes. A review of the minutes indicated, .New business .Dietary - staff not wearing hairnets . On 7/7/23 at 3:50 p.m., the Kitchen Corporate Consultant provided a copy of the Resident/Family Concern/Grievance Form, dated 4/27/23. A review of the document indicated, .Person receiving concern: Activity Director; Department responsible for concern: Dietary. Section 1: nature of concern .hairnets. During an interview on 7/5/23 at 1:00 p.m., the Kitchen Corporate Consultant indicated all staff hair was to be totally covered while in the kitchen. On 7/5/23 at 1:13 p.m., the Kitchen Corporate Consultant provided a copy of the Environmental Sanitation/Infection Control policy, dated 2012, and indicated it was the current policy in use by the facility. A review of the policy indicated, .staff involved in storing, preparing, distributing and serving food to residents practice habits of good personal hygiene to protect residents from contamination and food borne illness. Standards of personal hygiene reflect federal, state and local requirements .hair restraint that effectively covers head .is worn in food preparation areas .hair is arranged to prevent contamination of food, equipment, and utensils . On 7/7/23 at 3:30 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear hair restraints, such as hats, hair coverings or nets .that are designed and worn to effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a medical record were complete for 1 of 3 residents reviewed for medical records. (Resident B) Finding includes: During an interview on 12/29/22 at 2:07 p.m., Resident B indicated she was sent to the hospital a few weeks ago but she didn't remember why. The clinical record for Resident B was reviewed on 12/30/22 at 8:31 a.m. The diagnosis included, but was not limited to, anxiety disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 9/22/22, indicated Resident B was cognitively intact. A hospital Discharge summary, dated [DATE], indicated Resident B was sent to the emergency department and diagnosed with aspiration and pneumonia. The clinical record lacked information related to Resident B's transfer to the hospital. During an interview on 12/30/22 at 12:19 p.m., the DON (Director of Nursing) indicated Resident B was sent to the emergency department on 10/7/22. The staff should have documented when Resident B was sent to the hospital. On 12/30/22 at 10:00 a.m., the DON provided a copy of a facility policy, titled Change in a Resident's Condition or Status, dated 10/2010, and indicated this was the current policy used by the facility. A review of the policy indicated the nurse supervisor/charge nurse with record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This Federal tag relates to Complaint IN00397556. 3.1-50(a)(1)