Based on interview and record review, the facility failed to ensure a resident's choice was honored pertaining to selection of food items of their choice for 1 of 3 residents reviewed for resident rights. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/14/25 at 3:50 p.m. The diagnoses included, but were not limited to, encephalopathy (group of conditions that cause brain dysfunction), hemiplegia (loss of strength leading to paralysis on one side of the body), and dysphagia (difficulty swallowing). A Significant Change Minimum Data Set (MDS) assessment, dated 6/3/25, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance with toileting hygiene, and was always incontinent of bowel and bladder. A care plan, last revised 5/28/25, indicated Resident B required assistance with activities of daily living (ADLs) including eating and toileting. The approach included to provide assistance with eating as needed and assistance with toileting and/or incontinent care as needed related to Resident B being incontinent of bowel and bladder. An incident reported to the Indiana Department of Health (IDOH), dated 6/11/25, indicated it was reported that Certified Nurse Aide (CNA) 2 was rude to Resident B during dining service. The investigation file was reviewed, on 7/14/25 at 4:00 p.m., and contained the following statements:A typed statement that pertained to what CNA 2 was referring to regarding Resident B. The statement indicated, I told the resident he wasn't [sic] giving him any chocolate milk because it runs through him and nobody got time for that. A typed statement that pertained to what Resident B had indicated during a staff interview regarding the incident with CNA 2. Resident B indicated he recalled the interaction between CNA 2 and himself. He stated he asked for chocolate milk and CNA 2 declined as it would upset his stomach. A typed statement that pertained to what Licensed Practical Nurse (LPN) 3 had witnessed regarding CNA 2 and Resident B. LPN 3 indicated, I was in the dining room between the hours of 12:39pm [12:39 p.m.] - 12:45p [12:45 p.m.]. As I was passing meds [medications]. I heard [name of CNA 2] say to [name of Resident B] as he asked for chocolate milk, 'No, I'm not getting you no chocolate milk, it's gonna have you going up your back - I don't have time for that'. An interview conducted with the Executive Director (ED), on 7/14/25 at 4:18 p.m., indicated CNA 2 was educated on residents' choice and preferences. The ED believed CNA 2 was attempting to advocate for Resident B, but the staff needed to honor Resident B's preferences. A policy entitled Preferences for Daily Routine, revised 12/2015, was provided by the ED on 7/14/25 at 4:39 p.m. The policy indicated the purpose was to identify and develop a plan of care that reflects a resident's past and current daily customary routines. The information would be shared with the interdisciplinary team so that each department can address the residents' preferences. This citation relates to Complaint IN00462929. 3.1-3(u)(1)3.1-3(u)(3)

Based on observation, interview, and record review, the facility failed to timely implement a podiatry recommendation for 1 of 3 residents reviewed for foot care (Resident E).Findings include: The clinical record for Resident E was reviewed on 7/14/25 at 2:15 p.m. The resident's diagnosis included, but was not limited to, polyneuropathy (disorder of the nervous system).A physician's order, dated 9/25/24, indicated Resident E could be seen by the Podiatrist.On 7/14/25 at 2:45 p.m., Resident E was observed with the Director of Nursing (DON) in her room. She was lying in her bed, and her feet were observed to have thick, yellowing, crusty toenails on both big toes. Resident E indicated she had been seen by the Podiatrist recently.A Podiatry Group note, dated 6/14/25, indicated she had been seen by the Podiatrist and the nails on both feet had been debrided (reduced in size). There was a recommended new order of urea 40% cream (medication for dry skin and damaged nails) to all toenails daily for sixty days. The clinical record did not contain an order for urea 40% cream to be applied to Resident E's toenails daily for sixty days. During an interview on 7/14/25 at 4:15 p.m., the DON indicated when a resident had a podiatry recommendation it was normally given to her, and she processed the new order. The DON had not been made aware that Resident E had a recommended new order for urea cream. The urea cream should have been ordered. This citation relates to Complaint IN00463244.3.1-47(a)(7)

Based on interview and record review, the facility failed to follow up on grievances for 2 of 2 residents reviewed for grievances. (Resident B and Resident 41) Findings include: 1. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, completed 1/20/25, indicated she was cognitively intact. An interview was conducted with Resident B on 4/21/25 at 7:01 p.m. She indicated she had filed grievances and had not heard anything about a follow-up from the facility. Resident B indicated she was missing an arm sling, a backpack, a purse, and a box of crackers. An interview was conducted with the Social Services Consultant on 4/24/25 at 2:32 p.m. The Social Services Consultant indicated she could not find the grievances filled out by Resident B. Social Services Director (SSD) 4 indicated she spoke with Resident B and filled out grievances. SSD 4 indicated she did not know where the original grievances were located. 2. The clinical record for Resident 41 was reviewed on 4/23/25 at 2:00 p.m. The diagnoses included, but were not limited to, borderline personality disorder. A Quarterly MDS assessment, dated 9/16/24, indicated the resident was cognitively intact. Resident 41 was interviewed on 4/22/25 at 10:31 a.m. He indicated that within the last year, he entered his room and found Resident H sitting on his bed. He got angry, yelled, and swore at him to get out of his bed. Resident H stood up and staff came in to assist him back to his own room. Resident 41 was mad because the resident had done this before, and wanted his sheets changed because of Resident H's incontinence. Staff told Resident 41 he cannot yell or swear at other residents, but he was upset at finding the resident in his room again. He told a CNA (certified nurse aide) and the Weekend Supervisor about the incident. The Weekend Supervisor was interviewed on 4/24/25 at 10:48 a.m. She indicated Resident 41 told her about the incident several weeks ago. He was upset about the incident because Resident H frequently wanders into other residents' rooms. The Weekend Supervisor asked if he wanted her to fill out a grievance and he said yes. She completed the grievance and placed it into a bag in the conference room for the Director of Nursing (DON) to look over on Monday, which was her usual procedure for grievance forms. The DON was interviewed on 4/24/25 at 12:47 p.m. She did not recall seeing the grievance form. She hadn't heard of any residents having issues with Resident H's wandering, because he was pleasant and easily redirected. The Executive Director (ED) and Social Services Consultant were interviewed on 4/24/25 at 11:56 a.m. They could not locate the grievance Weekend Supervisor had filled out regarding the incident with Resident H. The ED said Resident 41 was usually very serious about his grievances and was likely very upset that Resident H was incontinent and sat on his bed. However, staff changed his sheets at the time of the incident, so they considered the issue resolved. A policy titled Resident Concerns and Grievances, revised 1/2019, noted If a concern/grievance of any kind is noted, the Concern/Grievance form is used .The Executive Director/Grievance Official will sign off on all completed concerns/grievance forms, ensuring resident and/or family satisfaction .All concern forms are to be maintained on-site for a minimum of three years. 3.1-3(k) 3.1-3(l)

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 3 residents reviewed for abuse. (Resident 37 and Resident 42) Findings include: 1. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident 42 was moderately cognitively impaired. The resident had impairments with her upper and lower extremities on one side. She utilized a walker and wheelchair. She required substantial assistance with dressing but was able to sit to stand independently with no assistance. A behavior care plan, dated 10/4/24, indicated Resident 42 had exhibited verbal aggression towards staff and anxiousness. 2. The clinical record for Resident 37 was reviewed on 4/22/25 at 9:57 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, anxiety disorder, and post-traumatic stress disorder. The Quarterly MDS assessment, dated 3/24/25, indicated Resident 37 was cognitively intact. The resident did not have any impairments with his upper or lower extremities. He utilized a walker and a cane. He was independent and did not need assistance with dressing and walking. A behavior care plan, start date of 4/17/25, indicated Resident 37 had been refusing medications and lab draws. A behavior care plan, start date of 4/17/25 with a revision date of 4/22/25, indicated Resident 37 had exhibited behaviors of self-pleasuring in common areas and sexually inappropriate behaviors with staff and a female peer. The interventions, but were not limited to, Ensure resident's safety . Provide resident with privacy to self pleasure himself . Remove from immediate area to further evaluate needs. A nursing note, dated 4/17/25, indicated Resident 37 had refused all meds during shift, resident tearful during shift, attempting to hug and kiss staff member, resident not easily directed, resident pulling out his penis and asking staff members to look at him, resident stated 'look at me' while resident pulled on his penis while lying in bed, resident asked to pull curtain and not pull out penis in front of staff, resident continued to jerk at his penis. writer pulled resident's curtain to give resident privacy, new and worsening event opened, DON [Director of Nursing] notified, MD [Medical Director] notified via MD binder of residents med refusal and behaviors. A nursing note, dated 4/18/25, indicated Resident refused all medication this shift, the writer went back the second time and found resident masturbating, gave resident some room and went back and resident was requesting for hug and kisses from writer . A behavior note, dated 4/19/25, indicated the resident was exhibiting behaviors of grabbing staff and kissing them on the neck. The resident was educated on the inappropriate behavior. The resident becoming aggressive towards staff in his attempt to touch/kiss them and he is pulling out his private parts and asking staff to look while he plays with himself. The medical provider was made aware of the increase in behaviors. A behavior note, dated 4/20/25 at 1:49 p.m. indicated the resident attempted to inappropriately touch the staff members. The resident was educated regarding the inappropriate behavior and redirection was provided. A nursing progress note, dated 4/20/25 at 4:35 p.m., indicated Resident 37 had gone into Resident 42's room and touched and kissed her inappropriately. Resident 37 was sent to the emergency room for evaluation. A reportable incident to the Indiana Department of Health, dated 4/20/25 at 3:07 p.m., indicated Resident 37 had entered Resident 42's room and touched her chest. The investigation for the reportable incident between Resident 37 and Resident 42 was provided by the Corporate Executive Director on 4/23/25 at 10:55 a.m. The file included, but was not limited to, the following documentation: A typed statement by the Social Services Director, dated 4/21/25, indicated .This a.m. I spoke with [Resident 37] to get more information on what happened 4/20/25 with him and a female peer [Resident 42]. Resident was laying across his bed on him [sic] stomach. Resident refused to look at the writer or sit up. Resident did not answer the writer's questions and told writer to get out of his room using profane language. After two more attempts, the resident continued on demanding that the writer leave the room. The writer excused herself and allowed resident to have space to himself. A typed statement by the Social Services Director, dated 4/22/25, indicated Resident 42 had stated Resident 37 had attempted to touch her and requested to have sexual relations. She refused. Resident 42 had indicated she does feel safe and not in danger. The resident denied any psychological distress from the incident. An observation and interview were conducted of Resident 37 in his room on 4/21/25 at 6:33 p.m. The resident was observed in bed with a blanket over his head. The resident was pleasant but had refused an interview. During that time, there was no observation of a staff person present by the resident's room nor in the resident's room providing one on one supervision. An observation and interview were conducted with Resident 42 on 4/22/25 at 11:44 a.m. The resident was observed in her room, dressed, and sitting in her wheelchair by her bed. She indicated Resident 37 had attempted to rape her a few days ago. Resident 37 had ambulated into her room and started touching her. She was clothed, but he was trying to remove her breast from her bra and touch her vagina. The staff came into her room and removed Resident 37 from her room. The resident had never done that before. Resident 42 indicated she felt safe in the facility with no concerns. An interview was conducted with the Business Office Manager on 4/23/25 at 3:40 p.m. She indicated, on 4/20/25, she had observed one of the Certified Nurse Aides (CNAs) bringing Resident 37 to the conference room. CNA 2 had reported she was going to get the nurse. Resident 42 had inappropriately touched Resident 37. An interview was conducted with the Corporate Executive Director on 4/23/25 at 3:56 p.m. She indicated a staff person should always be present while providing one on one supervision. Resident 37 should not have been left alone at any time on the evening of 4/21/25. An interview was conducted with CNA 2 on 4/24/25 at 9:44 a.m. She indicated she was the CNA that had brought Resident 42 to the conference room. On Sunday, 4/20/25, she overheard Resident 42 yelling out in the hallway, Someone help me! She and two other staff members had gone into the resident's room and observed Resident 42 sitting in her wheelchair using her arms pushing Resident 37 away from her. He was touching her breast. The residents were clothed. Resident 37 was redirected away from the resident and out of the room. She took Resident 42 to the conference room and reported the incident to the Weekend Supervisor (WS) 8. During that time, Resident 42 was highly upset and afraid. An interview was conducted with WS 8 on 4/24/25 at 10:49 a.m. She indicated a CNA had reported Resident 42 was brought into the conference room. It had been witnessed regarding Resident 37 inappropriately touching Resident 42. During an interview with Resident 42, she had reported to the WS 8 that Resident 37 had ambulated in her room and climbed on top of her while she was in her wheelchair. He put his hands on her vagina and breast while kissing her neck. Three CNAs came into the room and removed Resident 42 from her room. During that time, Resident 42 was crying and upset during the interview. The WS 8 indicated after receiving the report that she notified the Executive Director (ED), Director of Nursing (DON), and the police department. Resident 42 and Resident 37 were immediately placed on one-on-one supervision. After police arrival, Resident 37 was sent to the hospital for a psychiatric evaluation. He later returned to the facility and was placed back on-one-on one supervision. An interview was conducted with CNA 22 on 4/24/25 at 2:50 p.m. She indicated she was one of the three staff members that had observed the incident between Resident 37 and Resident 42. She heard a sound in the hallway like a baby crying. She and two other staff members rushed into Resident 42's room. Resident 42 was sitting in her wheelchair crying and Resident 37 was rubbing on her breast and vagina. The residents were clothed at that time. CNA 22 had to remove Resident 37's hands off Resident 42. He then was redirected out of her room. After, the residents were placed on one-on-one supervision until the police and ambulance arrived. Resident 37 was sent out to the hospital. An abuse policy was provided by the Executive Director on 4/22/25 at 8:55 a.m. It indicated, .Policy: It is the policy of [Name of corporation] to provide each resident with an environment that is free from abuse . [Name of corporation] will not permit residents to be subjected to abuse by anyone . other residents . Definitions/Examples of Abuse . Sexual abuse - nonconsensual sexual contact of any type with a resident. Examples may include but not be limited to fondling, touching, rubbing . kissing 3.1-27(a)(1)

Based on interview and record review, the facility failed to maintain evidence that an allegation of abuse was thoroughly investigated for 2 of 3 residents reviewed for abuse (Resident 37 and Resident 42). Findings include: 1. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident 42 was moderately cognitively impaired. The resident had impairments with her upper and lower extremities on one side. She utilized a walker and wheelchair. She did need substantial assistance with dressing but was able to sit to stand independently with no assistance. 2. The clinical record for Resident 37 was reviewed on 4/22/25 at 9:57 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, anxiety disorder, and post-traumatic stress disorder. The Quarterly MDS assessment, dated 3/24/25, indicated Resident 37 was cognitively intact. The resident did not have any impairments with his upper or lower extremities. He utilized a walker and a cane. He was independent and did not need assistance with dressing and walking. A Nursing Progress Note, written by Weekend Supervisor (WS) 8 at 4/20/25 at 4:30 p.m., indicated Resident 42 had reported that a male resident (Resident 37) had entered her room without permission and attempted to touch and kiss her inappropriately. The Power of Attorney, Physician, Executive Director, and the Director of Nursing Services had been notified. An interview was conducted with the Weekend Supervisor (WS) 8 on 4/24/25 at 10:49 a.m. She indicated a CNA (certified nurse aide) had reported Resident 42 was brought into the conference room. It had been witnessed, Resident 37 inappropriately touching Resident 42. During an interview with Resident 42, she had reported to WS 8 that Resident 42 had ambulated in her room and climbed on top of her while she was in her wheelchair. He put his hands on her vagina and breast while kissing her neck. Three CNAs came into the room and removed Resident 37 from her room. During that time, Resident 42 was crying and upset during the interview. WS 8 indicated after receiving the report, she notified the Executive Director (ED), Director of Nursing (DON), and the police department. Resident 42 and Resident 37 were immediately placed on one-on-one supervision. After the police arrival, Resident 37 was sent to the hospital for a psychiatric evaluation. He later returned to the facility and placed back on one-on-one supervision. She had spoken with the DON and the ED when the incident happened. On 4/25/25 at 9:12 a.m., the Executive Director (ED) provided the completed investigation file for the reportable incident between Resident 37 and Resident 42. The completed investigation file did not include a statement from WS 8. During an interview on 4/25/25 at 2:45 p.m., the Corporate Executive Director (CED) indicated that WS 8 had reported the incident to the ED and DON. The incident between Resident 37 and 42 had been reported to the Indiana Department of Health. She did not believe there was an actual written statement, but WS 8 had written progress notes about the incident in each of resident's medical records. An abuse policy was provided by the Executive Director on 4/22/25 at 8:55 a.m. It indicated, .Policy: It is the policy of [Name of corporation] to provide each resident with an environment that is free from abuse . [Name of corporation] will not permit residents to be subjected to abuse by anyone . other residents . Definitions/Examples of Abuse . Sexual abuse - nonconsensual sexual contact of any type with a resident. Examples may include but not be limited to fondling, touching, rubbing . kissing . Investigation .Resident to Resident Abuse .4. The staff member in charge will initiate the investigation immediately 5. The executive Director will be notified immediately of the report and the initiation of the investigation . Statements will be taken from individuals witnessing the incident . Resident Abuse- Staff member, volunteer, or visitor .The investigation will include . facts and observations by involved employees . facts and observations by witnessing employees . facts and observations from others who might have pertinent information . Facts and observations by the supervisor or individual whom the initial report was made . 3.1-28(d)

Based on interview and record review, the facility failed to timely refer a resident with a new diagnosis of a psychiatric condition for a Level 2 assessment for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for Preadmission Screening and Resident Review (Resident 33 and Resident 41). Findings include: 1. The clinical record for Resident 33 was reviewed on 4/22/25 at 2:33 p.m. The diagnoses included, but were not limited to, dementia and schizoaffective disorder. A Psychiatric Progress Note, dated 5/15/24, indicated the Preadmission Screening and Resident Review (PASRR) had no history of serious mental illness, intellectual disability, or developmental disability. A Quarterly Minimum Data Set (MDS) assessment, completed 11/5/24, indicated Resident 33 was cognitively intact. The diagnosis of schizoaffective disorder was not included in the MDS assessment. A Physician's Assistant (PA) progress note, dated 11/4/24, indicated the diagnosis of schizoaffective disorder had an onset date of 10/30/24. The plan was to administer olanzapine (anti-psychotic medication) 5 milligram (mg) which had been started the previous week. The clinical record did not contain information that a Level 1 or Level 2 review had been completed after the addition of the schizoaffective disorder diagnosis on 10/30/24. A Quarterly MDS assessment, completed 2/5/25, included the diagnosis of schizoaffective disorder. During an interview on 4/25/25 at 1:45 p.m., the Social Service Director (SSD) indicated Resident 33 had been referred for a Level 2 review the previous day. 2. The clinical record for Resident 41 was reviewed on 4/24/25 at 9:22 a.m. The diagnoses included, but were not limited to, borderline personality disorder. A Preadmission Screening and Resident Review (PASRR), dated 3/1/23, indicated the resident did not qualify for a Level 2 screening due to having no mental illness diagnoses. A Quarterly MDS assessment, dated 9/16/24, indicated the resident had no mental illness diagnoses and was cognitively intact. A Psychiatric Progress Note, dated 12/4/24, indicated Resident 41 had been diagnosed with borderline personality disorder with an onset date of 11/6/24. Due to the resident's behaviors and symptoms, he started Depakote (medication used to treat mood issues and behaviors) 250 milligrams at bedtime. The clinical record did not contain information that a Level 1 or Level 2 review had been completed after the addition of the borderline personality disorder diagnosis on 11/6/24. The Social Services Director (SSD) was interviewed on 4/23/25 at 1:54 p.m. She indicated she had not done a new Level 1 screening for Resident 41's new diagnosis, but that it was on her list to be completed. She would try to complete it as soon as possible, likely the next day. She was not sure what the time frame was for when a Level 1 needed to be completed after a new diagnosis. On 4/25/25 at 8:38 a.m., the Executive Director (ED) provided a copy of a newly completed Level 1 screening for Resident 41. A policy titled PASRR Policy, dated 11/2017, indicated It is the policy of this facility to ensure that any Pre-admission Screening and Resident Review [PASRR] recommendations which impact those with an Intellectual, Mental Disability or related conditions are completed as prescribed and PASRR assessments are updated with significant changes in mental or physical status .Any resident with an Intellectual, Mental Disability or related condition will be referred to the designated mental health or intellectual disability authority with a significant change in mental or physical status.

Based on observation, interview, and record review, the facility failed to timely pull a resident up in bed as requested repeatedly and provide consistent showers for 1 of 7 residents observed during medication administration and 1 of 2 residents reviewed for activities of daily living (ADL) care. (Resident E and Resident B) Findings include: 1. The clinical record for Resident E was reviewed on 4/22/25 at 10:30 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, and stroke resulted in hemiplegia (loss of strength on one side). The Quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated Resident E was moderately cognitively impaired. The resident had upper and lower impairments on one side with substantial maximum assistance by a staff member to roll left and/or right and sit to lying position. An observation was conducted of Resident E during a medication administration with Qualified Medication Aide (QMA) 10 on 4/21/25 at 6:47 p.m. The resident was observed in bed. The resident's head was not positioned at the top of the bed. The resident requested to be pulled up in bed. QMA 10 indicated at that time, Certified Nurse Aide (CNA) 22 was busy and would be with her when available. During that time, CNA 23 entered the resident's room requesting bleach wipes from QMA 10. At that time, Resident E requested again to be pulled up in bed. QMA 10 indicated CNA 22 would pull her up when she was done with another resident. After, QMA 10 left the resident's room and continued with medication administration with other residents. An interview was conducted with QMA 10 on 4/21/25 at 6:50 p.m. She indicated she would let CNA 22 know Resident E needed to be pulled up in bed when she saw her. An observation was conducted of Resident E in bed with Nurse Consultant 12 present in the room on 4/21/25 at 7:35 p.m. The resident's head was not positioned at the top of the bed. The resident indicated CNA 22 had not been into her room to pull her up in bed. During an interview with the Director of Nursing on 4/24/25 at 12:17 p.m. She indicated QMA 10 should have asked CNA 23 to assist with pulling Resident E up in bed. 2. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly MDS assessment, completed 1/20/25, indicated she was cognitively intact. An ADL care plan, revised on 2/20/25, indicated . Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between .' An interview was conducted with Resident B on 4/21/25 at 6:53 p.m. She indicated she does not get her showers as scheduled on a regular basis. She indicated her shower days were Monday and Thursday during the day. On 4/25/25 at 8:37 a.m., the Executive Director (ED) provided shower sheets for Resident B. The following date(s) were indicative of Resident B not receiving a shower on her scheduled shower days: 3/21/25, 4/17/25, and 4/21/25. An interview was conducted with Resident B on 4/25/25 at 10:49 a.m. She indicated she did have a shower, and her hair was washed on 4/24/25. She also indicated she did not get a shower or bed bath on 4/21/25. An interview was conducted with the Director of Nursing (DON) on 4/25/25 at 10:56 a.m. She indicated Resident B was scheduled for showers on Monday's and Thursdays. A partial bed bath was to be given to Resident B in between shower days. The DON indicated there was no policy on ADL care. She provided a copy of the AM (morning) Care Nursing Skills Competency check list. This citation relates to Complaint IN00456672. 3.1-38(a)(3)(A) 3.1-38(a)(3)(B) 3.1-38(b)(2) 3.1-38(b)(6)

2. The clinical record for Resident 42 was reviewed on 4/22/25 at 9:00 a.m. The diagnoses included, but were not limited to, stroke, major depressive disorder, physical debility, unsteadiness on her feet, and anxiety disorder. A physician order, dated 3/11/25, indicated the resident was to receive 14 units of aspart insulin three times a day. The order did not include parameters to hold the insulin. The April 2025 Medication Administration Record indicated the following days and times the aspart insulin was not administered as ordered: 4/2/25 - 12:00 p.m. - blood sugar reading of 94 = the insulin was not administered, 4/8/25 - 5:00 p.m. - there was no documentation recorded, 4/9/25 - 5:00 p.m. - there was no documentation recorded, 4/10/25 - 8:00 a.m. - blood sugar reading of 62 = the insulin was not administered, 4/15/25 - 12:00 p.m. - blood sugar reading of 75 = the insulin was not administered, and 4/23/25 - 12:00 p.m. - blood sugar reading = 129 = the insulin was not administered. An interview was conducted with the Director of Nursing on 4/25/25 at 11:29 a.m. She indicated she was unable to provide any reason nor provide documentation the medical provider was aware Resident 42's aspart insulin was not administered as ordered on 4/2/25, 4/8/25, 4/9/25, 4/10/25, 4/15/25, and 4/23/25. 3. The clinical record for Resident E was reviewed on 4/22/25 at 10:30 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, and stroke resulted in hemiplegia (loss of strength on one side). The Quarterly MDS assessment, dated 1/17/25, indicated Resident E was moderately cognitively impaired. A physician order, dated 11/12/24, indicated the staff was to apply 1% of Preparation H cream in the rectum every shift. The staff was to monitor the resident's blood pressure and heart rate. A physician order, dated 10/17/24, indicated the staff was to apply 20% Preparation H witch hazel pads during incontinent care every shift as needed. An observation was conducted of incontinent care for Resident E with Certified Nurse Aide (CNA) 30 on 4/22/25 at 10:24 a.m. During the incontinent care, the resident had reported to CNA 30 her rectum was burning. The resident had requested for cream to be applied to her rectum. At that time, CNA 30 removed her gloves and left the resident's room. She then returned to the resident's room with a tube labeled Preparation H. She then squeezed the cream into her hands and applied the cream around the resident's rectum. At that time, CNA 30 indicated the Preparation H rectal cream was provided to her to apply due to the resident's complaints of burning. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 4/25/25 at 11:29 a.m., the DON indicated CNA 30 should not be applying the Preparation H rectal cream to Resident E. 3.1-37(a) Based on observation, interview, and record review, the facility failed to administer medications and treatments as ordered for 1 of 5 residents reviewed for dignity, 1 of 5 residents reviewed for unnecessary medications, and 1 of 4 residents reviewed for activities of daily living. (Resident G, Resident 42, and Resident E) Findings include: 1. The clinical record for Resident G was reviewed on 4/22/25 at 12:12 p.m. The diagnoses included, but were not limited to, liver transplant and major depressive disorder. A physician's order, dated 10/10/24, indicated Resident G was to receive mycophenolate mofetil (immunosuppressive medication) 500 milligrams (mg) twice daily; to be given one hour prior or two hours after eating. A Quarterly Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident G was cognitively intact. During an interview on 4/22/25 at 12:12 p.m., Resident G indicated he had a liver transplant and had gone several days without his immunosuppressive medications. The facility had run out of his medication. He was worried because he did not want to have his transplant rejected by his body. The February, March, and April 2025 Medication Administration Record (MAR) indicated Resident G had not received his mycophenolate mofetil 500 mg as ordered on the following days: 2/2/25, 2/3/25, 3/5/25, 3/6/25, 3/7/25, 3/8/25, 3/9/25, 3/10/25, 3/11/25, and 4/18/25. The MAR indicated the reason for the missed doses was the drug was unavailable. During an interview on 4/25/25 at 2:34 p.m., the Doctor of Medicine (MD) indicated Resident G not receiving his scheduled mycophenolate mofetil as ordered was not good practice.

Based on observation, interview, and record review, the facility failed to ensure the resident's oxygen provided was as ordered for 1 of 7 residents observed during medication administration. (Resident E) Findings include: The clinical record for Resident E was reviewed on 4/22/25 at 10:30 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, and stroke resulted in hemiplegia (loss of strength on one side). The Quarterly Minimum Data Set assessment, dated 1/17/25, indicated Resident E was moderately cognitively impaired. A physician order, dated 9/25/24, indicated Resident E was to receive two liters of oxygen via nasal cannula (tubing that delivers oxygen through the nose) every shift. An observation was conducted of Resident E during a medication administration with Qualified Medication Aide (QMA) 10 on 4/21/25 at 6:47 p.m. The resident was observed in bed with her nasal cannula out of her nose lying on her chest. QMA 10 educated the resident at that time; she needed the nasal cannula in her nose to receive the oxygen. QMA 10 assisted the resident with placement of the nasal cannula in her nose. The resident's oxygen concentrator was observed on five liters of oxygen. QMA 10 indicated the resident should be on two liters of oxygen not five liters of oxygen. QMA 10 was unable to control the oxygen levels on the oxygen concentrator. QMA 10 would notify the nurse. Then, she left the resident's room and continued to administer medications to other residents. There was no observation of QMA 10 reporting to the nurse that the resident was receiving oxygen inconsistent with the physician's orders. An observation was conducted of Resident E with Nurse Consultant (NC) 12 on 4/21/25 at 7:35 p.m. The resident was in bed wearing her nasal cannula in her nose. The oxygen concentrator was set on five liters. After reviewing the resident's oxygen order, NC 12 indicated the resident should be on two liters. She then titrated the oxygen down to two liters and assessed the resident's oxygen saturations. An oxygen therapy procedure was provided on 4/23/25 at 4:42 p.m. It indicated .Verify resident and physician order . 3.1-47(a)(6)

2. The clinical record for Resident J was reviewed on 4/22/25 at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The admission MDS assessment, dated 3/24/25, indicated Resident J was cognitively intact. A care plan, dated 3/20/25, indicated Resident J was at risk for pain related to cellulitis of right lower limb, cellulitis of left lower limb, chronic venous hypertension with ulcer and inflammation of bilat [bilateral] lower extremity, chronic kidney disease, HTN [hypertension], anemia in other chronic disease, localized edema. A physician order, dated 3/21/25, indicated the resident was to receive 5-325 milligrams of hydrocodone as needed every 12 hours. An interview was conducted with Resident J on 4/22/25 at 11:18 a.m. She indicated there were long delays in receiving pain medication. She had to wait 30 minutes to an hour, at times, to receive pain medication after she had requested them. An interview was conducted with Resident J on 4/23/25 at 9:57 a.m. She indicated she was in pain and had requested two staff members that had previously come into her room for pain medication. She had started asking for pain medication between 8:00 a.m. and 9:00 a.m. that morning. The resident indicated her pain level was a four utilizing a pain scale of one being the least amount of pain to ten being the most amount of pain. She would like pain medication to relieve her pain. An observation and interview were conducted with LPN 25 on 4/23/25 at 10:01 a.m. LPN 25 was observed administering medications to other residents at that time. She indicated she was made aware by the Certified Nurse Aides (CNAs) that Resident J requested for pain medication. At 10:08 a.m., LPN 25 went into Resident J's room and spoke with her about her pain. 3.1-37(a) Based on observation, interview, and record review, the facility failed to provide adequate pain control for 2 of 2 residents reviewed for pain medication. (Resident D and Resident J) Findings include: 1. The clinical record for Resident D was reviewed on 4/24/25 at 4:08 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, completed on 3/5/25, indicated she was cognitively intact. A physician's order, dated 3/4/25, indicated to administer Tylenol 1000 milligrams (mg) every six hours as needed for pain. During an interview with Resident D on 4/21/25 at 7:07 p.m., she indicated she asked Licensed Practical Nurse 5 (LPN 5) for Tylenol at 3:00 p.m. She indicated she was still waiting for LPN 5 to administer the requested Tylenol. An observation was conducted of an interview with LPN 5 with Nurse Consultant (NC) 13 on 4/21/25 at 8:20 p.m. LPN 5 indicated he had not gotten to Resident D's medication pass at that time. He was in the process of preparing medication for Resident D's roommate. NC 13 requested LPN 5 to stop with roommate's medication pass and administer Resident D's Tylenol. LPN 5 administered two, 500 mg tablets of Tylenol by mouth to Resident D. An interview was conducted with NC 13 on 4/21/25 at 8:25 p.m. She indicated the medication should be administered shortly after it was requested.

Based on interview and record review, the facility failed to timely document behaviors and to initiate new interventions to the plan of care for a resident with dementia with behaviors of wandering and urinating in inappropriate places for 1 of 2 residents reviewed for accidents. (Resident H) Findings include: 1a. The clinical record for Resident H was reviewed on 4/22/25 at 2:40 p.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance, Alzheimer's disease, and anxiety. A Quarterly Minimum Data Set (MDS) assessment, completed 2/24/25, indicated Resident H was severely cognitively impaired, was able to ambulate 150 feet in the corridor with supervision of staff, and was occasionally incontinent of urine. 1b. The clinical record for Resident 41 was reviewed on 4/23/25 at 2:00 p.m. The diagnoses included, but were not limited to, borderline personality disorder. A Quarterly MDS assessment, dated 9/16/24, indicated Resident 41 was cognitively intact. Resident H's clinical record contained a progress note, dated 1/29/25, which indicated Resident H had displayed the behavior of exit-seeking and attempting to exit the kitchen door. The intervention used was to allow staff to walk outside with him to get some fresh air. The root cause was determined to be that Resident H was demented and fixated on going home. The intervention was to decrease access to the culinary department. A Provider progress note, dated 2/20/25, indicated Resident H had been seen for a comprehensive visit. He was less focused on getting out of the facility. The psychiatric provider had recently increased his Depakote (medication for seizures and mood stabilization) with effectiveness. A Social Service progress note, dated 3/3/25, indicated Resident H was followed up with regarding a negative verbal interaction with a fellow resident and daughter. Resident H did not recall the interaction and was going about his daily routine. During an interview on 4/22/25 at 10:31 a.m., Resident 41 indicated that within the last year, he entered his room and found Resident H sitting on his bed. Resident 41 had got angry, yelled, and swore at him to get out of his bed. Resident H stood up and staff came in to assist Resident H back to his own room. Resident 41 was mad because Resident H had done this before, and wanted his sheets changed because of Resident H's incontinence. Resident 41 had told a CNA (certified nurse aide) and the Weekend Supervisor about the incident. A care plan, last reviewed on 4/22/25, indicated Resident H may intrusively wander when looking for the bathroom, dining room or the porch. Resident has cognitive impairment related to Alzheimer's disease. The goal was for him to be easily redirected. The interventions, initiated on 9/25/23, were to redirect the resident to his room after meals, when looking for bathroom, and for staff to ask him if he was looking for bathroom, activity room, and to redirect the resident. A care plan, last reviewed on 4/22/25, indicated Resident H experienced the following behavior expressions of urinating in various places in the room and hallway due to his dementia. The goal was for him to not experience lasting distress, would not cause distress to others, and would not cause harm to self or others. The interventions, initiated on 8/21/24, were to assist with and offer routine toileting and to address any immediate needs such as hunger, thirst, pain, boredom, loneliness, or tiredness. A care plan, last reviewed on 4/22/25, indicated Resident H was at risk for intrusive wandering and exit seeking. He needed decreased access to the culinary department when not in service due to the resident attempting to exit the building via culinary exit doors and that resident was fixated on the need to go home. The goal was for him to be easily redirected. The interventions, initiated on 9/5/23, was for staff to assist in taking the resident outside during appropriate weather and as needed, assist him to his own room, and to assess for unmet needs. During an interview on 4/24/25 at 10:48 a.m., the Weekend Supervisor (WS) indicated Resident 41 had told her about the incident of Resident H lying in his bed several weeks ago. Resident 41 was upset about the incident because Resident H frequently wandered into other residents' rooms. Resident H definitely wanders; he had walked into other rooms before. Resident H had used other residents' bathrooms and sat on other beds because he was confused. The WS had suggested using stop signs on doors to deter Resident H from entering other residents' rooms. During an interview on 4/24/25 at 12:47 p.m., the Director of Nursing (DON) indicated she could not recall stop signs being suggested as an intervention for Resident H's wandering behaviors. Resident H did wander but was easily redirected. The DON had not heard of any other residents having issues with Resident H's wandering because he was pleasant and easily redirected. During an interview on 4/25/25 at 1:45 p.m., the Social Service Director (SSD) indicated there had been an incident between Resident H and Resident 41, a couple of weekends ago. She was unaware of the negative interactions Resident H had experienced that was referenced in the 3/3/25 progress note. Resident H did wander and would walk by his door at times. There had not been any new interventions attempted to make his room more identifiable for him. If a resident has a known behavior, the nursing staff should document the behavior using a behavior communication note. New or worsening behaviors should be documented using a New or Worsening Behavior Event. The facility held monthly behavior meetings, but the behavior communication notes were not always reviewed in the meeting. Resident H's clinical record did not contain information about Resident H wandering into Resident 41's room and lying in his bed. His plan of care had not been updated with new interventions such as the use of stop signs. There was no stop signs observed on any of the residents' rooms. On 4/23/25 at 4:43 p.m., the Executive Director provided the Behavior Management Policy, last revised in August 2022, which indicated .It is the policy of . to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non-pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and /or accommodating a resident's behavioral expressions .When a behavioral expression occurs, the staff communicates to the nurse what behavior occurred. The nurse records the behavior in Matrix. If the behavioral expression is new, worsening, or high risk, the nurse will record the behavior using the New/ Worsening Behavior Event. New or worsening behaviors are reviewed by the IDT [Interdisciplinary Team] for assessment and preventative actions. New/Worsening Behaviors include .Behaviors that had potential for risk to others including sexual advances, intrusive wandering, exit seeking .The IDT review is a discussion with the team as to the behavioral expression, an evaluation of interventions, presentation of new interventions if applicable and an assessment of any underlying causes of the behavior .If the behavioral expression is not new, worsening or high risk; the nurse will record the behavior in the progress notes using the Behavior Communication Note. The IDT will review progress notes the next business day to determine if immediate follow up action is required for the behavior communication. If the behavior requires an interdisciplinary response as described above, the IDT will complete the IDT behavior review. If not, the plan of care will be reviewed and updated if needed to include a description of the behavior and effective interventions . Resident with documented behaviors will have a Behavioral Health Monthly Review . 3.1-37(a)

Based on interview and record review, the facility failed to timely follow-up on pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. (Resident B) Findings include: A. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, completed 1/20/25, indicated she was cognitively intact. A pharmacy recommendation, dated 2/19/25, indicated the discontinuation of fenofibrate (used together with a proper diet to reduce and treat high cholesterol and triglyceride [fat- like substance] levels in the blood) 54 milligrams (mg) daily. If medication was discontinued a fasting lipid panel was to be collected at the 4-week mark and every 12 months. On 2/29/25 the Doctor of Medicine (MD) signed the pharmacy recommendation in agreement to discontinue fenofibrate and lab recommendations. The MD ordered a fasting lipid panel to be drawn on 3/3/25. A physician's order, dated 2/19/25, was noted for a lipid panel lab draw for 3/3/25. The facility was unable to provide results of this lab being completed. B. The Executive Director (ED) provided a copy of Resident B's urology notes, dated 8/2/24, on 4/25/25 at 9:12 a.m. The notes indicated . UA [urine analysis] today clear- she is currently in rehab setting- sill [sic] start suppressive PO [by mouth] abx [antibiotic] with macrodantin [nitrofurantoin] - convert to self-start therapy with Bactrim once she returns home. f/u [follow up] in about 6 months . A physician's order, dated 8/5/24, was noted for nitrofurantoin 50 milligrams (mg) once a day. The order was discontinued on 12/3/24. An email from the urologist, dated 10/3/24, was received from the ED on 4/25/25 at 9:12 a.m. The email indicated Resident B's insurance would not cover nitrofurantoin but would cover trimethoprim. A physician's order, dated 10/11/24, was noted for trimethoprim 100 mg once a day with no end date recorded. A pharmacy recommendation, dated 11/20/24, indicated .Please discontinue nitrofurantoin and trimethoprim while monitoring for signs and symptoms of recurrent UTI [urinary tract infection]. If prophylactic therapy should not be discontinued, please document the intended duration of therapy or stop date . On 11/20/24, the MD signed the document with the recommendation to refer to urology for management. During an interview with the Director of Nursing (DON) on 4/25/25 at 10:15 a.m., she indicated the resident did not go to the urology appointment in February of 2025. Resident B was on a prophylactic antibiotic but could not recall if urology was consulted about a rationale for continuation of the antibiotic. She could not explain why Resident B was on two prophylactic antibiotics at the same time. A policy entitled Antibiotic Stewardship Program, review date of 1/2023, was provided by the ED on 4/25/25 at 2:30 p.m. The policy indicated .Policy: The facility shall establish key elements for antibiotic prescribing and a system to monitor and manage antibiotic use. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.Procedure: The facility will establish an antibiotic stewardship team (AST) . 1. The AST will explore quality improvement and resident safety for opportunities that could incorporate antibiotic stewardship activities. 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure open and/or expiration dates were on insulin medication for 1 of 3 medication carts observed. (Resident 7, Resident 22, and Resident F) Findings include: 1. The clinical record for Resident 7 was reviewed on 4/22/25 at 11:30 a.m. The diagnoses included, but were not limited to, diabetes mellitus. A physician order, dated 9/4/24, indicated the staff was to administer 18 units of Novolin (intermediate-acting insulin) twice a day. 2. The clinical record for Resident F was reviewed on 4/22/25 at 11:45 a.m. The diagnoses included, but were not limited to, diabetes mellitus. A physician order, dated 3/11/25, indicated the staff was to administer 24 units of Humalog (fast acting insulin) three times a day. 3. The clinical record for Resident 22 was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A physician order, dated 4/18/25, indicated the resident was to receive a sliding scale of lispro insulin (fast acting insulin) three times a day. An observation was conducted of a medication cart with Registered Nurse (RN) 24 on 4/25/25 at 11:06 a.m. During that time, Resident 7's Novolin insulin, Resident F's Humalog insulin, and Resident 22's lispro insulin did not have a written open or expiration date. An interview was conducted with RN 24 on 4/25/25 at 11:10 a.m. She indicated the insulin medication should have open dates. A medication storage policy was provided by the Executive Director on 4/25/25 1:09 p.m. It indicated .Purpose of Policy: To provide guideline and procedure on the storage and expiration dates of medications . Procedure . 7. Medications should have an expiration date on the label . 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by utilizing hand hygiene prior to administering eye drop medications and to follow infection control practices by not timely removing feces and urine from a bedside table, and failure to wear a gown while disposing of bodily fluids for a resident in Enhanced Barrier Precautions for 2 of 7 residents observed during medication administration and 1 of 1 resident observed for Enhanced Barrier Precautions. (Resident H, Resident 29 and Resident 27) Findings include: 1. The clinical record for Resident H was reviewed on 4/21/25 at 6:30 p.m. The diagnoses included, but were not limited to, glaucoma (eye condition that damages optic nerve). A physician order, dated 4/17/25, indicated the resident was to receive one drop of timolol eye drops in both eyes twice a day. An observation was conducted of eye drop administration to Resident H with Qualified Medication Aide (QMA) 10 on 4/21/25 at 6:35 p.m. QMA 10 was observed at the medication cart pulling the medications for Resident H. During that time, QMA 10 touched the mediation cards, water cups, water pitcher, the medication cart drawers and keys. After, she entered the resident's room and administered the pill medications to the resident. She then administered the eye drops. There was no observation of hand hygiene prior to the administration of the medications nor the eye drops. 2. The clinical record for Resident 29 was reviewed on 4/21/25 at 6:57 p.m. The diagnoses included, but were not limited to, hypertension. A physician order, dated 4/8/25, indicated the resident was to receive two drops of Lumigan eye drops in both eyes at bedtime. An observation was conducted of eye drop administration to Resident 29 with QMA 10 on 4/21/25 at 6:57 p.m. QMA 10 was preparing and pulling medications at the medication cart for Resident 29. She was observed touching medication cards, keys, medication cart drawers, water cups and water pitcher. She then went into the resident's room. QMA 10 touched the resident's bedside table during the pill medication administration. After, she administered the eye drops to the resident by pulling the resident's bottom eye lid down. There was no observation of hand hygiene prior to administration of the resident's medications nor eye drops. An interview was conducted with QMA 10 on 4/21/25 at 7:26 p.m. She indicated she was unsure if she should wear gloves to administer eye medications, but she should utilize hand hygiene. An interview was conducted with the Director of Nursing on 4/24/25 at 12:17 p.m. She indicated the staff should be utilizing hand hygiene prior to the administration of eye drops. 3. Resident 27's clinical record was reviewed on 4/22/25 at 11:45 a.m. The diagnoses included, but were not limited to, human immunodeficiency virus (HIV), viral hepatitis B, Crohn's disease, and colostomy status (an externally connected bag to collect stool from the intestines). A Minimum Data Set (MDS) assessment, dated 3/6/25, indicated the resident was cognitively intact. A care plan, initiated on 2/21/25, indicated the resident required assistance and/or monitoring of morning and evening care, nutrition, hydration, and elimination. A care plan, initiated on 3/24/25, indicated the resident preferred to keep his urinal and colostomy containers at the bedside and he refused to allow staff remove them or clean his bedside table. It indicated Resident 27 had been educated on the potential hazards of having bodily fluids in containers next to food containers. A care plan, initiated on 2/23/25, indicated the resident required assistance with ADLs (activities of daily living) including eating and toileting. A care plan, initiated on 2/28/25, indicated the resident is at risk of transferring or becoming colonized with an MDRO [multidrug resistant organism] and requires enhanced barrier precautions due to an indwelling medical device, a chronic wound that requires a dressing, or colonization or infection with a MDRO in which contact precautions do not apply. A care plan approach, initiated on 2/28/25, indicated staff were to wear gowns and gloves prior to high contact resident care activities. An event report, dated 3/23/25, noted Res [Resident] empty [sic] colostomy bag inside of cups and cylinders and leave them on bedside table along with urine. res is able to use restroom but refuses to get up .staff asked res to use restroom and empty colostomy bag or feces into trash bag .educate resident on emptying bag into toilet or biohazardous bag. A resident progress report, dated 3/24/25, indicated Resident 27 had a behavior of storing urine and feces on his bedside table in cylinders because he had a preference of keeping track and recording his outputs. Nursing staff was to offer to record output and discard the waste. An event report, dated 3/27/25, noted res [resident] is able to ambulate to restroom but refuses to [sic] res has cylinders of urine and feces sitting at bedside table wanting staff to empty them for him .staff encouraged resident to use urinal or restroom and to empty bags into a trash/biohazard bag and secure the bag. On 4/21/25 at 7:51 p.m., Resident 27 was observed lying in bed with two open containers full of liquid stool sitting on his bedside table next to him, along with a urinal filled with dark yellow liquid. He had a colostomy bag attached to his abdomen which had liquid stool in it. A pizza box was sitting in a wheelchair next to the bed. Resident 27 was interviewed on 4/21/25 at 7:51 p.m. He indicated he emptied his own colostomy bag into the containers. Sometimes he emptied the containers himself but would also ask staff to empty them. On 4/21/25 at 7:55 p.m., the Nurse Consultant (NC) was notified about the containers of stool present on Resident 27's bedside table. She entered his room, performed hand hygiene and donned gloves. She grabbed one of the containers and took it to the restroom to dump it. She did not put on a gown. Resident 27 was interviewed on 4/22/25 at 11:09 a.m. He indicated he was okay with the state of his room. It would be nice if the staff came in and cleaned more. A hand hygiene policy was provided by the Executive Director on 4/23/25 at 4:42 p.m. It indicated Purpose of Policy: To provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganisms on the hands of all employees .5. Moments of hand hygiene .Before touching a resident .After touching a resident .After touching resident surroundings . A facility policy titled Enhanced Barrier Precautions, revised 3/2025, noted the purpose was to reduce transmission of multi-drug resistant organisms by wearing gown and gloves during high contact resident care activities with all residents who are at higher risk of acquiring or spreading an MDRO .Enhanced Barrier Precautions expands the use of PPE [personal protective equipment] beyond situations in which exposure to blood and bodily fluids is anticipated, it refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to promote a homelike environment for 3 of 5 residents reviewed for environment (Residents L, 9, and 17). Findings include: An observation was made on 4/21/25 at 7:49 p.m. The blinds in Resident L's room were broken. An observation was made on 4/22/25 at 9:41 a.m. Resident 9's room smelled strongly like urine and there was an area of scraped paint on the wall behind the bed. An observation was made on 4/22/25 at 10:14 a.m. The blinds in Resident 17's room were broken. In an interview with Resident 17, on 4/25/25 at 1:18 p.m., he indicated the broken blinds bothered him, especially when he had company, and they had been that way for three years. A walk-through tour was conducted with the Maintenance Supervisor (MS) and Housekeeping Supervisor (HS) on 04/25/25 at 1:10 p.m. During the tour, Resident L and Resident 17's blinds were broken. Resident 9's room smelled like urine and the paint on the wall was scraped. The MS was interviewed on 4/25/25 at 1:14 p.m. He indicated he was aware of the broken blinds in Resident 17 and Resident L's rooms, and they were on his list to be repaired. He had one box of blinds in his office and needed to order more but had to wait to see what next month's budget looked like. He was already aware of the scraped paint on the wall in Resident 9's room and needed to find the correct shade of paint for the repair. He expected to complete the work within the next few weeks. He was not able to provide any documentation or work orders. The HS was interviewed on 4/25/25 at 1:16 p.m. He indicated housekeeping staff were aware of the urine odor in Resident 9's room and they cleaned and mopped it daily. They would also spray an odor eliminator in the room daily. He thought the resident's mattress was the source of the odor and needed replaced. Nurse Consultant (NC) 13 was interviewed on 4/25/25 at 3:23 p.m. She indicated the facility did not have a specific policy for a homelike environment. A policy titled Resident Rights, dated 11/2015, indicated Each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs .the Resident has a right to a dignified existence, self-determination and communication with, and access to, persons and services inside and outside the Facility . 3.1-19(f)(5) 3.1-19(k) 3.1-19(l)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' respect and dignity were maintained for 2 of 3 residents reviewed for dignity, 3 of 8 resident interviews in abuse investigations, and 3 residents randomly observed during dining. (Resident B, D, F, J, K, L, M, and N) Findings include: 1. The clinical record for Resident J was reviewed on [DATE] at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident J was cognitively intact. An interview was conducted with Resident J on [DATE] at 11:18 a.m. She indicated the staff were disrespectful during care. The staff needed training to not rush during care. They were rushing and jerk you around. It was rough, but not abusive. 2a. The clinical record for Resident D was reviewed on [DATE] at 12:00 p.m. The diagnoses included, but were not limited to, depression. The Quarterly MDS assessment, dated [DATE], indicated Resident D was cognitively intact. 2b. The clinical record for Resident K was reviewed on [DATE] at 1:00 p.m. The diagnoses included, but were not limited to, hypertension. The Annual MDS assessment, dated [DATE], indicated Resident K was cognitively intact. An abuse investigation into a reportable incident, dated [DATE], was provided by the Corporate Executive Director on [DATE] at 10:55 a.m. The file included, but was not limited to, the following documentation: A statement by Resident D indicating the staff during care handled her roughly. A statement by Resident K indicated the staff were rough during care at times. On one occasion, it felt like the staff person was digging her nails in his skin during incontinent care. An interview was conducted with Resident K on [DATE] at 10:26 a.m. He indicated Certified Nurse Aide (CNA) 2 was having a bad day. She at times has had an attitude. There was a time, CNA 2 was wiping him so fast during incontinent care; she dug her nails in his skin. 5a. The clinical record for Resident M was reviewed on [DATE] at 12:25 p.m. The diagnoses included, but were not limited to, dementia. 5b. The clinical record for Resident L was reviewed on [DATE] at 12:25 p.m. The diagnoses included, but were not limited to, dementia. 5c. The clinical record for Resident N was reviewed on [DATE] at 12:25 p.m. The diagnoses included, but were not limited to, dysphagia (inability to swallow). On [DATE] at 12:25 p.m., lunch service in the main dining room was randomly observed. Resident L, Resident M, and Resident N had facility tablecloths folded and tied around their necks while sitting and waiting for their meals. During an interview on [DATE] at 12:26 p.m., the Minimum Data Set Coordinator indicated she was unsure why table clothes were being used as clothing protectors. During an interview on [DATE] at 12:37 p.m., the Nurse Consultant indicated the facility had clothing protectors available to be used in the dining room. An interview was conducted with Nurse Consultant 13 on [DATE] at 1:04 p.m. She indicated the staff were expected to treat the residents respectfully. A policy titled Resident's Rights, dated 11/2015, noted Each resident shall be treated with consideration, respect, and full recognition of his dignity, and individuality .the Resident has a right to a dignified existence, self-determination and communication with, and access to, persons and services inside and outside the Facility . This citation relates to Complaint IN00456672. 3.1-3(a) 3.1-3(t) 3.1-3(v)(1) 4. The clinical record for Resident B was reviewed on [DATE] at 12:00 p.m. The diagnoses included, but were not limited to, stroke. The Quarterly MDS assessment, dated [DATE], indicated Resident B was cognitively intact. During an interview with Resident B on [DATE] at 6:50 p.m., she indicated the staff would come in and yell at her because she pressed the call light at the wrong time. 3. The clinical record for Resident F was reviewed on [DATE] at 3:54 p.m. The diagnoses included, but were not limited to, anxiety, panic disorder, post-traumatic stress disorder, depression, borderline personality disorder, and schizoaffective disorder. An MDS assessment, dated [DATE], indicated Resident F was cognitively intact. An interview was conducted with Resident F on [DATE] at 3:38 p.m. She indicated she was treated differently because she was more able-bodied. CNA 2 had a poor attitude and demeanor. She was not polite and never smiled. Resident F had to make her own bed because CNA 2 would not do it. She had a hard time getting laundry done because staff said she can do it herself. She was made to put her laundry in a bag and put it by the door by some staff and others told her differently. A grievance was filed by Resident F on [DATE]. She indicated CNA 2 always picked on her and told her to make her own bed. If Resident F didn't like the meal that was served or wanted seconds, CNA 2 told her to go get it herself and she didn't like taking care of a resident who can do things herself. Resident F would request ice water and CNA 2 would bring half a cup of water to upset her. CNA 2 knew Resident F had a history of mental illness and would pick on her to upset her. She reported CNA 2 several times in the past and requested that CNA 2 no longer care for her. An interview was conducted with CNA 2 on [DATE] at 9:52 a.m. She indicated she had received abuse training and resident rights training. She regularly took care of Resident F who didn't need assistance with anything and did her own ADLs (activities of daily living). CNA 2 would strip her bed, and the resident would make it. She also brought the resident ice and water when she asked. Their relationship was fine until several months ago when CNA 2 stopped doing hair and nails for the residents, but Resident F wanted CNA 2 to continue to bring beauty supplies. After this, Resident F would get flustered and aggravated due to her mental illness and make smart comments which CNA 2 would ignore. She wasn't sure if the resident asked to have a different CNA or if the facility re-assigned her to keep the peace.

Based on observation, interview, and record review, the facility failed to ensure food was served at palatable temperatures for 4 of 4 residents reviewed for food and 14 of 54 residents that attend resident council. (Residents' B, D, 22, J, K, 33, 28, 13, 31, 4, G, H, 25, 23, E, 41, 6, and 48) Findings include: 1. The clinical record for Resident J was reviewed on 4/22/25 at 11:30 a.m. The diagnoses included, but were not limited to, cellulitis. The admission Minimum Data Set (MDS) assessment, dated 3/24/25, indicated Resident J was cognitively intact. An interview was conducted with Resident J on 4/22/25 at 11:18 a.m. She indicated the food was served cold. 2. The April 2025 resident council minutes were provided by the Activities Director on 4/23/25 at 9:31 a.m. The resident attendees were the following: Residents' 6, 23, H, 33, 41, 13, 25, 28, and G. The council indicated the food temperatures were not appropriate. During a resident council meeting on 4/23/25 at 11:05 a.m., the council attendees were the following: Residents' K, 33, 28, 13, 31, 4, G, H, 25, 23, E and 48. The council indicated the food was served cold. 3. The clinical record for Resident G was reviewed on 4/22/25 at 12:20 p.m. The diagnoses included, but were not limited to, liver transplant and major depressive disorder. A Quarterly MDS assessment, dated 3/24/25, indicated Resident G was cognitively intact. During an interview on 4/22/25 at 12:12 p.m., Resident G indicated the food was often served cold. He had received meals that were ice cold. He had filed grievances about the food, but it did not seem to get any better. 4. The clinical record for Resident 22 was reviewed on 4/23/25 at 10:34 a.m. The diagnoses included, but were not limited to, acute respiratory failure. A Quarterly MDS assessment, completed 2/22/25, indicated she was cognitively intact. During an interview on 4/21/25 at 6:33 p.m., she indicated the eggs were awful and cold. 5. The clinical record for Resident D was reviewed on 4/24/25 at 4:08 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly MDS Assessment, completed on 3/5/25, indicated she was cognitively intact. During an interview on 4/21/25 at 7:21 p.m., she indicated meals were not consistent, sometimes they were good, and other times they were not. Resident D indicated breakfast was usually the best meal, and the rest go downhill from there. 6. The clinical record for Resident B was reviewed on 4/22/25 at 12:00 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly MDS assessment, completed 1/20/25, indicated she was cognitively intact. During an interview with Resident B on 4/21/25 at 6:58 p.m., she indicated the food could use improvement. During an observation and interview on 4/24/25 at 12:45 p.m., the Regional Culinary Manager 3 (RCM 3) brought a test tray into the conference room. The temperatures were obtained by RCM 3, using the dietary department's thermometer. The tenderloin sandwich was 126.3 degrees Fahrenheit, the baked beans were 153 degrees Fahrenheit, and the pears were 50.7 degrees Fahrenheit. RCM 3 indicated the temperature for the tenderloin sandwich was below the proper holding temperature, and the pears were above the proper holding temperature. 3.1-21(a)(2) 3.1-21(i)(2)

A. Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and in good repair, the staff contained their hair in the kitchen, and food was not open to air, labeled, dated and not expired. This had the potential to affect 54 of 54 residents that eat food prepared in the facility kitchen. B. Based on observation, interview, and record review, the facility failed to cover trash cans when not in use in the kitchen with the potential to affect 54 or 54 residents who receive food out of the facility kitchen. Findings include: A. On 4/21/25 at 6:25 p.m., the facility kitchen was observed with Dietary Aide (DA) 15. The walk- in refrigerator was observed to have a metal can of butterscotch pudding with a piece of plastic wrap covering the open can. The can did not contain a date on which it was opened. There was an undated plastic storage container of macaroni and cheese, an undated jar of beef base, an undated bottle of orange juice and grape juice which were half empty, an undated container of ranch and Caesar salad dressing, an undated jar of pickle relish, a bag of pre-made scrambled eggs with no date, an undated plastic storage container of peaches, plastic wrapped open containers of deli ham, American cheese, and deli turkey with no open dates. There was a package of pepperoni that was open to air with no open date. There was a tray containing small bowls of peaches and a tray containing small bowls of mandarin oranges which were open to air and undated. There was a tray containing a thawed ground beef roll with red liquid present on the tray that was undated. There was a tray with a bag of thawed chicken that was present with no date. The dry storage area was observed to have a storage bin of oats with no lid and a package of blueberry muffin mix labeled open 3/11/25 and use by 4/10/25. The floor of the dry storage area had a sticky substance present on it. During an interview on 4/21/25 at 6:50 p.m., DA 15 indicated the kitchen floor had been that way since she started. She had worked at the facility for a week and a half. She was not sure why the food items were not covered. She had not been instructed on dating items. She had been shown how to use the date label maker. On 4/23/25 at 12:10 p.m., lunch service was observed in the facility kitchen. DA 17 was observed at the tray line setting up trays with silver wear and placing small bowls of grapes on trays. He had a growth of hair on his upper lip and chin. His beard net was around his neck and not covering his beard. DA 17 indicated his beard net should be in place over his facial hair while he was serving food. During an interview on 4/23/25 at 1:45 p.m., the Dietary Manager (DM) indicated items in the refrigerator should be labeled and dated with the date opened and a discard date. Food items should be covered while in the refrigerator. The items identified on 4/21/25 had been disposed of. The floor in the dry storage area was sticky. The staff had mopped the floor, and she was unsure why it was still sticky. Staff with facial hair should wear beard nets while preparing and serving food. On 4/23/25 at 2:58 p.m., the Corporate Executive Director provided the Food Storage Policy, last reviewed May 2023, which indicated .Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored at appropriate temperatures and by methods designed to prevent contamination .Leftover prepared foods and processed meats such as lunchmeat, are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded. Leftover foods can be held at 41 degrees F [Fahrenheit] or less for no more than 3 days. The day the food was prepared shall be counted as Day 1 .Food items that are not considered potentially hazardous including, commercially prepared mayonnaise, salad dressing, mustard, ketchup, BBQ sauce, pickles, and pickle relish will be labeled when opened and, to ensure quality, used or disposed of within 90 days of the opening or per the use-by-date, whichever comes first. Follow the manufacturer's directions regarding the need to refrigerate after opening in order to preserve quality. The day the original container is opened shall be counted as day 1 .Dry Storage . All foods shall be covered or wrapped tightly, labeled, and dated. On 4/23/25 at 2:58 p.m., the Corporate Executive Director provided the Culinary Personal Hygiene Policy, last revised May 2024, which indicated .Culinary employees with facial hair must also wear a beard restraint . B. On 4/21/25 at 6:25 p.m., the facility kitchen was observed with Dietary Aide (DA) 15. The dry storage area was observed to have an unattended busing cart with a trash can attached to the end of the cart. The trash can had food waste visible and there was no lid on the trash can. On 4/23/25 at 12:20 p.m., the dry storage area was observed with the Dietary Manager (DM). An unattended busing cart with a trash can on the end was observed in the dry storage area. The trash can was uncovered and had food substances present in the can. The soiled dish area of the kitchen had an unattended trash can with food items present in the can. The lid to the trash can was sitting beside it. There were no staff using the trash can. During an interview on 4/23/25 at 1:45 p.m., the DM indicated she was unsure if the busing cart trash can had a lid, but the trash bag could have been removed prior to it being placed in the area. The trash can in the soiled dish area should have been covered when not in use. On 4/23/25 at 2:58 p.m., the Corporate Executive Director provided the Kitchen Safety Guidelines, last revised February 2025, which indicated .Plastic liners are to be used inside all trash containers and the containers are kept covered with lids . 3.1-21(i)(2) 3.1-21(i)(3) 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to timely provide assistance with dressing for 1 of 1 resident reviewed for ADL (Acts of Daily Living) care (Resident 6). Findings include: The clinical record for Resident 6 was reviewed on 4/16/24 at 3:21 p.m. The Resident's diagnosis included, but were not limited to, dementia and heart failure. A care plan, initiated 6/16/2020, indicated Resident 6 required assistance with ADL care related to his dementia, heart failure and muscle weakness. The goal was for him to improve current functional status. The interventions included, but were not limited to, assist with toileting and/or incontinent care, start date 6/16/2020, and assist with dressing, grooming, and hygiene as needed. Encourage him to do as much for self as possible, start date 6/16/2020. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/4/24, indicated he had moderately impaired cognition and needed cues and supervision with dressing. On 4/16/24 at 3:21 p.m., Resident 6 was observed sitting in his wheelchair in his room. He was wearing a brown t-shirt and purplish sweatpants with a binder clip attached to the waist band. The sweatpants were not pulled up to his waist and the back of the waist band was around his thighs. He indicated the sweatpants were too big for him. On 4/17/24 at 9:13 a.m., Resident 6 was observed wearing the same sweatpants and t-shirt. On 4/18/24 at 9:20 a.m., Resident 6 was observed wearing the same purplish pants and brown shirt. A blue sweatshirt and a pair of grey sweatpants were laying on the chair in his room. On 4/19/24 at 9:24 a.m., Resident 6 was observed sitting in his room. He continued to wear the same purplish sweatpants with the waist band at his mid-thigh. During an interview on 4/19/24 at 9:36 a.m., CNA (Certified Nursing Assistant) 2 indicated Resident 6 would change his clothing if approached correctly. He was wearing the same clothing as the day before. She would assist him is changing his clothing. 3.1-38(b)(4)

2. The clinical record for Resident 27 was reviewed on 4/16/24 at 2:02 p.m. The Resident's diagnosis included, but were not limited to, constipation, heart failure and chronic kidney disease. A care plan, initiated 12/8/22, indicated Resident 27 was at risk for constipation due to her medications and mobility deficit. The goal was for her to have a soft formed bowel movement at least every 3 days. The approaches included, but were not limited to, notify physician if no bowel movement after 3rd day, initiated 12/8/22, administer medications as ordered, initiated 12/8/22, monitor bowel function, initiated 12/8/22, and abdominal assessment if no BM x 4 days. Document and notify physician of abnormal findings, initiated 12/8/22. A physician's order, dated 3/13/24, indicated she was to receive Dulcolax 5 mg tablet once every 24 hours as needed for constipation. A physician's order, dated 3/14/24, indicated she was to receive Milk of Magnesia suspension 30 milters once a day as needed for constipation. A Significant Change of Status MDS (Minimum Data Set) Assessment, completed 3/20/24, indicated she was cognitively intact and was dependent on staff for toileting. During an interview on 4/16/24 at 2:02 p.m., Resident 27 indicated she did not feel well. She was constipated and it had been at least 3 days since she had a bowel movement. She did not feel like eating. The April 2024 bowel record for Resident 27 was as follows: 4/1/24 at 1:55 a.m.- no bm (bowel movement), 4/1/24 at 6:43 a.m.- small bm, 4/1/24 at 7:58 p.m.- large bm, 4/2/24 at 9:03 p.m.- no bm, 4/3/24 at 9:09 p.m.- no bm, 4/4/24 at 9:37 p.m.- no bm, 4/5/24 at 10:12 p.m.- no bm, 4/8/24 at 6:17 a.m.- no bm, 4/8/24 at 9:24 p.m.- no bm, 4/9/24 at 8:10 p.m.- no bm, 4/10/24 at 7:43 p.m.- no bm, 4/11/24 at 9:04 p.m.- no bm, 4/13/24 at 6:28 a.m.- no bm, 4/14/24 at 10:21 p.m.- small bm, 4/15/24 at 1:52 a.m.- no bm, 4/15/24 at 6:17 a.m.- no bm, 4/16/24 at 4:45 p.m.- large bm, 4/18/24 at 7:33 p.m.- no bm, 4/19/24 at 8:24 p.m.- no bm, 4/20/24 at 6:18 a.m.- no bm, and 4/20/24 at 10:27 p.m.- no bm. The April 2024 MAR (Medication Administration Record) did not indicate that Resident 27 had received any doses of her as needed Dulcolax or Milk of Magnesia during April. During an interview on 4/22/24 at 11:36 a.m., the IPF (Infection Preventionist Float) indicated that normally bowel movement status should be documented each shift. On 4/22/24 at 11:36 a.m., the IPF provided the Bowel Elimination policy, dated 1/2015, which read .It is the policy of . to ensure that each resident maintains a safe and healthy bowel elimination pattern .4. Bowel movements will be recorded on the facility EMR [Electronic Medical Record] and/or record daily by the direct care staff. 5. A resident bowel report will be completed by the assigned charge nurse of resident [s] who have not had a bowel movement for 3 consecutive days. 6. Any resident not having a bowel movement for 3 consecutive days, will be given a laxative or stool softener, as prescribed by the physician, at the end of the 3rd day .8. If by the 4th afternoon, the resident [s] has not had results, the nurse will do an abdominal assessment, chart the results of the assessment, and notify the physician for further order . 3.1-37(a) Based on interview and record review, the facility failed to assess a resident's skin condition; timely clarify the dosage and administration time of a resident's antipsychotic medication; administer insulin as ordered; and monitor frequency of bowel movements for a resident with constipation for 1 of 1 resident review for constipation, 1 of 5 residents reviewed for unnecessary medications, and 1 of 1 resident reviewed for skin conditions. (Residents B and 27) Findings include: 1a. The clinical record for Resident B was reviewed on 4/17/24 at 9:00 a.m. The diagnoses for Resident B included, but were not limited to, type 2 diabetes mellitus, borderline personality disorder, somatization disorder, post-traumatic stress disorder and bipolar disorder. A care plan dated 4/17/24 indicated .Resident is at risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus .Approach .medications as ordered .Monitor blood sugars as ordered . A physician order dated 4/1/24 indicated Resident B was to receive 10 units of lispro insulin prior to meals three times a day. The April 2024 Medication Administration Record (MAR) for Resident B indicated the following days and times the lispro insulin was not administered: 4/4/24 at 8:00 a.m., 4/5/24 at 12:00 p.m., and 5:00 p.m., 4/11/24 at 8:00 a.m., 5:00 p.m., and 4/12/24 at 8:00 a.m., During an interview with Resident B on 4/17/24 at 9:25 a.m., she indicated she does not receive her insulin as often as she should. There are times she misses dosages and does not receive at all. An interview was conducted with the Director of Nursing Services (DNS) on 4/19/24 at 3:34 p.m. She indicated she was unsure why the resident had not received her lispro insulin on 4/4/24, 4/5/24, 4/11/24, and 4/12/24. 1b. A physician order dated 3/23/24 indicated Resident B was to receive 400 milligrams of seroquel at bedtime. A physician order dated 4/1/24 indicated Resident B was to receive 50 milligrams of seroquel twice a day. A psych visit note dated 4/3/24 for Resident B indicated .Staff has reported that she has made multiple false accusations against the facility staff. This clinician discussed her case with collaborating physician, who believes that her behaviors are due to her borderline personality disorder and somatization disorder .Antipsychotic use .Seroquel dosage/route/: 450 mg [milligrams] po [by mouth] qhs [every night] and 50 mg daily. A medical provider visit note dated 4/4/24 indicated Resident B was to receive 400 milligrams of seroquel at night and 50 milligrams of seroquel in the morning and afternoon. The April 2024 Medication Administration Record (MAR) indicated the resident was to receive 50 milligrams of seroquel at 9:00 a.m., and 1:00 p.m. The resident was to receive 400 milligrams of seroquel at bedtime. An interview was conducted with the DNS on 4/19/23 at 11:46 a.m. She indicated she will contact the pysch provider to clarify the dosage and administration time of Resident B's seroquel medication. 1c. An interview was conducted with Resident B on 4/17/24 at 9:25 a.m. She indicated she has an area on her stomach that was opened, and she needs a dressing applied. The staff are not addressing it. A physician order 4/3/24 indicated staff was to Cleanse area to umbilicus twice a day. Keep area as clean and dry as possible. The April 2024 Treatment Record indicated the staff were cleansing the area twice a day. The resident's clinical record did not include assessments of an area on her umbilicus. The weekly skin assessments dated 4/3/24 and 4/10/24 did not indicate the resident had any skin altercations. A wound management note dated 4/17/24 indicated the resident had an old biopsy site reopen. The location of the skin area was the umbilicus. The measurements 1 centimeter in length and 1 centimeter in width with a depth of 0.5 centimeters. The area had bloody drainage. An interview was conducted with the DNS on 4/19/23 at 11:46 a.m. She indicated she did not know the reason why there was an order placed on 4/3/24, to cleanse Resident B's umbilicus twice a day. She was unable to locate any skin assessments that included the staff assessing the area on her umbilicus prior to 4/17/24. A skin management policy was provided by the Infection Preventionist Float on 4/22/24 at 11:47 a.m. It indicated .Procedure for wound prevention: .6. any skin altercations noted by the direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The license nurse is responsible for assessing all skin altercations by the direct caregivers on the shift reported .

Based on observation, interview, and record review, the facility failed to provide oral care, as ordered by the physician, and to timely obtain a physician's order to provide gastrostomy tube site care for 1 of 1 resident reviewed for tube feeding (Resident 23). Findings include: The clinical record for Resident 23 was reviewed on 4/16/24 at 2:40 p.m. The Resident's diagnosis included, but were not limited to, dysphagia (inability to swallow), aphasia (inability to speak), and gastrostomy (g-tube). A care plan, initiated 11/8/2018, indicated Resident 23 was at risk for complications related to enteral feedings. The goal was for him to be free from complications related to enteral feeding. The approaches included, but were not limited to, cleanse around site as ordered, initiated 11/8/2018, and elevate head of bead, initiated 11/08/2018. A physician's order, dated 1/28/2021, indicated to provide oral care every shift. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/28/24, indicated his long- and short-term memory was intact. He was independent with decision making and was dependent on staff for oral hygiene. On 4/16/24 at 2:40 p.m., Resident 23 was observed laying in his bed with his g-tube visible. There was dried brown drainage present on the base of his g-tube. His mouth had a white film present on his teeth and lips. On 4/18/24 at 12:04 p.m., Resident 23's g-tube site was observed with LPN (Licensed Practical Nurse) 3. LPN 3 removed an undated drainage sponge from Resident 23's g-tube site. LPN 3 indicated the g-tube site was care for on the night shift daily. The ostomy site had a brown dried crust at the base of the tube. Resident 23 indicated he had drainage at his g-tube site often by shaking his head yes and putting his thumb up. He indicated that his g-tube site was not cleansed each night by shaking his head no. Resident 23's mouth had a white film present on his teeth and lips. On 4/18/24 at 2:02 p.m., Resident 23 was observed with LPN 3. LPN 3 indicated that oral care was provided each shift by either the nurse or the certified nursing assistants. The bedside table drawers were observed to have an unopened toothbrush in a plastic wrapper. There were no oral swabs present in the bedside table. LPN 3 indicated that Resident 23 was in need of oral care. Resident 23 indicated that mouth care was not provided each shift by shaking his head no and indicated that he would like to have oral care done each shift by putting his thumb up and shaking his head yes. During an interview on 4/18/24 at 2:17 p.m., the DNS (Director of Nursing Services) indicated that Resident 23's medical record did not contain an order for g-tube site care and that oral care should be done as ordered by the physician. On 4/18/24 at 2:19 p.m., the DNS provided the Enteral Tube Skills Competency, last reviewed 9/2019, which read .enteral Tube- Dressing Change and Site Care . Dressing or site care of enteral tube site should be done at least daily. 3.1-44(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The clinical record for Resident 38 was reviewed on 4/17/24 at 10:00 a.m. The diagnosis for Resident 38 included, but was not limited to, schizophrenia. A care plan dated 9/7/23 indicated Resident gets agitated and will yell and cuss .Approach Encourage resident to do an activity such as bingo .Encourage resident to communicate frustration in a positive way Redirect resident to a calmer and quieter space . A physician order dated 2/8/24 indicated resident was to receive 100 milligrams of zoloft daily. The medication was discontinued on 4/17/24. A physician order dated 3/8/24 indicated resident was to receive 50 milligrams of zoloft totaling 150 milligrams daily. The medication was discontinued on 4/17/24. A social services note for Resident 38 dated 3/12/24 indicated resident had became anger when the Executive Director checked for a missing item in his room per his family request. The resident was upset and cussing. The resident's clinical record did not include any other documented behaviors the resident had in March. A behavior progress note for Resident 38 dated 4/11/24 indicated Date and Time of behavioral expression: 4/11/24 2:40 p.m. Location of expression: hallway, Describe the specific behavioral expression: cursing and using foul language towards staff, Interventions attempted: attempt to determine root cause, Effectiveness of Interventions: not effective, Suggestions/Other information: bx [behavior monitoring] . The resident's clinical record did not include any other documented behaviors the resident had in April. During a resident council meeting on 4/16/24 at 2:00 p.m., Resident 38 was observed upset and left the meeting angry and cussing loudly down the hallway. The resident's clinical record did not include documentation of the incident on 4/16/24. A psych follow up visit note for Resident 38 dated 4/17/24 indicated .He denies difficulty sleeping or changes in appetite. Per staff reports, resident does have episodes of verbal aggression, irritability, and outbursts due to anger .Plan .increase sertraline [Zoloft] to 200 mg [milligrams] daily due to reports of verbal aggression and irritability . A physician order dated 4/17/24 indicated resident was to receive 200 milligrams of zoloft daily. An interview was conducted with Social Services Director on 4/22/24 at 2:39 p.m. She indicated when direct care staff observe residents having behaviors they need to report the behavior to a nurse. The behavior should be documented in the progress notes. If the behavior was new or worsening the staff would open an event in the resident's record. An interview was conducted with Executive Director (ED) on 4/22/24 at 2:27 p.m. She indicated there are occasions Resident 38 exhibits aggression and irritability. There should be documentation in the progress notes if staff observe the resident's behaviors. The staff are not following the facility's behavior management policy. A behavior management policy was provided by the Infection Preventionist Float on 4/22/24 at 2:36 p.m. It indicated .Policy: It is the policy of American Senior Communities to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expressions .Procedure: 3. When a behavioral expression occurs, the staff communicates to the nurse what behavior occurred. The nurse records the behavior in Matrix. 4. If the behavioral expression is new, worsening, or high risk, the nurse will record the behavior using the New/Worsening Behavior Event. New or Worsening Behaviors include: a. Behaviors that are new for the resident, b. Behaviors that are directed at another resident (Note: follow abuse reporting and prohibition protocols), c. Behaviors that are increasing in either frequency or severity, d. Behaviors that have potential for risk to others including sexual advances, intrusive wandering, exit seeking and chronic combativeness with care. The IDT [Interdisciplinary] team is a discussion with the team as to the behavioral expression, an evaluation of interventions, presentations of new interventions if applicable and an assessment of any underlying causes of the behavior (ie pain,, environmental stressor, medical illnesses, etc.) The root cause and preventative interventions will be included in the resident's care plan. 5. If the behavior expression is not new, worsening or high risk; the nurse will record the behavior in the progress notes using the Behavior Communication Note. The IDT will review progress notes the next business day to determine if immediate follow up action is required for the Behavior Communication. If the behavior requires an interdisciplinary response as described above, the IDT will complete the IDT Behavior Review. If not, the plan of care will be reviewed and updated if needed to include a description of the behavior and effective interventions . 3.1-43(a)(1) Based on interview and record review, the facility failed to adequately monitor and document behaviors for 1 of 1 resident reviewed for mood and behaviors and 2 of 5 residents reviewed for unnecessary medications. (Residents 38 and 45) Findings include: 1. The clinical record for Resident 45 was reviewed on 4/17/24 at 1:43 p.m. His diagnoses included, but were not limited to: schizoaffective disorder, bipolar disorder, insomnia, neurocognitive disorder, encephalopathy, and extrapyramidal and movement disorder. He was admitted to the facility on [DATE] from another skilled nursing facility. The 1/14/24 New/Worsening Behavior Communication Event indicated Resident 45 grabbed a female staff's breast/buttocks inappropriately. The intervention attempted in response to the behavior was to explain that it was inappropriate and encouraged not to do it again. The effectiveness of the interventions were somewhat effective, but Resident 45 did it again after the first action. The interventions put into place to prevent another behavior was to redirect as needed. The 1/23/24 behavioral symptoms care plan indicated the goal was for him to be free of incidents of inappropriate behavior in touching female staff. An approach, starting 1/23/24, was to redirect him as needed and remind him when a behavior was inappropriate. The care plan did not reference or address the potential for him to have an inappropriate sexual behavior towards another resident. The 2/24/24 New/Worsening Behavior Communication Event indicated after dinner in the hallway, Resident 45 was allegedly touching females breast. The interventions attempted in response to the behavior was a chair placed in the hallway by nurses station; redirection; and encourage resident to stay separate during meals and activities. The effectiveness of the interventions was indicated as helpful. Another resident was affected by this behavior and Resident 45 was removed from the other residents environment. On 4/22/24 at 9:30 a.m., the ED (Executive Director) provided the investigative file into the above 2/24/24 behavior event. The file included the 2/28/24 follow-up incident report. The report indicated on 2/24/24, Resident B alleged that Resident 45 made contact with her chest during conversation. The residents were immediately separated. The ED, DNS (Director of Nursing Services,) and physician were notified and an investigation was initiated. The 2/28/24 follow up section of the report indicated Resident B went about her daily routine with no signs or symptoms of psychosocial distress. The root cause of Resident 45's behavioral expression was age and cognition. The file included a documented interview with Resident B conducted on 2/28/24 by the SSD (Social Services Director.) The interview indicated Resident B informed the SSD that Resident 45 tended to come into her room and watch television without asking. When Resident B redirected Resident 45 and asked him to leave, he would leave without incident. One day last week, Resident 45 was walking closely behind Resident B and she was talking with other residents. Resident 45 walked up closely to Resident B and said hello, that she was pretty, and grazed her breast with his open hand. Resident B stated that she screamed and told him to stop and informed nursing staff, who redirected Resident 45 and informed him that was not appropriate to touch peers in that manner. The file included an undated documented interview with RN (Registered Nurse) 6 conducted by the ED. It read, Staff member reported to ED that [name of Resident B] was alleging inappropriate contact by [name of Resident 45.] When asked if she had witnessed this contact, [name of RN 6] stated no. The file included a documented interview with Resident 44 conducted on 2/28/24 by the ED. The interview indicated another resident was sitting in between him and Resident B. He saw Resident 45 approach Resident B and grab her breast. Resident B told Resident 45 he couldn't touch her. Resident 44 just stood there, looking at them. The 4/4/24 Quarterly MDS (Minimum Data Set) assessment indicated Resident 44 had a BIMS (brief interview for mental status) score of 15, indicating he was cognitively intact. He did not have any care plans referencing a history of making false allegations. An interview was conducted with Resident 44 on 4/22/24 at 11:25 a.m. He indicated RN 6 was doing paperwork in the conference room with the door open. He, another resident, and Resident B were in the hallway just outside of the conference room. Resident 45 was walking down the hallway towards them, and once he reached Resident B, he grabbed her breast. Resident 44 saw Resident 45 let go of his walker, stop, and grab Resident B's breast. Resident B jumped back when it happened. Then she went into the conference room and talked to RN 6 about it. Resident 44 saw Resident 45 touch a female staff member inappropriately once too. An interview was conducted with the SSD on 4/22/24 at 11:38 a.m. She indicated Resident 44, who witnessed Resident 45 grab Resident B's breast in the hallway, had no history of false allegations of which she was aware. If he said something, she was likely to believe him. He's not one to make up a story. The 2/24/24, 4:15 p.m. progress note, recorded as a late entry by the SSD on 2/26/24 at 8:53 a.m., read, This writer spoke with resident to see if she was displaying any s/s [signs/symptoms] of psycho-social distress due to inappropriate interaction with peer. This writer listened to resident's thoughts and feelings on situation and validated her perception of what transpired. Resident was calm stated see [sic] felt that she will just [sic] in her room and eat her meals for a couple of days. This writer encouraged her not to self-isolate and that this is her home and she is free to move about. Staff can address any issues or situations that arise. The 2/23/24 Quarterly MDS assessment for Resident 42 indicated she had a BIMS score of 15, indicating she was cognitively intact. She did not have any care plans referencing a history of making false allegations. An interview was conducted with Resident 42 on 4/17/24 at 11:07 a.m. She indicated Resident 45 would just walk into other residents' rooms uninvited. Her roommate, Resident 39, woke up one morning and he was standing at the foot of her bed claiming she was in his bed. Resident 45 was fixated on Resident 39. Earlier in the week, Resident 45 put his wheel chair in their doorway and wouldn't leave. She stated, He doesn't know what he's doing. She'd never seen Resident 45 touch anyone, but he would follow Resident 39 around and ask if he could live with her. She stated, Staff cant watch him 24 hours a day We all have to watch him It's not up to us to have to monitor him. The 2/24/24 Quarterly MDS assessment for Resident 39 indicated she had a BIMS score of 15, indicating she was cognitively intact. She did not have any care plans referencing a history of making false allegations. An interview was conducted with Resident 39 on 4/17/24 at 1:51 p.m. She indicated she woke up one night about a month ago at 3:00 a.m. to Resident 45 at the foot of her bed, telling her she was in his bed. She told the SSD about it, who informed her she was working with him on it. Another time, he was at her door and asked if he could live with her. The same day, he followed her down the hallway telling her he loved her. One day, he stood at the door and wouldn't leave. An interview was conducted with the SSD on 4/22/24 at 11:38 a.m. She reviewed Resident 39's and Resident 42's care plans and indicated she knew Resident 39 and Resident 42 had a history of backing each other up, kind of move as one, but to her knowledge, neither Resident 39 nor Resident 42 had a history of making false allegations, and neither had a care plan referencing such. The 2/25/24 New/Worsening Behavior Communication Event indicated on 2/24/24 at 10:30 p.m., Resident 45 asked a female staff member to help him fix his television, and as she reached up to do so. Resident 45 tried to pull down her pants. The physician suggested a neuro-psyche stay. The 2/25/24 Physician Communication Tool Event indicated Resident 45 was transferred to a neuropsychiatric hospital for a psychiatric evaluation. The 2/25/24 psychiatric evaluation from the neuropsychiatric hospital read, This provider reviewed clinical documentation provided by the skilled nursing facility and there is very minimal detail regarding his mood or sexual behaviors There is no documentation that this patient has hit or harmed anyone nor harmed himself. The most documented behavior is the patient is noncompliant with use of his walker. An interview was conducted with the SSD on 4/22/24 at 11:38 a.m. She indicated in January, 2024 it was relayed to her that Resident 45 touched a female staff member's breast and buttocks over the weekend. As far as interventions put in place afterwards to address his sexually inappropriate behavior, there was a care plan approach to remind him the behaviors were inappropriate and to redirect him. No other interventions were put in place at that time, and there were no interventions to address a potential for him to be sexually inappropriate with residents too. After the 2/24/24 sexually inappropriate behavior towards staff, they added the intervention of care in pairs, effective 2/26/24. The care in pairs should have gone into place after the 1/14/24 event. Resident 45 was fairly new to the facility when the first incident happened with staff on 1/14/24, and they were still learning his behaviors at that time. Resident 45 wore a wanderguard, because when he first came to the facility, he was going up to doors, trying to get out. He'd gone into quite a few other residents rooms and started watching television, such as Resident 19, Resident 7, and Resident 28. The other residents would tell him to leave and he would just get up and walk out. The SSD had never seen him go in or come out of anyone's room. She knew Resident 45 was a concern for some of the other residents because he was younger. There were no progress notes or events in the electronic health record that referenced the frequent occurrences of Resident 45 going into other residents' rooms uninvited. Resident 45 had a care plan to address his potential for elopement, but none to address his wandering into other residents rooms uninvited. An interview was conducted with the SSD on 4/22/24 at 12:45 p.m. She indicated there was no care plan to address him going into other residents rooms uninvited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent for 1 of 5 residents observed during medication pass. There were 34 opportunities with 2 errors resulting in a 5.88% medications error rate. The errors involved 1 resident (Resident 43) in the sample of 5. Findings include: The clinical record for Resident 43 was reviewed on 4/17/24 at 1:00 p.m. The diagnosis for Resident 43 included, but was not limited to, type 2 diabetes mellitus. A care plan dated 2/27/24 indicated staff was to obtain blood sugars as ordered. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 43 was cognitively intact. A physician order dated 1/9/24 indicated the staff was to obtain blood sugars four times a day. The scheduled times were 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. A physician order dated 4/16/24 indicated the resident was to receive 22 units of lantus insulin. A physician order dated 4/17/24 indicated the resident was to receive 12 units of lispro insulin three times a day. An observation was made of breakfast room trays delivered to residents' rooms on 4/18/24 at 9:06 a.m. During medication administrations, an observation was made of Resident 43's blood sugar obtained by License Practical Nurse (LPN) 3 on 4/18/24 at 9:37 a.m. LPN 3 was observed removing a glucometer from the medication cart, and then entered Resident 43's room. At that time, the resident was at the bedside eating her breakfast tray. The resident had consumed half of the meal that was on the tray. LPN 3 obtained Resident 43's blood sugar, and then left the room. After, LPN 3 returned back to the medication cart. LPN 3 was observed pulling Resident 43's lantus flex pen from the medication cart and dialing up 22 units. There was no observation of priming the lantus flex pen at that time. After collecting the lispro from the medication supply room, LPN 3 then was observed administering the 22 units of lantus and 12 units of lispro to Resident 43 in her right arm. An interview was conducted with LPN 3 on 4/18/24 at 9:45 a.m. She indicated she still needed to obtained Resident 3 and Resident 18's blood sugars that morning. An interview was conducted with the Director Nursing Services (DNS) on 4/19/24 at 11:46 a.m. She indicated LPN 3 should obtain blood sugars prior to the reidents eating their meals, and the insulin flex pens should be primed prior to dialing up the insulin dosage. An interview was conducted with Resident 43 on 4/22/24 at 3:23 p.m. She indicated the staff frequently check her blood sugar after she eats her meals. How to use your Lantus SoloStar pen manufacture instructions at website www.lantus.com dated 8/2022, was retrieved on 4/22/24. It indicated .Step 3. Perform A Safety Test. Dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test .Always perform the safety test before each injection . 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to serve breakfast at safe and palatable temperatures with the potential to affect 54 of 55 residents residing at the facility. Findings include: During a Resident Council meeting on 4/16/24 at 3:00 p.m., 8 of 10 residents who attended indicated that breakfast was often served cold. During an interview on 4/17/24 at 11:06 a.m., Resident 43 indicated that breakfast was served cold most days. A grievance form, dated 4/10/24, indicated that Resident B had a concern that the food was sometimes cold. On 4/18/24 at 8:25 a.m., breakfast service was observed in the facility kitchen. Three plates of fried eggs and 1 plate of scrambled eggs were observed sitting on the counter in back of the steam table. Seven plates of fried eggs were observed sitting on the shelf above the stove. FC (Facility Cook) 5 was observed taking a plate of fried eggs from the counter behind the steam table and placing them on a tray to be served. The tray was taken from the serving area and served to a resident. At 8:35 a.m., the DM (Dietary Manager) obtained the temperature of the scrambled eggs sitting on the counter behind the steam table at 100 degrees Fahrenheit. The temperature of one plate of fried eggs from the shelf above the stove was obtained at 86 degrees Fahrenheit. The temperature of the sausage patties on the steam table was 109 degrees Fahrenheit. FC 5 indicated that the fried eggs had been cooked about 5 to 7 minutes before serving had started. The DM indicated that the fried eggs should be microwaved prior to being served and the sausage would be reheated prior to serving any more of them. At 9:35 a.m., the IPF (Infection Preventionist Float) provided a breakfast tray containing scrambled eggs, sausage patties, oatmeal, and toast from the hallway food cart. The temperature of the food upon delivery were obtained. The sausage patty was 129.3 degrees Fahrenheit, and the oatmeal was 130.5 degrees Fahrenheit. On 4/18/24 at 2:03 p.m., the Executive Director provided the Food Temperatures Policy, last revised 6/23, which read . The facility will maintain proper food temperature control to prevent food borne illness . Hot foods that are potentially hazardous will be held for service at or above 135 degrees Fahrenheit . All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food 3.1-21(a)(2)

Based on observation and interview, the facility failed to maintain the first-floor shower room in good condition and to timely repair a leaking pipe for the pot filler in the kitchen with the potential to affect 55 of 55 residents residing at the facility. Findings include: 1. On 4/16/24 at 12:00 p.m., the facility kitchen was observed with the RD (Registered Dietician) and the (DM) Dietary Manager A pipe located to the side of the stove was observed to have a clear pasty substance present at the joints and rusted joint clamps. The copper pipe had a heavy patinated appearance. There was a puddle of water present under the pipe. The DM indicated the water on the floor was because the pipe of the pot filler was leaking and believed a work order had been done. The RD indicated that due to the appearance of the pipe and the rust present on the pipe clamps, the pipe had been leaking for a while. On 4/18/24 at 2:03 p.m., the Executive Director provided a service request, dated 4/16/24, requesting service to the water leak in the kitchen. 2. During an interview on 4/17/24 at 11:04 a.m., Resident 42 indicated that the shower room on the first floor was often dirty and smelled of urine. On 4/22/24 at 1:35 p.m., the first-floor shower room was observed. The tile floor in the shower room appeared dingy and appeared that it had dirt on the floor. There were 2 bags of soiled linen sitting on the floor. On 4/22/24 at 3:11 p.m., the first-floor shower room was observed with the ED (Executive Director) and MS (Maintenance Supervisor). The shower room tile was dry but appeared stained and dirty. There were dried dark brown tracts present on the floor from the wheels of the shower chair. There were stained tiles that appeared dirty around the shower drain and a dark brown stain against the wall of the shower by the floor. The ED indicated that the shower room floor looked stained. 3.1-19(f)(5)

2. An interview with Resident 45 was conducted on 5/5/23 at 10:30 a.m. in her room. During the interview an observation was made of Resident 45's bedside table. Sitting on her bedside table was a clear medication cup which contained 3 unidentified pills. When asked about the medications in the cup, Resident 45 indicated, when she woke up that morning, the cup with the pills was already sitting on the table. She indicated, she was unsure if the medication in the cup was even hers. Resident 45 indicated, she took more morning medications than what was in the cup and stated she was not going to take them for that reason. This was not the first time medications had been left for her to take when she awoke. An interview with Float DNS (Director of Nursing Service) conducted on 5/5/23 at 11 a.m. indicated, Resident 45 did not have a self-administration of medication evaluation completed for the medications which were left at bedside. Medications should not be left at bedside if the resident has not been evaluated for self-administration of medications. A Self-Administration of Medications policy was received from Float DNS on 5/5/23 at 11 a.m. The policy indicated, If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. A Physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medications will be included in the self-administration plan .The resident will be assessed for continued self-administration of medications quarterly and with any significant change of condition. The resident's care plan will be updated to include self-administration. 3.1-11 Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document that self administration of medications and treatments were clinically appropriate for 2 of 2 residents randomly observed for self-administration of medications and medications at bedside. (Residents 20 and 45) Findings include: 1. The clinical record for Resident 20 was reviewed on 5/8/23 at 11:04 a.m. His diagnoses included, but were not limited to: schizophrenia, chronic pain, and hypertension. The 4/18/23 Quarterly MDS (Minimum Data Set) assessment indicated he had a BIMS (brief interview for mental status) score of 10, indicating he was moderately cognitively impaired. The physician's orders indicated to administer 500 mg of divalproex 3 times a day for schizophrenia; 650 mg of Tylenol 3 times a day for chronic pain; and 20 mg of Lasix once a day for hypertension. There was no self-administration of medication evaluation in Resident 20's clinical record. An observation of Resident 20 was made and interview was conducted with LPN (Licensed Practical Nurse) 15 on 5/8/23 at 10:53 a.m. Resident 20 was standing in the doorway of his room, holding a medication cup with 4 pills inside, asking if he was going to pass out and stating he needed a band-aid. There was no staff member present with him. LPN 15 was standing nearby in front of a medication cart in the hallway. LPN 15 indicated she did not administer the medications inside of the cup Resident 20 was holding to him and would check with QMA (Qualified Medication Aide) 22. LPN 15 walked over to Resident 20 and took the cup of medications from him. LPN 20 walked down the hallway to QMA 22, who was standing in front of another medication cart towards the end of the hall. QMA 22 informed LPN 15 that Resident 20 kept saying he was going to take the medications on his own. LPN 15 and QMA 22 walked back down the hallway into Resident 20's room with the cup of medications and encouraged Resident 20 to take the medications. After leaving Resident 20's room, LPN 15 indicated the medications inside of the cup were Depakote, Lasix, and Tylenol. An interview was conducted with the RNC (Regional Nurse Consultant) on 5/8/23 at 12:07 p.m. He indicated Resident 20 did not have a self-administration of medication evaluation completed and should not be administering his own medications.

Based on observation and interview, the facility failed to ensure a resident had the right to reasonable accommodations by having the resident's personal items blocking the only sink in a room from use of the other roommate for 1 of 2 residents reviewed for food. (Resident 39) Findings include: An interview with Resident 39 was conducted on 5/5/23 at 10:54 a.m. Resident 39 indicated, he was unable to wash his hands in his room because his roommate had so many personal items stacked under and around the sink, he was unable to use the sink. An observation of the area around Resident 39's sink was made at the same time as the interview. Resident 39's roommate had a pink basin with a urinal in it under the sink, many bottles of soda under the sink; a large chair with more personal items was positioned in front of the sink; and a laundry basket containing some clothing and his roommate's leg holders from his wheelchair was on the left side of the sink. An environmental tour of the facility was conducted with ED on 5/11/23 at 11:40 a.m. During the tour the following was witnessed: Resident 39's roommate still had the laundry basket with wheelchairs leg supports in it next to the sink, soda pop bottles and pink basin with urinal under the sink and the large chair in front of the sink. The bathroom light fixture did not have its cover and the call light panel between both beds when pressed on, would recess into the wall. An interview with ED conducted at the end of the environmental tour indicated, Resident 39's roommate should not have his personal items stored in a manner which blocks Resident 39 from accessing the sink. 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 promote and facilitate resident self-determination through support of a resident's choice to choose a shower over a bed bath and to have his fingernails cleaned and cut routinely for 1 of 3 residents reviewed for ADL's (Activities of Daily Living) (Resident 37) and a resident who wanted to be awakened and placed in his wheelchair so he may eat breakfast in his wheelchair for 1 of 1 residents reviewed for choices (Resident 16). Findings include: 1. The clinical record for Resident 37 was reviewed on 5/9/23 at 3:37 p.m. Resident 37's diagnoses included, but not limited to, hemiplegia and hemiparesis (difficulty/inability to move left side of body) to the left dominant side, congestive heart failure (CHF), heart attack, and depression. An observation and interview with Resident 37 was conducted on 5/5/23 at 2:42 p.m. Resident 37 indicated, he preferred getting a shower rather than a bed bath. When asked if he received showers over bed baths, he indicated 'no' by turning his head side to side. An observation of Resident 37's fingernails of both hands appeared to be long in length and had dark, black grime packed underneath his fingernails. Resident 37's admission MDS (Minimum Data Set) dated 12/24/21 indicated, he required extensive assistance of two persons for transfers and was totally dependent on two persons for bathing. Resident 37's Quarterly MDS dated [DATE] indicated, he required extensive assistance of two persons for transfers and was totally dependent on one person for bathing. The facility's Preferences for Customary Routine and Activities for Resident 37 and dated 12/21/21 indicated, it was very important for him to choose between tub bath, shower, bed bath/sponge bath. It also indicated, the type of bathing he was used to was a shower. Resident 37's care plan dated 12/20/21 indicated he required assistance with ADL's including, but not limited to, transfers. An approach was to assist with bathing as needed per resident preference and offer showers two times per week and partial baths in between. A review of Resident 37's POC (point of care) charting for bathing was completed on 5/9/23 for the time period of 3/1/23 to 5/9/23. The POC indicated, during the specified time frame, Resident 37 had received 83 complete bed baths and only 3 showers. An observation of Resident 37 was conducted on 5/9/23 at 4:30 p.m. Resident 37 had just come out of the shower room from having a shower. The underneath of his fingernails were still long and packed with black grime. They did not appear to have cleaned under or clipped. An interview with Resident 37 was conducted on 5/10/23 at 9:50 a.m. When he was asked: if anyone had offered to cut his nails when he had his shower yesterday, he indicated, 'no' by shaking his head side to side; if he liked his fingernails the length they were, he indicated, 'no'; and if the grime under them bothered him, he indicated, 'yes' by shaking his head up and down. An interview with RNC (Regional Nurse Consultant) was conducted on 5/10/23 at 10:09 a.m. RNC indicated, resident's fingernails should be cut and cleaned when necessary and if they pose a potential to cause skin injuries. A Fingernail Care skills validation - CNA (Certified Nursing Assistant) was received on 5/10/23 at 10:31 a.m. from Float Social Services. It indicated, the procedure steps: 6. Fill basin halfway with warm water and have resident check water temperature, 7. Soak resident's hands and pat dry .9. Clean under nails with orange stick. 10. Clip fingernails straight across, then file in a curve .15. Document procedure. 2. The clinical record for Resident 16 was reviewed on 5/9/23 at 9:24 a.m. Resident 16's diagnoses included, but not limited to, major depressive disorder, dysphagia (difficulty/inability to swallow), and osteoarthritis. An interview conducted with Resident 16 on 5/5/23 at 11:52 a.m. indicated, he preferred to be out of bed in the morning at 5 a.m. so that when breakfast arrives he can eat while sitting in his wheelchair. He indicated, staff comes in the morning and gets his roommate up and in his wheelchair because he liked to eat breakfast in the dining room , but, Resident 16 did no want to eat in the dining room and wishes to eat in his room. He stated, he has asked staff when they are getting up his roommate for them to get him up as well and they act like they don't want to do it. Resident 16 indicated, sometimes the staff doesn't get him up at all. An interview conducted with Resident 16 on 5/11/23 at 1:35 p.m. indicated, he has not refused to get up and into his wheelchair for breakfast and still wishes to be up and in his wheelchair prior to breakfast being served. An interview conducted with CNA on 5/9/23 at 9:56 a.m. indicated, she was aware that Resident 16 prefers awakened and up in his wheelchair early in the morning. She indicated, it was the night shift's responsibility to get him up prior to leaving, but they didn't get him up that morning. She was unsure as to why they didn't assist him to his wheelchair that morning. When asked how she knew Resident 16 was to be up and in his wheelchair prior to night shift leaving she stated, because there was a list taped onto the wall in nursing station with 8 Resident's names on it and his was one of them. An interview with DNS (Director of Nursing Services) conducted on 5/9/23 at 9:30 a.m. indicated, when the facility admits a new resident, an activity member will conduct and interview with the resident for their preferences. After the interview, a care plan for preferences should be completed. DNS indicated, she had not been made aware of Resident 16's preference but then added him to the Night Shift Get Up's list of residents who wanted to get up early. The list had 5 resident room numbers listed at the time she added Resident 16 to the list. Resident 16's quarterly MDS (Minimum Data Set) dated 4/4/23 indicated, he was totally dependent on the assistance of two persons for transfers. Resident 16's care plan dated 7/11/19 indicated, he requires assistance with ADLs including, but not limited to, bed mobility, transfers, and eating. The interventions included, to be up as desired in his high back wheelchair with assistance of a mechanical lift and two staff members; and to assist with eating and drinking as needed. Resident 16's current care plan did not include resident preferences. A Preferences for Daily Routine policy was received from the RNC (Regional Nurse Consultant) on 5/9/23 at 10:51 a.m. The policy indicated, Purpose: To identify and develop a plan of care that reflects a resident's past and current daily customary routines .Activity Director or designee will complete the Preferences for Daily Customary Routines worksheet upon admission of a new resident, quarterly and upon significant change to the resident .The information from the worksheet will be shared with the interdisciplinary team so that each department can address the resident's preferences. This Federal tag relates to Complaint IN00402254. 3.1-3(u)(1) 3.1-3(u)(3) 3.1-3(v)(1)

Based on interview and record review, the facility failed to notify the physician of a resident's fall for 1 of 1 resident reviewed for accidents. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on 5/4/23 at 12:50 a.m. Her diagnoses included, but were not limited to: dementia, anxiety, and Parkinson's disease. The 2/4/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. The 4/18/23 Annual MDS assessment indicated she required extensive assistance of 2 persons for bed mobility and transfers and extensive assistance of 1 person for dressing. The ADL care plan, last reviewed/revised 5/2/23, indicated she required assistance with ADLs including bed mobility, transfers, eating and toileting. Approaches were to provide care in pairs, starting 7/28/23; to assist with bed mobility as needed; to assist with dressing/grooming/hygiene as needed; and to assist with transfers as needed. The fall care plan, last reviewed/revised 5/2/23, indicated she was at risk for falls due to Parkinson's disease, debility, hypertension, a history of falls, arthritis, cognition, neuropathy, age, incontinence, medications, requiring assistance for mobility, and altered awareness of immediate physical environment. The goal was for fall risk factors to be reduced in an attempt to avoid significant fall related injury. An interview was conducted with Resident 35 on 5/4/23 at 12:55 p.m. She indicated CNA 21 left her on the edge of her bed and she fell yesterday. An interview as conducted with CNA 21 on 5/10/23 at 2:38 p.m. She indicated she'd worked at the facility for 2 years as a CNA. Resident 35 required a lot of assistance with ADLs. She was recently taken off of her Parkinson's medications. She required only one person to assist her with dressing, but 2 people to assist her with getting up. When she assisted Resident 35 with dressing, Resident 35 was usually sitting on the edge of her bed with her feet on the floor while CNA 21 dressed her and put her bra on. Resident 35 had fallen before. Last week, CNA 21 left the room to get a nurse and Resident 35 fell while she was gone. CNA 21 left Resident 35 sitting up on the edge of the bed with her feet on the ground. CNA 21 left the room to get another staff member to help her transfer Resident 21 into her chair. I was gone 2 seconds to get the nurse. When CNA 21 returned, Resident 35 was on the floor by the side of her bed. Resident 35 was not hollering out afterwards and didn't complaint of any pain, but had a scratched up knee. Three staff members, CNA 21 included, along with QMA (Qualified Medication Aide) 22, and the FDNS (Float Director of Nursing Services,) assisted her off the floor and into her chair. CNA 21 did not recall exactly what day the fall occurred, but definitely last week. Resident 35's clinical record did not indicate she had a fall the previous week. There was no fall event, fall assessment, IDT (Interdisciplinary Team) note, or progress note referencing a fall the previous week or notification of a fall to Resident 35's physician. An interview was conducted with the FDNS on 5/10/23 at 3:42 p.m. She indicated CNA 21 came and got her one day last week and informed her she needed help getting Resident 35 off the floor. She went into Resident 35's room where she saw Resident 35 on the floor. She did not have any injuries or any complaints of pain. A QMA was already present in the room doing vitals. A charge nurse was also present, but she was unsure who it was. There should be a post fall assessment in Resident 35's clinical record. She didn't do one herself, because the other nursing staff handled it, but she did not follow up to make sure. Resident 35 was able to bend and sit up afterwards and did not have any skin tears or any other apparent injury. The 5/10/23 event from the clinical record read, Obtain x-ray of lumbar and right knee (pain lower pain and pain/swelling knee). Diclofenac Gel 1% 2 gm right knee QID [4 times daily ]Resident seen by MD. New orders received: Obtain x-ray of lumbar and right knee .Pharmacy and Mobilex made aware. The 5/11/23, 2:17 a.m. nurse's note read, resident had complaints of pain and resident stated NURSE NURSE NURSE very loudly for duration of shift disturbing other residents during night hours. resident requested Tylenol and voltaren cream to be rubbed on her this writer fulfilled tasks resident stated your doing it wrong put more on now no new orders at this time call light within reach. An interview was conducted with the RNC (Regional Nurse Consultant) on 5/11/23 at 10:05 a.m. He indicated Resident 35 did not have a post fall assessment or an IDT review of the fall or any verification of physician notification. He indicated there was currently an order for an x-ray, but their radiology provider wouldn't do it STAT [immediately] and hadn't come in yet. They offered to send Resident 35 out for the x-ray, but she declined. The 5/11/23, 8:47 a.m. nurse's note read, Spoke with resident as the X-ray tech [technician] had to reschedule the imaging and offered to send the resident to the Hospital for immediate imaging and the resident declined saying No they are coming I want it done here. Will cont [continue] to follow up. An interview was conducted with Resident 35 on 5/11/23 at 10:45 a.m. She indicated CNA 21 left her on the edge of the bed after getting her bra on. CNA 21 didn't have everything she needed, so she left. I was saying wait. I'm going to fall. She shut the door, and I fell by the time she got back The Fall Management policy was provided by the RNC on 5/11/23 at 9:07 a.m. It read, It is the policy of [name of facility] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls Post fall .3. The physician will be contacted immediately, if there are injuries, and orders will be obtained. If there are no injuries, notify the physician during normal business hours. 4. The family will be notified immediately by the charge nurse of falls with injury. If there are no injuries, notify the family during day or evening hours (if a fall occurred during the middle of the night, wait until morning) 5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be competed in full in order to identify possible root causes of the fall and provide immediate interventions. 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls. The fall event will be reviewed by the team. IDT note will be written. The care plan will be reviewed and updated, as necessary. Hot Charting will be initiated post fall. 3.1-5(a)(1)

Based on interview and record review, the facility failed to address grievances for 1 of 1 residents reviewed for grievances. (Resident D) Findings include: The clinical record for Resident D was reviewed on 5/8/23 at 1:00 p.m. The diagnoses for Resident D included, but were not limited to, type 2 diabetes mellitus, cirrhosis, seizures, and ascities. A nursing progress note dated 1/23/23 indicated Writer received call from [Resident D's Representative] who c/o [complaints of] res. [resident] c/o not being changed for 3 1/2 hrs [hours]. Writer informed caller that aides are actively in res. room changing res. while speaking with caller. Writer attempted to explain to caller that res. is in facility for therapy and to increase functionality, so res. expelling feces and urine into her brief would be regression since res. arrived to facility using a bed pan. Caller cont. [continued] to be irate and refused to listen to writer, stating that she would be contacting director . A Social Services Director note dated 1/23/23 The writer was approached by one of the aides in the hallway. The aide reported she was with the resident at an appointment on this date and one of the staff members informed her that the resident was criticizing the facility and the staff. The writer met with the resident to discuss her concerns. Resident reported she does not like the facility and she would like to transfer to another facility. The writer asked what facility would she like to transfer to, and she reported she was not sure and that she would let the writer know. The resident was educated on the grievance process and was provided with grievances. SS [Social Services] will continue to provide monitor and provide support as needed. The resident's clinical record did not include follow up on any care grievances the resident had reported to the social services. An interview was conducted with Regional Nurse Consultant on 5/8/23 at 1:45 p.m. He indicated he was unable to provide any grievance forms for Resident D. An interview was conducted with Resident D's Representative on 5/8/23 at 2:30 p.m. She indicated she was unhappy with the care and treatment that was provided to Resident D during her stay. She had reported the concerns to the Executive Director by phone multiple times that included: skin treatments, mannerism of the staff, missing personal items, food served, and staff assistance with care needs and nothing was done. An interview was conducted with Executive Director (ED) on 5/8/23 at 3:40 p.m. He indicated he did not have any grievances for Resident D. He did have multiple conversations via phone texing with Resident D's Representative. He had returned to the facility at times to observe the resident due to some of the discussions he had with Resident D's Representative. For example: She was worried Resident D might fall, so he returned to the facility to check on the resident. The ED indicated he had recently replaced his cell phone, so he could not confirm what texts he had received from Resident D's Representative that were concerns. He did recall that she had mentioned concerns with customer service issues with the staff. He probably should have filled out grievance forms regarding the concerns she had mentioned, but he had not. A Resident Concerns and Grievances policy was provided by the Regional Nurse Consultant on 5/9/23 at 11:46 a.m. It indicated .Policy: Resident, representative or family concerns/grievances occurring during the resident's stay shall be responded to promptly and without fear of reprisal or discrimination. Each resident has the right to: file grievances orally or in writing; file a grievance anonymously, and to obtain a written decision regarding his or her grievance .The Executive Director/Grievance Official shall review all complaints and agree with the actions taken towards resolution. Responses to resident, representative and/or family shall be made as soon as possible and preferably immediately. Actions take to resolve the complaint shall be made within 72 hours from the time the Concern/Grievances form was received unless there is a compelling reasons for delay. Actions taken must prevent further potential violations of any resident rights. Actions taken include contacting the resident, representative and/or family with an explanation of the steps the facility will take to resolve the complain and to ensure their satisfaction .Actions taken must be documented Procedure .If a concern/grievance of any kind is noted, the Concern/Grievance Form is used. The person receiving the concern completes Section I. The following information is placed on the form by the individual completing the record. Date incident occurred, Time incident occurred, Date concern/grievance was received, Name of person receiving the concern/grievance, Department receiving the concern/grievance, Detailed accounting of concern/grievance, Date the complaint form was completed. The concern/Grievance Form is then referred to the Department Leader for review and actions taken. Actions taken will be recorded in Section II by the Department Leader. Section III of the form is to be completed by the employee designated to ensure satisfaction with the resolution of complaints .The Executive Director/Grievance Official will then complete Section IV The Executive Director/Grievance Official will sign off on all completed concern/grievance forms, ensuring resident and or family satisfaction. The Executive Director/Grievance Official is responsible for overseeing process, receiving and tracking grievances through the conclusion, lead any investigations as necessary, maintain the confidentiality of all information associated with grievances, issue written grievance decisions to the resident .All concern forms are to be maintained on-site for a minimum of three years. This Federal tag relates to Complaint IN00402254. 3.1-7(a)(2)

Based on interviews and record review, the facility failed to protect the resident ' s right to be free from verbal abuse by a staff member for 1 of 4 residents reviewed for abuse (Resident 17). Findings include: The clinical record for Resident 17 was reviewed on 5/10/23 at 8:57 a.m. The Resident's diagnosis included, but were not limited to, rheumatoid arthritis and diabetes. A care plan, initiated 7/7/21, indicated he needed assistance with bed mobility, eating, transfers, and toilet use. The goal was that he had a desire to improve his current function. The approaches included, but were not limited to, transfer using a mechanical lift and 2 staff members, initiated 7/27/21, assist with med mobility as needed, initiated 7/7/21, and assist with eating and drinking as needed, initiated 7/7/21. A care plan, initiated 9/29/21, indicated he displayed behaviors such as yelling at the staff and calling them inappropriate names during care. The goal was for him to be easily redirected when yelling or using inappropriate language. The interventions that were initiated 9/29/21 included, but were not limited to, allow resident to express his feelings and validate his feelings, offer redirection, and allow him time and space when he is unruly during care. An Annual MDS (Minimum Data Set) Assessment, completed 4/18/23, indicated Resident 17 was cognitively intact. A Behavior Event, dated 5/4/23 at 6:45 a.m. by LPN 3, indicated that Resident 17 was observed to be screaming with aide. The Behavior Event had been Invalidated by the DNS on 5/5/23 at 12:33 p.m. The Invalidation Note indicated it was not a new or worsening behavior and that the resident was care planned for these outbursts. During an interview on 5/10/23 at 8:57 a.m., LPN (Licensed Practical Nurse) 3 indicated she had come in and given a statement about an incident that happened during the night shift on Wednesday of last week. LPN 3 had heard yelling coming from a room down the hallway. LPN 3 went to investigate and witnessed CNA (Certified Nursing Assistant) 4 and Resident 17 going back and forth with each other. Resident 17 was calling CNA 4 a b**** and CNA 4 had called Resident 17 a crippled m****** f*****. LPN 3 had intervened and calmed CNA 4 and Resident 17 down. Then CNA 5 came up the hallway and started yelling that CNA 4 was her daughter. LPN 3 reported the incident to the DNS (Director of Nursing Services) and the ED (Executive Director) on the morning of 5/4/23. The incident happened around 5:00 a.m., and LPN 3 had reported the incident about 7:30 or 8:00 a.m. She had reached out to the DNS for clarification about the incident. She had left a message for the ED. She had given her written statement to the DNS. During an interview on 5/10/23 at 9:11 a.m., Resident 17 indicated there was a young lady who was mean to him last week. The young lady was always grouchy and would throw his things. She had said all kinds of mean things to him last week, but he couldn't remember exactly what had been said. During an interview on 5/10/23 at 9:20 a.m., the RNC (Regional Nurse Consultant) indicated there had been no reportable incidents submitted in the last week which involved Resident 17. On 5/10/23 at 9:50 a.m., the ED, DNS, Float DNS, Float ED, and RNC were interviewed, and all indicated they had no knowledge of CNA 4 cursing at or calling Resident 17 names. The ED indicated he knew about an interaction between two employees, CNA 4 and CNA 5 being in an argument in the hallway. The DNS indicated she had received a call from LPN 3 on that morning, but it was about CNA 4 and CNA 5 screaming at each other while CNA 4 was providing care to Resident 17's roommate. The Float ED indicated he had been informed of an incident of 2 staff members using foul language in the hallway during the morning meeting on 5/4/23. The ED, DNS, Float ED, and RNC indicated they did not have a written statement from LPN 3 about CNA 4 cursing at Resident 17, and that if the Resident 17 had been cursed at and called names by CNA 4, it would have been verbal abuse. During an interview on 5/10/23 at 1:52 p.m., LPN 8 indicated she had worked at the facility on the night shift that started on 5/3/23 and ended the morning on 5/4/23. LPN 8 had been in orientation with LPN 3. LPN 8 was sitting at the nurses' station with LPN 3 when they heard yelling and went to investigate. When LPN 8 got to the room she witnessed CNA 4 and Resident 17 going back and forth with each other. Resident 17 had called CNA 3 a b**** and wanted some ice and CNA 4 had called Resident 17 a b**** and told him to get up and get the ice himself. CNA 4 had been providing care for Resident 17's roommate and yelling back and forth with Resident 17 while doing the care. LPN 3 had broken them up and gotten Resident 17 some ice. Resident 17 had calmed down. LPN 8 did not recall another staff member coming to the room and yelling. LPN 8 and LPN 3 had returned to the nurses' station. Immediately upon returning to the nurses' station, LPN 3 indicated she was going to let the DNS know about what had happened. LPN 8 had watched LPN 3 text someone. LPN 8 did not see the text message but assumed LPN 3 was reporting the verbal abuse. CNA 4 had not been removed from the facility. LPN 8 was unsure of exactly what time the incident had occurred, but knew it was not at the end of the shift. At around 6:00 a.m., CNA 4 came to the nurses' station and informed LPN 3 that she was leaving for the day. During an interview on 5/10/23 at 3:50 p.m., the DNS indicated the Behavior Event had been invalidated because there was already a care plan for Resident 17's behaviors with the staff. A behavior communication note should have been completed. The DNS had educated LPN 3 about the behavior communication note last weekend. On 5/4/23 at 2:15 p.m., the Float ED provided the Abuse Prohibition, Reporting, and Investigation policy, last revised January 2023, which read .It is the policy of .to provide each resident with an environment that is free from abuse .Definitions/ Examples of Abuse . Verbal Abuse- the use of oral, written, and/ or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability .Prevention .Supervisory personnel are responsible to monitor, through observation and counseling as needed, staff/ resident interactions, and the provision of care and services to residents .Investigation . The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director Of Nursing Services .Resident Abuse- Staff member, volunteer, or visitor .Any individual who witnesses abuse, or has suspicions of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director .Any Staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed . The Executive Director and/ or Director of nursing will be immediately notified of the report and the initiation of the investigation .An incident report will be initiated within 2 hours of the allegation . The investigation will include: Facts and observations by involved employees. Facts and observations by witnessing employees. Facts and observations by witnessing non-employees. Facts and observations by other employees who work with the alleged staff member . This Federal tag relates to Complaint IN00402254. 3.1-27(b)

Based on interview and record review, the facility failed to assure timely reporting of witnessed verbal abuse of a resident for 1 of 4 residents reviewed for abuse (Resident 17). Findings include: 1. The clinical record for Resident 17 was reviewed on 5/10/23 at 8:57 a.m. The Resident's diagnosis included, but were not limited to, rheumatoid arthritis and diabetes. An Annual MDS (Minimum Data Set) Assessment, completed 4/18/23, indicated Resident 17 was cognitively intact. A Behavior Event, dated 5/4/23 at 6:45 a.m. by LPN 3, indicated that Resident 17 was observed to be screaming with aide. The Behavior Event had been Invalidated by the DNS on 5/5/23 at 12:33 p.m. The Invalidation Note indicated it was not a new or worsening behavior and that the resident was care planned for these outbursts. During an interview on 5/10/23 at 8:57 a.m., LPN (Licensed Practical Nurse) 3 indicated she had come in and given a statement about an incident that happened during the night shift on Wednesday of last week. LPN 3 had heard yelling coming from a room down the hallway. LPN 3 went to investigate and witnessed CNA (Certified Nursing Assistant) 4 and Resident 17 going back and forth with each other. Resident 17 was calling CNA 4 a b**** and CNA 4 had called Resident 17 a crippled m****** f*****. LPN 3 had intervened and calmed CNA 4 and Resident 17 down. Then CNA 5 came up the hallway and started yelling that CNA 4 was her daughter. LPN 3 reported the incident to the DNS (Director of Nursing Services) and the ED (Executive Director) on the morning of 5/4/23. The incident happened around 5:00 a.m., and LPN 3 had reported the incident about 7:30 or 8:00 a.m. She had reached out to the DNS for clarification about the incident. She had left a message for the ED. She had given her written statement to the DNS. During an interview on 5/10/23 at 9:11 a.m., Resident 17 indicated there was a young lady who was mean to him last week. The young lady was always grouchy and would throw his things. She had said all kinds of mean things to him last week, but he couldn't remember exactly what had been said. During an interview on 5/10/23 at 9:20 a.m., the RNC (Regional Nurse Consultant) indicated there had been no reportable incidents submitted in the last week which involved Resident 17. On 5/10/23 at 9:50 a.m., the ED, DNS, Float DNS, Float ED, and RNC were interviewed, and all indicated they had no knowledge of CNA 4 cursing at or calling Resident 17 names. The ED indicated he knew about an interaction between two employees, CNA 4 and CNA 5 being in an argument in the hallway. The DNS indicated she had received a call from LPN 3 on that morning, but it was about CNA 4 and CNA 5 screaming at each other while CNA 4 was providing care to Resident 17's roommate. The Float ED indicated he had been informed of an incident of 2 staff members using foul language in the hallway during the morning meeting on 5/4/23. The ED, DNS, Float ED, and RNC indicated they did not have a written statement from LPN 3 about CNA 4 cursing at Resident 17, and that if the Resident 17 had been cursed at and called names by CNA 4, it would have been verbal abuse. During an interview on 5/10/23 at 1:52 p.m., LPN 8 indicated she had worked at the facility on the night shift that started on 5/3/23 and ended the morning on 5/4/23. LPN 8 had been in orientation with LPN 3. LPN 8 was sitting at the nurses' station with LPN 3 when they heard yelling and went to investigate. When LPN 8 got to the room she witnessed CNA 4 and Resident 17 going back and forth with each other. Resident 17 had called CNA 3 a b**** and wanted some ice and CNA 4 had called Resident 17 a b**** and told him to get up and get the ice himself. CNA 4 had been providing care for Resident 17's roommate and yelling back and forth with Resident 17 while doing the care. LPN 3 had broken them up and gotten Resident 17 some ice. Resident 17 had calmed down. LPN 8 did not recall another staff member coming to the room and yelling. LPN 8 and LPN 3 had returned to the nurses' station. Immediately upon returning to the nurses' station, LPN 3 indicated she was going to let the DNS know about what had happened. LPN 8 had watched LPN 3 text someone. LPN 8 did not see the text message but assumed LPN 3 was reporting the verbal abuse. CNA 4 had not been removed from the facility. LPN 8 was unsure of exactly what time the incident had occurred, but knew it was not at the end of the shift. At around 6:00 a.m., CNA 4 came to the nurses' station and informed LPN 3 that she was leaving for the day. During an interview on 5/10/23 at 3:50 p.m., the DNS indicated the Behavior Event had been invalidated because there was already a care plan for Resident 17's behaviors with the staff. A behavior communication note should have been completed. The DNS had educated LPN 3 about the behavior communication note last weekend. On 5/11/23 at 9:55 a.m., the Float ED provided an incident reported to Indiana Department of Health which indicated the incident date and time was 5/10/23 at 9:50 a.m. Resident 17 had indicated that CNA 4 was always saying mean things to him and that she always throws things. It was reported by a nurse that the staff member was arguing in the room with a resident and using foul language. During an interview on 5/11/23 at 10:00 a.m., the Float ED and RVPO (Regional [NAME] President of Operations) indicated the actual date and time of the incident should have been 5/4/23 and the incident report would be amended with the correct date. On 5/4/23 at 2:15 p.m., the Float ED provided the Abuse Prohibition, Reporting, and Investigation policy, last revised January 2023, which read .It is the policy of .to provide each resident with an environment that is free from abuse .Definitions/ Examples of Abuse . Verbal Abuse- the use of oral, written, and/ or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability .Prevention .Supervisory personnel are responsible to monitor, through observation and counseling as needed, staff/ resident interactions, and the provision of care and services to residents .Investigation . The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director Of Nursing Services .Resident Abuse- Staff member, volunteer, or visitor .Any individual who witnesses abuse, or has suspicions of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director .Any Staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed . The Executive Director and/ or Director of nursing will be immediately notified of the report and the initiation of the investigation .An incident report will be initiated within 2 hours of the allegation . The investigation will include: Facts and observations by involved employees. Facts and observations by witnessing employees. Facts and observations by witnessing non-employees. Facts and observations by other employees who work with the alleged staff member . This Federal tag relates to Complaint IN00402254. 3.1-28(c)

2. The clinical record for Resident 17 was reviewed on 5/10/23 at 8:57 a.m. The Resident's diagnosis included, but were not limited to, rheumatoid arthritis and diabetes. An Annual MDS (Minimum Data Set) Assessment, completed 4/18/23, indicated Resident 17 was cognitively intact. A Behavior Event, dated 5/4/23 at 6:45 a.m. by LPN 3, indicated that Resident 17 was observed to be screaming with aide. The Behavior Event had been Invalidated by the DNS on 5/5/23 at 12:33 p.m. The Invalidation Note indicated it was not a new or worsening behavior and that the resident was care planned for these outbursts. During an interview on 5/04/23 at 12:11 p.m., the Float ED (Executive Director) indicated he had received a report in morning meeting about an incident between an aide and a resident and it would be reported. During an interview on 5/10/23 at 8:57 a.m., LPN (Licensed Practical Nurse) 3 indicated she had come in and given a statement about an incident that happened during the night shift on Wednesday of last week. LPN 3 had heard yelling coming from a room down the hallway. LPN 3 went to investigate and witnessed CNA (Certified Nursing Assistant) 4 and Resident 17 going back and forth with each other. Resident 17 was calling CNA 4 a b**** and CNA 4 had called Resident 17 a crippled m****** f*****. LPN 3 had intervened and calmed CNA 4 and Resident 17 down. Then CNA 5 came up the hallway and started yelling that CNA 4 was her daughter. LPN 3 reported the incident to the DNS (Director of Nursing Services) and the ED (Executive Director) on the morning of 5/4/23. The incident happened around 5:00 a.m., and LPN 3 had reported the incident about 7:30 or 8:00 a.m. She had left a message for the ED on his phone and had given her written statement to the DNS. During an interview on 5/10/23 at 9:11 a.m., Resident 17 indicated there was a lady who was mean to him last week and had said mean things to him. He could not remember exactly what was said because it had been a few days. During an interview on 5/10/23 at 9:50 a.m., the DNS indicated she had received a call from LPN 3 the morning of 5/4/23. The call had been about two C.N.A.'s screaming outside of Resident 17's room. During an interview on 5/10/23 at 9:50 a.m., the Float ED indicated he was made aware of an incident of 2 staff members using foul language in the hallway during the morning meeting on 5/4/23. On 5/10/23 at 10:28 a.m., the DNS provided the timecard for CNA 4 which indicated she had started work at the facility on 5/3/23 at 11:35 p.m. and clocked out from work at the facility at 6:37 a.m. on 5/4/23. On 5/10/23 at 12:24 p.m., the DNS provided a copy of the completed investigation file of the incident of CNA 4 and CNA 5 yelling in the hallway. The investigation file included a statement given to the ED by CNA 5 which indicated CNA 5 stated there were words exchanged between staff but that no words were involving a resident. The investigation file did not contain an Alleged Abuse Interview form for Resident 17. The investigation file did not contain any other staff interviews. During an interview on 5/10/23 at 1:52 p.m., LPN 8 indicated she had worked at the facility on the night shift that started on 5/3/23 and ended the morning on 5/4/23. LPN 8 was sitting at the nurses' station with LPN 3 when they heard yelling and went to investigate. When LPN 8 got to the room she witnessed CNA 4 and Resident 17 going back and forth with each other. Resident 17 had called CNA 3 a b**** and wanted some ice and CNA 4 had called Resident 17 a b**** and told him to get up and get the ice himself. LPN 8 was unsure of exactly what time the incident had occurred, but knew it was not at the end of the shift. At around 6:00 a.m., CNA 4 came to the nurses' station and informed LPN 3 that she was leaving for the day. LPN 8 had not been questioned about the incident between Resident 17 and CNA 4 by any staff member of the facility. During an interview on 5/10/23 at 3:50 p.m., the DNS indicated the Behavior Event had been invalidated because there was already a care plan for Resident 17's behaviors with the staff. A behavior communication note should have been completed. The DNS had spoken LPN 3 about the behavior communication note last weekend. 3. On 5/5/23 at 1:35 p.m., the ED provided a copy of the incident report about an AR (Anonymous Resident) allegation of abuse submitted to the Indiana Department of Health on 5/4/23. The incident report read .Brief Description of the Incident .Description added 5/4/23 Resident reported that he/she overhead[sic] a resident yelling out at a staff member. Resident reports that staff member responded, 'you won't talk to me that way.' Resident also reports that interaction took place over several minutes. Reporting resident wished to remain anonymous . On 5/8/23 at 10:10 a.m., the RVPO provided a copy of the updated incident report submitted to the Indiana Department of Health on 5/5/23 which read .Follow up added--5/5/23 Clarification of verbiage for resident report: Resident reported being startled by light being turned on the room and stated, 'D***, who turned the light on? Resident then stated that CNA 5 said, 'You can't cuss at me', then 'went off' on her and was 'yelling at her', which went on for several minutes . On 5/10/23 at 4:12 p.m., the Float ED provided a copy of the completed investigation file for the AR allegation of verbal abuse. The completed investigation file contained an incident report, dated 5/4/23 at 12:01 p.m. The staff involved was CNA 5. The incident report read .Brief Description of the Incident .Description added 5/4/23 Resident reported that he/she overhead[sic] a resident yelling out at a staff member. Resident reports that staff member responded, 'you won't talk to me that way.' Resident also reports that interaction took place over several minutes. Reporting resident wished to remain anonymous .Follow up added--5/5/23 Clarification of verbiage for resident report: Resident reported being startled by light being turned on the room and stated, 'D***, who turned the light on? Resident then stated that CNA 5 said, 'You can't cuss at me', then 'went off' on her and was 'yelling at her', which went on for several minutes . Follow up added--5/10/23 Investigation complete. Through investigation it was determined that staff member was arguing with other staff. Investigation revealed that while a staff members was coming out of a resident's room they were right outside of the room where a resident may have overheard an exchange Staff were in serviced on resident rights and professional behavior. The file also included a statement given to the ED by CNA 5 which indicated CNA 5 stated there were words exchanged between staff but that no words were involving a resident, and two Employee Coaching and Counseling form, one signed by CNA 4, and one signed by CNA 5. During an interview on 5/10/23 at 4:20 p.m., the ED indicate that he had believed the AR report of alleged verbal abuse was regarding the same incident as the incident between the 2 staff members yelling in the hallway on 5/4/23. He had not interviewed any other staff who may have been there. He had not spoken with either of the LPN's who had worked the night shift on 5/3/23. The ED was responsible for the abuse investigations at the facility. On 5/4/23 at 2:15 p.m., the Float ED provided the Abuse Prohibition, Reporting, and Investigation policy, last revised January 2023, which read .It is the policy of .to provide each resident with an environment that is free from abuse .Definitions/ Examples of Abuse . Verbal Abuse- the use of oral, written, and/ or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability .Prevention .Supervisory personnel are responsible to monitor, through observation and counseling as needed, staff/ resident interactions, and the provision of care and services to residents .Investigation . The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director Of Nursing Services .Resident Abuse- Staff member, volunteer, or visitor .Any individual who witnesses abuse, or has suspicions of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director .Any Staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed . The Executive Director and/ or Director of nursing will be immediately notified of the report and the initiation of the investigation .An incident report will be initiated within 2 hours of the allegation . The investigation will include: Facts and observations by involved employees. Facts and observations by witnessing employees. Facts and observations by witnessing non-employees. Facts and observations by other employees who work with the alleged staff member . This Federal tag relates to Complaint IN00402254. 3.1-28(d) Based on interview and record review, the facility failed to identify an alleged perpetrator of an abuse allegation to protect residents during the investigation; to interview other staff members as part of the investigation; to ensure that a resident was protected against further potential abuse or mistreatment during the investigation of verbal abuse; and that an allegation of verbal abuse was thoroughly investigated for 3 of 4 resident's reviewed for abuse (Residents 17, 35, and Anonymous Resident) Findings include: 1. The clinical record for Resident 35 was reviewed on 5/4/23 at 12:50 a.m. Her diagnoses included, but were not limited to: dementia, anxiety, and Parkinson's disease. The 2/4/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. An interview was conducted with Resident 35 on 5/4/23 at 12:55 p.m. She indicated there were 2 staff members with the same first name that worked at the facility. One was a CNA (Certified Nursing Assistant) and the other one sat behind the desk. She was verbally abused by the one who sat behind the desk. She told her to shut up all the time, as recently as yesterday. The above allegation was reported to the FED (Float Executive Director) immediately after the interview. On 5/5/23 at 1:34 p.m., the ED (Executive Director) provided a copy of the 5/4/23 incident report for Resident 35's allegation of verbal abuse. The report indicated CNA 21 was suspended pending investigation. CNA 21 was not the staff member Resident 35 indicated as having verbally abused her. CNA 21 was the staff member with the same first name as the staff member Resident 35 indicated as having verbally abused her. The report indicated resident and staff interviews were to be conducted. An interview was conducted with the ED on 5/5/23 at 1:34 p.m. He indicated he spoke with Resident 35 this morning. CNA 21 was suspended as a result of Resident 35's allegation of verbal abuse. The ED was going to look into whether or not there was another staff member with the same first name as CNA 21. An interview was conducted with the FED on 5/5/23 at 1:55 p.m. He indicated he was unsure if there were 2 staff members with the same first name as the one Resident 35 alleged in her allegation of verbal abuse. He was unsure who interviewed Resident 35 about her allegation. CNA 21 was assigned to care for Resident 35 the day prior to her allegation, so that was why she was suspended pending investigation. An interview was conducted with the ED on 5/5/23 at 3:50 p.m. He indicated he was uncertain who actually interviewed Resident 35 about her allegation of verbal abuse, but would find out. There was not another staff member with the same first name as CNA 21. An interview was conducted in person at the facility with CNA 21, who was currently working, on 5/10/23 at 2:38 p.m. She indicated she'd worked at the facility as a CNA for 2 years. She was suspended on 5/4/23 while working. She was in the dining room, serving lunch, when she was pulled and informed by the DNS (Director of Nursing Services) and the RNC (Regional Nurse Consultant) that a resident made an allegation of verbal abuse against her. She'd been a CNA for 30 years and had never had anything on my license. CNA 21 was shocked and hurt at the allegation, as she had a good rapport with Resident 35. She tried to go above and beyond to make Resident 35 happy. CNA 21 would let Resident 35 use her personal cell phone to talk to her sister. She would never tell Resident 35 to shut up. There was an agency staff member with the same first name as hers, who regularly worked at the facility as a nurse. The progress notes from Resident 35's electronic health record included 52 nurse's notes written by LPN 24, who shared the same first name as CNA 21. The notes were dated between 2/1/23 and 5/4/23 when Resident 35 made the allegation of verbal abuse. An interview was conducted with LPN 24 via telephone on 5/11/23 at 10:14 a.m. She indicated she worked on and off at the facility in the float pool as needed. She last worked at the facility on 4/30/23, and she'd been there a lot starting in November or December, 2022. While working at the facility, she cared for Resident 35 regularly. Resident 35 would call the desk a lot, question her medications or start yelling. She tried to help her as much as she could. If you talked to her, she would calm down. She'd never been frustrated with Resident 35 and never told her to shut-up. Prior to this interview, no one from the facility had called her, asked her for a statement, questioned her about any residents, or notified her not to come into the facility. An interview was conducted with the FED, ED, and RVPO (Regional [NAME] President of Operations) on 5/10/23 at 3:06 p.m. The RVPO indicated the facility had their own float staffing pool. The FED indicated it was possible there was another staff member who worked at the facility with the same first name as CNA 21. The ED indicated CNA 21 worked at the facility all the time and took care of Resident 35, so nothing triggered as far as suspending LPN 24 pending Resident 35's allegation of verbal abuse. An interview was conducted with the ED on 5/11/23 at 9:48 a.m. He indicated the investigation into Resident 35's allegation of verbal abuse was completed and let CNA 21 come back to work after its' completion. He interviewed Resident 35 about her allegation on 5/4/23 and would look for documentation of the interview. Resident 35 informed him during the interview that someone with the same first name as CNA 21 and LPN 24 told her to shut up and was pretty sure she said [first name of CNA 21 and LPN 24] behind the desk. He was unsure if anyone assessed Resident 35 for harm. No one informed LPN 24 or her agency that LPN 24 was suspended pending investigation. They would normally call and suspend an alleged perpetrator, but due to the confusion with the 2 staff members with the same first name, they didn't suspend LPN 24. He also may not have interviewed any staff members who regularly worked with Resident 35, LPN 24, CNA 21, or any staff at all about Resident 35's allegation of verbal abuse. The ED provided a copy of the investigative file into Resident 35's 5/4/23 allegation of verbal abuse. It did not include interviews with LPN 24, CNA 21, or any other staff member. It included an interview with Resident 35 that read, Res [Resident] reported info [information] yesterday May 4 2023. The documented interview with Resident 35 did not include any other information. The file included employee coaching and counseling forms for CNA 21, CNA 5, and CNA 4 and documented interviews with 24 other residents. On 5/11/23 at 11:19 a.m., the ED provided his documented interview with Resident 35. There was no date on the interview. On 5/11/23 at 11:49 a.m., the ED provided the 5/9/23 follow up incident report to the IDOH (Indiana Department of Health.) It read, Investigation completed. Employee was brought back and received coaching and counseling on customer service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for a resident on hospice services to include care and services the facility and hospice will provide for 1 of 1 residents reviewed for hospice (Resident 1); and a resident with risk factors in skin alteration to include individualized interventions for 1 of 1 residents reviewed for skin conditions (Resident 37). Findings include: 1. The clinical record for Resident 1 was reviewed on 5/8/23 at 9:40 a.m. Resident 1's diagnoses included, but not limited to, senile degeneration of the brain, hemiplegia (inability or difficulty moving a side of the body) affecting right side, stage III pressure ulcer to right buttock, non-pressure ulcer to left lower leg with fat layer exposed, and protein-calorie malnutrition. Resident 1's significant change MDS (Minimum Data Set) dated 3/13/23 indicated, Resident 1 had severe cognitive impairment; was totally dependent on the assistance of two persons for transfers, toileting and bathing; required extensive assistance of two persons for bed mobility; and extensive assistance of one person for eating. A physician's order dated 3/8/23 indicated, to call the hospice company for Resident 1 for questions and/or a change in condition. Resident 1's care plan dated 3/8/23 and last revised on 3/14/23 indicated, Resident 1 required hospice related to senile degeneration of brain. The interventions dated 3/8/23 included, but not limited to, administer pain medication as ordered and to notify hospice of unrelieved or worsening pain; the name and phone number of her hospice; assess for signs of pain, both verbal and non verbal; hospice aide visits: nursing facility will provide scheduled hospice care in the event hospice unable to make visit; hospice licensed nurse visits: nursing facility will provide scheduled hospice care in the event hospice unable to make visit; hospice social worker visits: nursing facility will provide scheduled hospice care in the event hospice unable to make visit; and hospice to provide medication to nursing facility related to hospice diagnosis. The care plan did not indicate how many or which days hospice providers were to visit, what services they were to provide; the specific medications to be provided. An IDT (interdisciplinary team) note in Resident 1's chart indicated, on 5/5/23 at 4:21 p.m. a significant change assessment was added related to Resident 1's weight loss over the last 180 days. The IDT note did not indicate if the hospice had been notified of the significant weight loss. An interview conducted on 5/8/23 at 10:29 a.m. with QMA (Qualified Medication Assistant) 22 indicated, she was unaware of when Resident 1's hospice company was supposed to come in nor what services they provide to her. An interview with Float Social Services conducted on 5/8/23 at 11:54 a.m. indicated, the coordination of care between the facility and the hospice providers was usually the social services director with an IDT component. She indicated, the last social services person left at the beginning of April. Since then, the facility has had other social service members assisting but believes the facility liaison for the resident would be nursing staff since their wasn't a permanent replacement as of yet. A review of Resident 1's hospice binder was performed on 5/8/23 at 12:01 p.m. The binder did not contain a hospice care plan. A Hospice policy was received from Regional [NAME] President of Operations (RVPO) on 5/8/23 at 10:58 a.m. The policy indicated, It is the policy of this facility that when a resident elects the hospice benefit that the contracted hospice company and facility will coordinate to establish both a person centered plan of care reflecting the physical, spiritual, mental and psychosocial needs of the resident as well as a pattern of communication between the hospice company, healthcare professionals, facility staff and resident/representative .The plan of care will include: a. Resident choices/preferences b. Pain/discomfort management c. Care and services (including medications and supplies) that the facility and hospice will provide in order to be responsive to the resident's needs and desire for hospice care. d. A revision of other care plans to ensure consistency with the hospice care plan of care and individual's needs and preferences . Facility staff will contact the hospice company with any significant change in the resident's condition .The Social Services Director or designee will act as the Hospice Coordinator which will be responsible for the following functions: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process . b. Communicating with hospice representatives and other healthcare providers . c. Ensuring that the facility communicates with the hospice medical director, the patient's attending physician, and other reactivation .to coordinate the hospice care with the medical care provided by other physicians. d. Obtaining the following information from the hospice: i. The most recent hospice plan of care specific to each patient . vi. Hospice medication information specific to each patient. 2. The clinical record for Resident 37 was reviewed on 5/9/23 at 3:37 p.m. Resident 37's diagnoses included, but not limited to, hemiplegia affecting dominant left side, congestive heart failure, stroke, moderate protein-calorie malnutrition, major depressive disorder, and anxiety. Resident 37's quarterly MDS dated [DATE] indicated, he required extensive assistance of two persons for transfers and was totally dependent on one person for bathing. A physician's order dated 1/18/22 indicated, to apply Eucerin cream mixed with Vaseline to face and hands related to dry skin twice a day and as needed. An observation of Resident 37 was conducted on 5/5/23 at 2:35 p.m. Resident 37 was sitting outside in the front courtyard. Resident 37 was scratching his right arm and the skin on his face, head, neck and arms was dry, white, and flaky. When asked if his skin was bothering him, he nodded up and down indicating 'yes'. When asked if he was in pain, he again nodded his head up and down and then began to cry. Resident 37's care plan was provided by DNS (Director of Nursing) on 5/10/23 at 10:26 a.m. The care plan included, but not limited to, a risk for skin breakdown due to: slightly limited sensory perception, skin occasionally moist, chair fast, very limited mobility, stroke with left sided weakness and history of protein calorie malnutrition. Interventions included, but not limited to house barrier cream at bedside - use as directed. Resident 37's care plan did not address the individualized approach of applying the mixture of Eucerin and Vaseline twice daily to assist in the prevention of skin breakdown nor did it include a care plan related to his excessively dry skin. An interview with MDSC (Minimum Data Set Coordinator) was conducted on 5/10/23 at 10:31 a.m. MDSC indicated, she had not included in Resident 37's care plan for his risk for impaired skin integrity the intervention of the twice daily use of two different moisturizers (Eucerin and Vaseline, to be mixed together) because she believed since the use of these two moisturizers were marked on the MAR (medication administration record), they did not need to be included in the care plan. An IDT (Interdisciplinary team) Comprehensive Care Plan policy was received on 5/10/23 at 10:42 a.m. from MDSC. The policy indicated, It is the policy of the facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific intervention based on resident needs and preferences to promote the resident's highest level of functioning .as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms. This Federal tag relates to Complaint IN00402254 and IN00400685. 3.1-35(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure discharge summaries that included recap of resident's stay for 2 of 3 residents reviewed for discharge. (Resident D and Resident 4) Findings include: 1. The clinical record for Resident 4 was reviewed on 5/9/23 at 10:00 a.m. The diagnosis for Resident 4 included, but was not limited to, absence of left knee. A progress note dated 4/11/23 indicated Resident 4 had discharged . A Discharge summary dated [DATE] indicated the resident went home with daughter. The summary did not include a recap of the resident's stay. An interview was conducted on 5/9/23 at 3:01 p.m. He indicated he was unable to locate a discharge summary for Resident 4 that included a recap of her stay. 2. The clinical record for Resident D was reviewed on 5/8/23 at 1:00 p.m. The diagnosis for Resident D included, but was not limited to, type 2 diabetes mellitus. A progress note dated 3/29/23 indicated Resident D had discharged home and discharge instructions had been explained to the resident and signed. The Discharge summary dated [DATE] did not include a recap of the resident's stay. An interview was conducted with Regional Nurse Consultant on 5/9/23 at 11:46 a.m. He indicated the discharge summary should have a recap narrative of the resident's stay. Resident's D discharge summary does not include the recap narrative. This Federal tag relates to Complaint IN00402254. 3.1-36(a)(1)

Based on observation, interview, and record review, the facility failed to provide materials for written communication to 1 of 1 resident reviewed for communication and sensory services. (Resident 23) Findings include: The clinical record for Resident 23 was reviewed on 5/4/23 at 2:30 p.m. His diagnoses included, but were not limited to, aphasia. The 2/28/23 Quarterly MDS (Minimum Data Set) assessment indicated he had a BIMS (brief interview for mental status) score of 15 indicating he was cognitively intact. He had unclear speech; difficulty communicating some words or finishing thoughts; and understood others with clear comprehension. The 6/6/18 care plan, last reviewed/revised 3/12/23, indicated he had difficulty making himself understood related to his speech being garbled and unclear. The goal was for his needs to be met daily. Approaches were to encourage him to use a communication board when expressing himself and to provide materials for written communication to enhance communication. An observation and interview was conducted with Resident 23 in his room on 5/4/23 at 2:58 p.m. He was lying in bed and made a writing motion with his right hand, indicating he wanted to write something down during the interview. There was a permanent red marker and erasable white board on the bedside table next to him. The whiteboard had red permanent markings on it in the middle of the board. There was no eraser material or other writing materials on the table. LPN (Licensed Practical Nurse) 23 was retrieved from the nurses station to assist. LPN 23 looked through the top drawer of a side table for writing materials, but was unable to locate any, so she left the room to retrieve some. LPN 23 returned with a black erasable marker, handed it to Resident 23 and left the room. Resident 23 used the black erasable marker to begin writing on the whiteboard to the left of the red permanent markings that were already on the board. An observation and interview with Resident 23 was made in his room on 5/8/23 at 11:39 a.m. He was sitting in a Broda chair in his room. His bedside table was in front of him with a black erasable marker and 2 erasable whiteboards on it. One of the whiteboards was completely covered with red permanent markings. The other board was the same board he used during the 5/4/23, 2:58 p.m. observation that had red permanent markings in the middle of the board. There was no eraser material or other writing material on his bedside table. Resident 23 indicated the whiteboards and other writing materials were not always available for use. An interview and observation was made with Resident 23 on 5/8/23 at 2:08 p.m. He was sitting in his Broda chair in his room. His bedside table was in front of him with the same black erasable marker and 2 erasable whiteboards with red permanent markings. There was no eraser material or other writing materials on his bedside table. Resident 23 smiled and indicated he wanted a new erasable whiteboard with no markings on it and an eraser. He pointed to the paper towel dispenser on the wall that was out of reach to him and indicated staff used paper towel to erase his board, but did not provide paper towel within reach for him to use. There was no paper towel on his bedside table. An observation of Resident 23 was made with the FSS (Float Social Services) on 5/8/23 at 2:14 p.m. Resident 23 informed the FSS he wanted a new/different whiteboard and an eraser. The Communication Barriers/Interpreter Services policy was provided by the FSS on 5/8/23 at 3:05 p.m. It read, It is the policy of [name of facility] to assist residents in facilitating communication for those with communication barriers. Procedure: 1. Resident's communication, including language and comprehension abilities, will be assessed upon admission. 2.These methods will be added to the plan of care; and may include methods such as communication books/boards . 3.1-38(a)(2)(E)

2. The clinical record for Resident 37 was reviewed on 5/9/23 at 3:37 p.m. Resident 37's diagnoses included, but not limited to, hemiplegia affecting dominant left side, congestive heart failure, stroke, moderate protein-calorie malnutrition, major depressive disorder, and anxiety. A copy of Resident 37's Optometrist's report dated 1/13/23 indicated, the plan included, but not limited to, consult with primary care physician regarding surgical recommendation, recommend social services consult with family regarding need for cataract surgery, follow up in 4 to 5 months, referral for Ophthalmology consult, and a new medication order for artificial tears gel to be applied in both eyes at bedtime. A Social Services note dated 2/6/2023 at 10:39 a.m. indicated, Resident was seen by the eye doctor on 1/13/23. Recommendations: Artificial tears Gel, apply one drop in both eyes at bedtime. A referral was made for Ophthalmology for cataract surgery. Since that time, no social services notes indicated, Resident 37's family/representative had been made aware of the recommendation for cataract surgery, the referral to Ophthalmology nor was the order for artificial tear drops placed in his orders. An interview with Float Social Services conducted on 5/10/23 at 11:44 a.m. indicated, she was unaware if Resident 37's referral, recommendation for surgery, or the new medication order had been followed- up on. She indicated, the previous Social Services person was still at the facility at that time and would need to look into it. A Float Social Services note dated 5/10/2023 at 1:32 p.m. indicated, the writer spoke with Resident 37's daughter on that date regarding eye doctor's recommendation for cataract surgery. The daughter of Resident 37 stated that her dad had one cataract surgery and that she had wanted him to wait to have the other eye surgery performed however, now she was interested in the referral being made. An interview with Float social Services conducted on 5/10/23 at 3:28 p.m. indicated, the referral to Ophthalmology should have been followed up on sooner. An interview with RNC (Regional Nurse Consultant) conducted on 5/11/23 at 11:27 a.m. indicated, Resident 37's new artificial tears medication order had not been addressed as of yet. RNC indicated, usually when a resident uses ancillary services they return with the report in hand however, if they do not come back to the facility with any paperwork from the appointment, the process should entail the social worker to forward onto nursing any new orders from the ancillary services. Based on observation, interview and record review, the facility failed to routinely obtain pulse and to hold a medication when pulse was below 65, as ordered by the physician; to follow up on an Optometrist's recommendation timely; and complete a post fall assessment and review for 1 of 1 resident reviewed for accidents, 1 of 1 resident reviewed for vision, and 1 of 5 residents reviewed for unnecessary medications (Residents 30, 35, and 37). Findings include: 1. The clinical record for Resident 30 was reviewed on 5/5/23 at 11:18 a.m. The Resident's diagnosis included, but was not limited to, hypertension and moderate protein- calorie malnutrition. A care plan, initiated 10/27/22, indicated he was at risk for ineffective tissue perfusion related to his hypertension. The goal was for him to maintain adequate tissue perfusion as evidenced by blood pressure within normal limits for resident. The interventions that were initiated 10/27/22 included, but were not limited to, administer medications as ordered and monitor vital signs. A physician's order, dated 2/1/23, indicated he was to receive metoprolol succinate (heart medication) extended released tablet 25 mg (milligram) twice a day and to hold the medication if his systolic blood pressure was less than 110 or his heart rate was less than 65. The April and May 2023 MAR (Medication Administration Record) were reviewed, and no pulse rates were documented as obtained prior to giving the metoprolol. The April and May vital signs report indicated that Resident 30's heart rate was documents as below 65 on the following days: 4/15, 4/16, 4/18, 4/21, 4/29, 4/30, and 5/3/23. The metoprolol had not been held on any of those dates. During an interview on 5/8/23 at 3:50 p.m., the RNC (Regional Nurse Consultant) indicated the Resident 30's heart rate should have been obtained prior to each administration of the metoprolol and that the medication should have been held for a heart rate less than 65. 3. The clinical record for Resident 35 was reviewed on 5/4/23 at 12:50 a.m. Her diagnoses included, but were not limited to: dementia, anxiety, and Parkinson's disease. The 2/4/23 Quarterly MDS (Minimum Data Set) assessment indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. The 4/18/23 Annual MDS assessment indicated she required extensive assistance of 2 persons for bed mobility and transfers and extensive assistance of 1 person for dressing. The ADL care plan, last reviewed/revised 5/2/23, indicated she required assistance with ADLs including bed mobility, transfers, eating and toileting. Approaches were to provide care in pairs, starting 7/28/23; to assist with bed mobility as needed; to assist with dressing/grooming/hygiene as needed; and to assist with transfers as needed. The fall care plan, last reviewed/revised 5/2/23, indicated she was at risk for falls due to Parkinson's disease, debility, hypertension, a history of falls, arthritis, cognition, neuropathy, age, incontinence, medications, requiring assistance for mobility, and altered awareness of immediate physical environment. The goal was for fall risk factors to be reduced in an attempt to avoid significant fall related injury. An interview was conducted with Resident 35 on 5/4/23 at 12:55 p.m. She indicated CNA 21 left her on the edge of her bed and she fell yesterday. An interview as conducted with CNA 21 on 5/10/23 at 2:38 p.m. She indicated she'd worked at the facility for 2 years as a CNA. Resident 35 required a lot of assistance with ADLs. She was recently taken off of her Parkinson's medications. She required only one person to assist her with dressing, but 2 people to assist her with getting up. When she assisted Resident 35 with dressing, Resident 35 was usually sitting on the edge of her bed with her feet on the floor while CNA 21 dressed her and put her bra on. Resident 35 had fallen before. Last week, CNA 21 left the room to get a nurse and Resident 35 fell while she was gone. CNA 21 left Resident 35 sitting up on the edge of the bed with her feet on the ground. CNA 21 left the room to get another staff member to help her transfer Resident 21 into her chair. I was gone 2 seconds to get the nurse. When CNA 21 returned, Resident 35 was on the floor by the side of her bed. Resident 35 was not hollering out afterwards and didn't complaint of any pain, but had a scratched up knee. Three staff members, CNA 21 included, along with QMA (Qualified Medication Aide) 22, and the FDNS (Float Director of Nursing Services,) assisted her off the floor and into her chair. CNA 21 did not recall exactly what day the fall occurred, but definitely last week. Resident 35's clinical record did not indicate she had a fall the previous week. There was no fall event, fall assessment, IDT (Interdisciplinary Team) note, or progress note referencing a fall the previous week. An interview was conducted with the FDNS on 5/10/23 at 3:42 p.m. She indicated CNA 21 came and got her one day last week and informed her she needed help getting Resident 35 off the floor. She went into Resident 35's room where she saw Resident 35 on the floor. She did not have any injuries or any complaints of pain. A QMA was already present in the room doing vitals. A charge nurse was also present, but she was unsure who it was. There should be a post fall assessment in Resident 35's clinical record. She didn't do one herself, because the other nursing staff handled it, but she did not follow up to make sure. Resident 35 was able to bend and sit up afterwards and did not have any skin tears or any other apparent injury. The 5/10/23 event from the clinical record read, Obtain x-ray of lumbar and right knee (pain lower pain and pain/swelling knee). Diclofenac Gel 1% 2 gm right knee QID [4 times daily ]Resident seen by MD. New orders received: Obtain x-ray of lumbar and right knee .Pharmacy and Mobilex made aware. The 5/11/23, 2:17 a.m. nurse's note read, resident had complaints of pain and resident stated NURSE NURSE NURSE very loudly for duration of shift disturbing other residents during night hours. resident requested Tylenol and voltaren cream to be rubbed on her this writer fulfilled tasks resident stated your doing it wrong put more on now no new orders at this time call light within reach. An interview was conducted with the RNC (Regional Nurse Consultant) on 5/11/23 at 10:05 a.m. He indicated Resident 35 did not have a post fall assessment or an IDT review of the fall or any verification of physician notification. He indicated there was currently an order for an x-ray, but their radiology provider wouldn't do it STAT [immediately] and hadn't come in yet. They offered to send Resident 35 out for the x-ray, but she declined. The 5/11/23, 8:47 a.m. nurse's note read, Spoke with resident as the X-ray tech [technician] had to reschedule the imaging and offered to send the resident to the Hospital for immediate imaging and the resident declined saying No they are coming I want it done here. Will cont [continue] to follow up. The Fall Management policy was provided by the RNC on 5/11/23 at 9:07 a.m. It read, It is the policy of [name of facility] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls Post fall .3. The physician will be contacted immediately, if there are injuries, and orders will be obtained. If there are no injuries, notify the physician during normal business hours. 4. The family will be notified immediately by the charge nurse of falls with injury. If there are no injuries, notify the family during day or evening hours (if a fall occurred during the middle of the night, wait until morning) 5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be competed in full in order to identify possible root causes of the fall and provide immediate interventions. 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls. The fall event will be reviewed by the team. IDT note will be written. The care plan will be reviewed and updated, as necessary. Hot Charting will be initiated post fall. This Federal tag relates to Complaints IN00402254 and IN00399680. 3.1-37(b)

Based on interview and record review, the facility failed to timely address dietary recommendations for a resident with weight loss for 1 of 2 residents reviewed for nutrition (Resident 30). Findings include: The clinical record for Resident 30 was reviewed on 5/5/23 at 11:18 a.m. The Resident's diagnosis included, but was not limited to, hypertension and moderate protein- calorie malnutrition. A Significant Change of Status MDS (Minimum Data Set) Assessment, completed 12/11/22, indicated Resident 30 had severe cognitive impairment. An IDT (Interdisciplinary Team) Progress note, dated 3/15/23, indicated he was being reviewed for weight loss. His weight was down 11 pounds in 1 week. The recommendation was to start Ensure Plus (dietary supplement) 240 ml (milliliter) daily. The clinical record did not contain a physician's order to start Ensure Plus. A Significant Change of Status MDS Assessment, completed 3/22/23, indicated he had severe cognitive impairment. He needed supervision of 1 staff member for eating, and he had experienced a significant weight loss. His weight was 194 pounds. An IDT progress note, dated 4/10/23, indicated Resident 30's weight was 192 pounds. The new recommendation was to ensure the previous recommendation for Ensure Plus 240 ml was initiated to add calories and protein. A physician's order, dated 4/11/23, indicated to give 237 ml of Ensure Plus daily. A care plan, last updated 4/23/23, indicated he was at risk for altered nutritional status and had a significant weight loss in 30 days. The goal was for him to regain weight back to his desired weight range of 205 pounds + or - 5 pounds. The interventions included, but were not limited to, administer supplements as ordered, initiated 3/15/23. During an interview on 5/9/23 at 3:30 p.m., the DNS (Director of Nursing Services) indicated the nutritional supplement should have been implemented after it was recommended in March 2023. On 5/9/23 at 10:33 a.m., the Regional [NAME] President of Operations provided the Resident Weight Monitoring policy, last revised 12/2022, which read .Any significant unexplained weight loss is considered a change in condition and must be addressed by the Interdisciplinary Care Plan Team . 3.1-46(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with PTSD (Post Traumatic Stress Disorder) received appropriated treatment, in coordination with psychiatric services, to mitigate triggers of past trauma for 1 of 1 resident reviewed for mood and behavior (Resident 43). Finding include: The clinical record for Resident 43 was reviewed on 5/4/23 at 11:39 a.m. The Resident's diagnosis included, but were not limited to, severe major depressive disorder without psychotic features, anxiety disorder, panic disorder, and PTSD. An admission MDS (Minimum Data Set) Assessment, completed 2/18/23, indicated she was cognitively intact. PHQ-9 (Patient Health Questionnaire) score was 17, which indicated moderately severe depression, and she had no behaviors. A Notice of PASRR (Preadmission Screening and Resident Review) Level II Outcome Notice, dated 2/24/23, indicated Resident 43 needed rehabilitative services, support counseling from nursing facility staff, education regarding medications and side effects, and mental health services to help with symptoms of anxiety and depression. A care plan, initiated 2/27/23, indicated Resident 43 had experienced trauma due to lack of family support and was at risk for experiencing re-traumatization, feeling unsafe/ untrusting, and/or distressed. The goal was to eliminate or mitigate (reduce) triggers that may cause re-traumatization. The approaches, initiated 2/27/23, were to provide behavioral health services through the facility provider, encourage per support and socialization, encourage Resident 43 and her representatives to give input in developing and reviewing the plan of care, ensure she had a sense of emotional and physical safety, establish and encourage open communication between staff and resident. A care plan, initiated 2/27/23, indicated Resident 43 was at risk for signs and symptoms of anxiety such as worried facial expressions, repetitive movements, shortness of breath, nausea, sweating, tremors, irritability, insomnia and reporting anxiety due to her diagnosis of anxiety. The goal was for her to no have increased signs and symptoms of anxiety. The approaches, initiated 2/27/23, were to encourage activities of interest, encourage family support and involvement, encourage her to verbalize fears and anxiety, offer validation and reassurance, maintain a calm environment, move her to a quiet area as needed, administer medications as ordered by physician, and psychiatric services as appropriate. A Psychiatry Initial Consult, dated 3/16/23, indicated the history of her present illness included an admission to an acute care hospital on 2/11/23 for pneumonia. She was initially calm during the consultation but became tearful while discussing her past. She was alert and oriented to person, place, time, and events. She reported being homeless and losing everything upon moving to the area. She had no family support. She had a history of experiencing depression, anxiety, panic attacks as recently as yesterday. She reported a history of PTSD from being physically and sexually abused and from her mother's untimely death when she was [AGE] years old. She reported increased symptoms of depression and anxiety. The facility staff report ongoing complaints of anxiety and increased episodes of crying and tearfulness, and trouble participating in therapy after her a.m. medications. She had never smoked cigarettes, used alcohol, or taken recreational drugs. Her mood was anxious, crying, depressed mood, tearful, and labile (rapid, often exaggerated changes in mood, where strong emotions or feelings occur). Her anxiety symptoms were excessive worry, anxiety and fearfulness. Clonazepam (anti-anxiety medication) 0.5 mg (milligram) every 8 hours as needed was prescribed to treat anxiety. The follow up was to adjust medications and have nursing continue to give supportive care, monitor target behaviors and record, and to report any new or worsening behaviors. A Psychiatric Progress Note, dated 3/30/23, indicated Resident 43 reported ongoing anxiety and panic attacks and that clonazepam had been effective. Staff reports no new or worsening behaviors, and that mood has been stable. The plan was to continue current medication regimen. On 5/5/23 at 2:50 p.m., the Float SSD (Social Service Director) provided a Resident Concern/ Grievance Form, dated 4/5/23 at 2:53 p.m., which indicated Resident 43 had a concern about not receiving her medications on time, not being woken up for her scheduled pain medications, and not receiving her anti-anxiety medication every 8 hours as scheduled. The action taken for the grievance was that it was explained to Resident 43 that her clonazepam (anti-anxiety medication) was scheduled on an as needed basis and would not be offered to her if she did not request it. The times of the scheduled medications were changes so that they would not be given at shift changes, and that a care plan had been created for her to be woken up for her medications, per her preference. A physician's order, dated 4/26/23, indicated to change clonazepam .5 mg to 1 tablet every bedtime as needed for anxiety. A physician's order dated 5/4/23, indicated to change clonazepam .5 mg to 1 tablet every 12 hours as needed for anxiety. A care plan, initiated 5/5/23, Resident 43 had episodes of verbal aggression toward staff related to recent changes in medications. The goal was for her to allow staff to reassure and/or redirect resident during discussions of medication changes. The approaches, initiated 8/10/22, included to allow her to voice concerns as needed, reassure her that provider will assess medications and adjust as needed, and consult physician, nurse practitioner, or psychiatric services as needed. During an interview on 5/4/23, Resident 43 indicated she had bad anxiety, depression, and PTSD from things that had happened to her in her life. She became upset because she felt she had to justify her need for medications. She had frequent panic attacks and the physician had changed her anxiety medication without talking to her. She didn't understand why the medication change was done, but the psychiatric nurse practitioner had straightened the problem out when Resident 43 asked about it. Resident 43 began to cry and indicated a had a nurse that told her she was taking too much medication. The nurse tried to explain that she was being Resident 43's advocate, but it didn't seem that way to Resident 43. Resident 43 felt judged by the nurses because she would set the alarm on her phone in order to ask for her anxiety pills when they were due to be given. he nurses would make comments to her like oh, it must be 9 o'clock, she's coming for her meds. Resident 43 felt that the nurses were judging her and couldn't understand that she really needed the medications, she wasn't just taking them for no reason. During an interview on 5/8/23 at 10:56 a.m., CNA (Certified Nursing Assistant) 7 indicated she was aware Resident 43 had a history of trauma. CNA 7 did not know any specific approaches that were to be used for Resident 43. During an interview on 5/8/23 at 1:50 p.m. CNA 6 indicated she had no knowledge of any resident who had a history of trauma. During an interview on 5/8/23 at 5:35 p.m., CNA 5 indicated that Resident 43 may have a trauma history because of her behaviors. CNA 5 had been instructed by LPN (Licensed Practical Nurse) 3 to provide care for Resident 43 in pairs due to Resident 43 getting into it with LPN 3 last week. During an interview on 5/9/23 at 2:50 p.m., the DNS (Director of Nursing Services) indicated that Resident 43 often became upset about her medications. She was a clock watcher when it came to taking her medications and would set an alarm to take them. Resident 43 would snap off at the nurse about her medications and tell the nurses she didn't like all the questions about her medications. Resident 43 had become very upset when the nurse practitioner had decreased her clonazepam to one time daily at bedtime. The nurse practitioner had decreased the clonazepam because it could interact with another medications Resident 43 took routinely. The Psychiatric Nurse Practitioner had seen Resident 43 and the clonazepam was increased to every 12 hours as needed, which had calmed Resident 43 down a little. During an interview on 5/9/23 at 2:59 p.m., the RNC (Regional Nurse Consultant) indicated that when Resident 43 was admitted the staff had attempted to talk with her about things which could trigger Resident 43's anxiety or depression related to her PTSD. Resident 43 had not been forthcoming with any triggers. During an interview on 5/10/23 at 8:57 a.m., LPN 3 indicated that Resident 43 had gone off on every single nurse in the building, including her. Resident 43 was like clockwork, she would come up to the front and ask for her medications and would get very upset if she didn't get it. Resident 43 had called her everything but a child of God. LPN 3 had asked Resident 43 why she was getting a new medication for anxiety and depression and Resident 43 had told LPN 3 that she sure knew how to make a m***** f***** feel bad. Resident 43 wanted to take her anti-anxiety medication at the same time as her narcotic pain medication. LPN 3 had educated Resident 43 that taking the medications together could sedate Resident 43, but Resident 43 still wanted the medications as close together as possible. During an interview on 5/10/23 at 3:35 p.m., the DNS indicated she was aware Resident 43 had the behavior of cursing at the staff and that there should be a care plan addressing that behavior. During an interview on 5/11/23 at 9:29 a.m., the PNP (Psychiatric Nurse Practitioner) indicated that the facility had not consulted with her about any things that may trigger Resident 43 or about Resident 43's plan of care. The PNP indicated that a trigger at the moment for Resident 43 was the upcoming Mother's Day. Resident 43 had expressed increased anxiety related to Mother's Day coming since she had unexpectantly lost her mother at a young age. On 5/9/23 at 1:16 p.m., the Float SSD provided the Trauma Informed Care policy, last revised October 2022, which read . It is the policy of this facility to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident .For the resident to feel safe in their environment and trust caregivers despite past trauma. Trauma survivors can include .survivors of physical- sexual- or mental abuse, other violent crimes, a history of .homelessness, or who have suffered traumatic loss of a loved one .Trauma- informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization . Behavioral health services will assist with resident and Interdisciplinary Team in developing a plan of care which will be added to the medical record. This plan of care will incorporate individual experiences, customary routines, and cultural preferences of the individual's needs .

Based on observation, interview, and record review, the facility failed to ensure a medication was not administered after being dropped onto a medication cart, hand hygiene was done prior to donning gloves, and that gloves were donned prior to administering insulin for 3 of 5 residents randomly observed for medication administration (Resident 16, 33, and 197) Findings include: 1. On 5/8/23 at 9:29 a.m., QMA (Qualified Medication Aide) 22 was observed administering medications to Resident 16. QMA 22 obtained his medication cards from the drawer of the medication cart. She then began to remove the medications from the card into a plastic medication cup. As she did this, one of the medications fell onto a piece of paper which was sitting on top of the medication cart. QMA 22 obtained a plastic spoon from the medication cart and used the spoon to pick up the pill that had fallen onto the medication cart and placed it in the plastic medication cup with the other medications. She took the plastic medications cup into the resident and administered all of the medications to Resident 16. During an interview on 5/8/23 at 9:45 a.m., QMA 22 indicated she had not disposed of the pill that had fallen on the medication cart because it had fallen on the piece of paper, not directly on the cart. 2. On 5/9/23 at 11:53 a.m., RN (Registered Nurse) 31 was observed performing a blood sugar check for Resident 197. She obtained the needed items from the medication cart and took them into Resident 197's room. RN 31 then donned a pair of gloves. She did not do hand hygiene prior to donning the gloves. She obtained the blood sugar and removed her gloves. She then did hand hygiene using alcohol-based hand gel and returned to the medication cart. She obtained an insulin pen from the medication cart and set the pen for the prescribed amount of insulin. RN 31 then went back into Resident 197's room with the insulin pen. She administered the prescribed amount of insulin into Resident 197's right arm. She did not do hand hygiene or don gloves prior to administering the insulin. RN 31 then left the room and performed hand hygiene with alcohol-based hand gel. 3. On 5/9/23 at 12:05 p.m., RN 31 was observed performing a blood sugar check for Resident 33. She obtained the needed items from the medication cart and took them into Resident 33's room. RN 31 then donned a pair of gloves. She did not do hand hygiene prior to donning the gloves. She obtained the blood sugar and removed her gloves. RN 31 then did hand hygiene using alcohol-based hand gel as she left the room. During an interview on 5/9/23 at 12:10 p.m., RN 31 indicated she normally did hand hygiene prior to donning gloves and that she normally wore gloves while administering an insulin injections. On 5/9/23 at 3:27 p.m., the RNC (Regional Nurse Consultant) provided the Hand Hygiene Policy, last revised 12/2021, that read .Hand hygiene- a general term that applies to hand washing, antiseptic hand wash and alcohol-based hand rub .Indications for Hand-rubbing .Before and after removing gloves . On 5/9/23 at 3:27 p.m., RNC provided the Insulin Pen Administration Nursing Skills Competency, last reviewed 10/2019, which read .3. Gather needed supplies. 4. Perform hand hygiene . 6. Put on gloves . On 5/9/23 at 3:27 p.m., the RNC provided the Medication Pass Procedure, last reviewed 12/2016, which read .17. Wasted or dropped medication destroyed properly and documented per policy . 3.1-18(b)

Based on interview and record review, the facility failed to ensure a resident had an infection that met the criteria for antibiotic usage prior to providing an antibiotic for 1 of 6 residents reviewed for unnecessary medications. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on 5/9/23 at 9:00 a.m. The diagnoses for Resident 35 included, but were not limited to, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, chronic kidney disease, and pulmonary hypertension. A nursing progress note dated 4/14/23 indicated Aide came and got writer and when writer went into resident's room resident had a napkin with yellow/green sputum resident had been coughing up. Upon respiratory assessment writer heard coarse crackles and resident sounded very congested .Writer contacted on-call and got new orders for chest x-ray 2 view and Augmentin 500 mg [milligrams] PO BID [twice a day by mouth] x 10 days. Writer notified mobilex of x-ray orders and they confirmed order for today confirmation number 39021756. Writer pulled first dose of ATB [antibiotic] out of EDK [electronic drug dispensing unit] and administered to resident as ordered . A physician order dated 4/14/23 indicated Resident 35 was to receive 500 mg of Augmentin twice a day. The order was discontinued on 4/20/23. The April 2023 Medication Administration Record indicated Resident 35 had received the 500 mg of Augmentin starting a dose on the evening of 4/14/23, and then continued to receive twice a day on 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23 and 4/20/23. A radiology report date of service on 4/16/23 with a reported result on 4/16/23 at 4:51 p.m, indicated .The lungs demonstrate no significant consolidation, masses, effusions, or pneumothorax . A physician visit note dated 4/18/23 indicated .Nursing staff report pt [patient] started having cough 3 days ago and has yellow/green sputum. CXR [chest x-ray] was ordered (still pending) and she was started on Augmentin 500 mg PO BID x 10 days .On exam she is not coughing and does not appear SOB [shortness of breath] or ill appearing. She is a poor historian due to dementia. Her vitals are stable and she is afebrile [no fever] .Physical exam: .Respiratory: respiratory effort: no dyspnea [difficulty breathing/shortness of breath], no wheezing, rales/crackles, or rhonchi and diminished air movement .Assessment Plan: .1. cough - .please call with CXR results when available . A physician visit note for Resident 35 dated 4/19/23 indicated .Patient reports sinus problems; congestion with post nasal drainage. She reports sore throat. She reports cough but reports no wheezing and no shortness of breath. She reports muscle weakness .She reports no chest pain and no shortness of breath when lying down .Physical Exam: .Respiratory: respiratory effort: no dyspnea .no wheezing or rales/crackles and breath sounds normal and good air movement .Assessment/Plan: 1. Acute sinusitis - sinus congestion with drainage and sinus tenderness. suspect that drainage is contributing to cough. Patient has already been receiving ABX due to prior concern for pneumonia. Don't see need to extend use of ABX. Add Allegra 180 mg for 7 days . Resident 25's clinical record indicated Resident 35 continued to receive the 500 mg of Augmentin twice a day through 4/20/23. An interview was conducted with Float Director of Nursing (DNS) on 5/10/23 at 3:47 p.m. She indicated she was the infection preventionist and had taken over the antibiotic stewardship program in April. She uses Mcgreers to determine if antibiotic usage was necessary to treat an infection. Resident 35's infection did not meet the Mcgreers criteria to treat with an antibiotic. She had not notified the medical provider prior to starting the Augmentin antibiotic on 4/14/23, as she normally would have to clarify if the medical provider did want to continue with the antibiotic treatment prior to confirmation of the chest x-ray the resident had pneumonia. This Federal tag relates to Complaints IN00402254.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The clinical record for Resident 1 was reviewed on 5/8/23 at 9:40 a.m. Resident 1's diagnoses included, but not limited to, senile degeneration of the brain, hemiplegia affecting right side (inability/difficulty with moving a side of the body), protein-calorie malnutrition, convulsions, stage III pressure wound to right buttock, non-pressure wound to left lower leg with fatty layer exposed, and congestive heart failure. A physician's order indicated, Resident 1 was placed on hospice services on 3/8/23. Resident 1's care plan dated 3/8/23 indicated, she required hospice related to senile degeneration of brain with a goal to experience death with dignity and physical comfort. Interventions included, but not limited to, administer pain medication as ordered and to notify the physician and hospice of unrelieved or worsening pain. Physician's orders dated 3/8/23 indicated, for Resident 1 to receive 30 mg of morphine extended release every 12 hours and receive 10 mg (milligrams) of morphine concentrate every 2 hours as needed for dyspnea (rapid breathing) and anxiety. Resident 1 also had an order for acetaminophen 650 mg every 4 hours as needed for mild pain/fever. A physician's order dated 3/7/23 indicated, to monitor Resident 1 for effectiveness of routine pain medication every shift and indicate yes or no. If, no, complete pain assessment and notify physician and/or hospice. A review of Resident 1's March, April and May 2023 MARs (medication administration record) conducted on 5/8/23 at 10:08 a.m. indicated, Resident 1 did not receive the scheduled 30 mg of morphine as ordered on the following dates and times: April 15th - 8 a.m. dose April 17th - 8 a.m. dose April 24th- 8 a.m. dose April 27th - 8 a.m. dose May 7th - 8 a.m. dose A hospice nurse's note dated 3/21/23 indicated, Resident 1 reports mild pain and asked QMA (Qualified Medication Assistant) to administer as needed morphine. The review of the March MAR indicated, Resident 1 did not receive the as needed pain medication on 3/21/23. A hospice nurse's note dated 3/31/23 indicated, Resident 1 finally sleepy per QMA. Resident 1 having increased pain. A review of Resident 1's treatment administration record (TAR) for April and May indicated, her routine medication was not effective on the following dates and times: April 1st - day shift; under yes/no it indicated, 120 April 17th - evening shift; under yes/no it indicated, 120 April 24th - day shift April 25th - evening shift April 26th - day shift April 26th - evening shift May 2nd - day shift A review of Resident 1's April and May 2023 MARs (medication administration record) conducted on 5/8/23 at 10:08 a.m. indicated, she had not received any as needed medications on the days it was documented that her routine medications were not effective. An IDT (Interdisciplinary team) pain interview dated 5/5/23 indicated, Resident 1 had pain and/or was hurting in the last 5 days; frequently experienced pain/hurting over the last 5 days; her pain limited her day-to-day activities; and rated the intensity of her worst pain over the last 5 days as severe. The clinical record for Resident 1 did not indicate the pain's intensity during any of the medication administrations as per policy. 4. The clinical record for Resident 37 was reviewed on 5/9/23 at 3:37 p.m. Resident 37's diagnoses included, but not limited to, hemiplegia affecting dominant left side, congestive heart failure, stroke, moderate protein-calorie malnutrition, major depressive disorder, and anxiety. A physician's order dated 4/15/22 indicated, for Resident 37 to receive 650 mg of acetaminophen twice a day routinely and as needed for up to 3 times a day for muscle wasting and atrophy. A physician's order dated 3/13/23 indicated, to monitor Resident 37 for effectiveness of routine pain medication every shift and indicate yes or no. If, no, complete pain assessment and notify physician and/or hospice. A review of Resident 37's April and May 2023 TAR indicated, his routine pain medication was not effective on the following dates and times: April 4th - day shift April 17th - night shift April 23rd - night shift; under yes/no it indicated, 120 May 2nd - day shift The clinical record for Resident 37 did not indicate the pain's intensity during any of the medication administrations as per policy. A pain management policy was provided by the Regional [NAME] President Director of Operations on 5/8/23 at 10:58 a.m. It indicated .Policy: It is the policy of [name of facility] to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management Residents are assessed for pain upon admission, weekly and during medication administration .The following will be used when assessing pain. * Nursing admission Observation * Weekly summary * IDT Pain Interview or PAINAD (Pain Assessment in Advanced Dementia Scale) * Ongoing nursing assessments can also be documented in matrix progress notes or matrix vitals . Interviewable Resident - Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or Wong-Baker FACES scale .Non-interviewable Resident- Pain medications will be prescribed and given based upon nursing assessment of the following: * NON-VERBAL SOUNDS . * VOCAL COMPLAINTS OF PAIN . * FACIAL EXPRESSIONS . * PROTECTIVE BODY MOVEMENTS OR POSTURES * [NAME]-BAKER FACES Scale . Residents receiving routine pain medications should be assessed each shift by the charge nurse during rounds and/or medication pass .Additional information including, but not limited to reasons for administration, and effectiveness of pain medication will be documented on the Electronic Medication Administration Record (EMAR) .The licensed nurse will monitor the efficacy of the analgesia and keep the physician informed of any indicators of drug or dosage change as it relates to the resident's pain management. This Federal tag relates to Complaint IN00402254 and IN00400685. 3.1-37(a) 2. The clinical record for Resident D was reviewed on 5/8/23 at 1:00 p.m. The diagnoses for Resident D included, but were not limited to, type 2 diabetes mellitus, cirrhosis, seizures, and ascities. A pain care plan dated 1/11/23 indicated Resident D was at risk for pain. Interventions were the following: .Observe for adverse side effects of pain medication including, but not limited to over sedation, constipation, skin rash, nausea/vomiting, loss of appetite, change in mental status, stomach upset. Document abnormal findings and notify MD [medical provider], Assist with positioning to comfort, .Document effectiveness of prn [as needed] medications, .Administer meds as ordered, .Observe for non verbal signs of pain: changes in breathing, vocalizations, mood/behavior changes, eyes change expression, sad/worried face, crying, teeth clenched, changes in posture, .Offer nonpharmacological interventions such as quiet environment, rest, shower, back rub, reposition . A physician order dated 1/11/23 indicated Resident D was to receive 20 milligrams of baclofen three times a day for muscle spasms. A physician order dated 1/11/23 indicated staff was to monitor for effectiveness of routine pain medication every shift and complete pain assessment if not effective. The January 2023 Medication (MAR) indicated Resident D's pain was controlled with routine pain medication from 1/11/23 through 1/31/23 every shift. A nursing vitals assessment note dated 1/12/23 indicated Resident D was experiencing pain in her lower extremities. The resident's clinical record did not include a pain assessment of the resident's pain on 1/12/23, that included intensity of pain utilizing a pain scale and how the resident's pain was addressed. A nursing progress note dated 1/25/23 resident crying from pain in bilateral legs/feet stating level of pain 10/10. no prn medication available. On-call services contacted. new order for Biofreeze TID [three times a day] as needed per NP [Nurse Practitioner]. Resident made aware. Thin layer of Biofreeze applied to BLE [bilateral lower extremities] and will continue to monitor effectiveness. A pain assessment was completed on 1/25/23. It indicated the resident had complaints of excruciating pain in BLE. The medical provider notified an ordered biofreeze three times a day. A physician order dated 1/25/23 indicated Resident D was to receive biofreeze three times a day to lower extremities for pain as needed. The order was discontinued on 2/22/23. The clinical record did not indicate if the biofreeze was effective and/or if nonpharmacological interventions were provided on 1/25/23. A physician order dated 2/1/23 indicated Resident D was to receive lidocaine patches to bilateral extremities daily. A nursing progress note dated 2/17/23 indicated, Resident complaining of BLE pain, resident crying requesting for pain medication. On call notified new order for Tylenol 650 mg, on call made aware of allergies to percocet and lortab, resident states she has no reaction to Tylenol, on call states cont [continue] with Tylenol. A physician order 2/17/23 indicated Resident D was to receive 325 milligrams of Tylenol every 6 hours for pain as needed. The order was discontinued on 2/19/23. A pain assessment dated [DATE] indicated Resident D had complaints of pain in bilateral lower extremities. A physician order dated 2/22/23 indicated Resident D was to receive biofreeze to lower extremities for pain four times a day. A physician order dated 2/22/23 indicated Resident D was to receive 300 milligrams of neurotin daily. The February 2023 MAR indicated Resident D's pain was controlled with routine pain medication from 2/1/23 through 2/28/23 every shift. The resident's clinical record did not include the pain intensity of the resident's pain, if the Tylenol was effective, and/or if nonpharmacological interventions were provided on 2/17/23 and 2/22/23. A nursing progress note for Resident D dated 3/16/23 indicated resident had complaints of pain requested pain med when given acetaminophen resident stated i want a muscle relaxer or pain pill not this writer educated resident about current orders resident told writer to get out no new orders call light within reach. A nursing progress notes for Resident D dated 3/19/23 indicated resident requested pain pill resident stated i have a as needed pain pill writer informed resident that the pill she has that is as needed is for after seizure activity writer offered prn acetaminophen . resident stated that's not gone do nothin no new orders call light within reach. The March 2023 MAR indicated Resident D's pain was controlled with routine pain medication 3/1/23 through 3/28/23 every shift. The resident's clinical record did not include a pain assessment that had been conducted on 3/16/23 nor 3/19/23 that included pain intensity, how the resident's pain was addressed and/or if nonpharmacological interventions were provided. An interview was conducted with Regional Nurse Consultant on 5/9/23 at 12:17 p.m. He indicated the staff will assess a resident's pain and document a yes or a no if the resident's pain was controlled with their routine pain medication. If the resident responds with a no the pain medication was not controlling his or her pain then the staff will do a pain assessment. He was unable to provide pain assessments and nonpharmacological interventions provided to Resident D to address her pain. Based on interview and record review, the facility failed to timely address residents' pain; assess residents' pain that included effectiveness of as needed pain medications; and ensure nonpharmacological interventions were provided to address a residents pain for 1 of 2 residents reviewed for pain, 1 of 1 resident reviewed for rehabilitation and restorative services, and 1 of 1 residents reviewed for hospice per facility policy. (Residents D, F, 1, and 37) Findings include: 1. The clinical record for Resident F was reviewed on 5/8/23 at 11:46 a.m. Her diagnoses included, but were not limited to: coronary artery disease, congestive heart failure, and chronic kidney disease. She was admitted to the facility on [DATE] and discharged to the hospital on 1/20/23. The 12/28/22 pain care plan indicated she was at risk for pain. The goal was for her to be free from adverse effects of pain. Approaches were to administer medications as ordered; assist with positioning to comfort; notify MD if pain is unrelieved and/or worsening; and to offer non-pharmacological interventions such as quiet environment, rest, shower, back rub, and reposition. The physician's orders indicated for her to have PT (physical therapy) treatment 5 times a week for 8 weeks, starting 12/21/22. They indicated Roxicodone (oxycodone) - Schedule II tablet; 15 mg; amt: 15 mg; oral Special Instructions: Indication: pain Every 4 Hours PRN, effective 12/19/22. There were no other pain medications ordered for her. An interview was conducted with the TD (Therapy Director) on 5/9/23 at 3:16 p.m. She reviewed Resident F's therapy notes and indicated Resident F received all 3 disciplines of therapy while residing at the facility. She was on PT 5 times a week from 12/21/22 to 1/5/23. She started out with the ability to walk 10 feet, then discharged requiring a Hoyer lift. She recalled she was regressing and not doing better. She was complaining of pain in her lower back with a compression fracture in November, 2022. She recalled discussing pain management with physical therapy, but Resident F wasn't really interested in that, such as modalities, different ways to move around the room. The 12/29/22 note referenced education of exercises bedside, but she refused to get out of bed. Resident F was consistently complaining of pain at a level of 8 on a scale of 1 to 10. The pain never changed during her therapy treatment. There was education regarding getting out of bed to decrease pain, but she refused. The 1/2/23 physical therapy note indicated, Low back pain 9/10 limiting functional mobility task. The 1/3/23 occupational therapy note read, continued to c/o [complain of] back pain throughout treatment session. The 1/4/23 physical therapy note read, Low back pain 9/10 limiting all functional mobility tasks. Pt [Patient] unable to sit on the EOB [edge of bed] d/t [due to] c/o low back pain. The 12/21/22, 4:14 p.m. nurse's note indicated she complained of back and stomach pain. The 12/27/22, 2:07 p.m. nurse's note indicated she complained of back, stomach and leg pain. There was no information in the clinical record, including the nurse's notes, medication administration records, and treatment administration records to indicate the facility addressed the above referenced complaints of pain. An interview was conducted with the DNS (Director of Nursing Services) on 5/10/23 at 3:50 p.m. She reviewed Resident F's clinical record and indicated she did not see any other pain medications ordered other than the oxycodone. She was going to look into whether the facility addressed the complaints of pain referenced in the 12/21/22 at 4:14 p.m. nurse's note, 12/27/22 at 2:07 p.m. nurse's note, 1/4/23 physical therapy note, 1/2/23 physical therapy note, and 1/3/23 occupational therapy note and whether anyone notified the physician of her unrelieved pain. An interview was conducted with the RNC (Regional Nurse Consultant) on 5/11/23 at 9:42 a.m. He indicated there was no verification of any pain interventions for the above 5 dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by the dishwasher not reaching an adequate wash temperature causing residents to eat off of Styrofoam and using plastic utensils, not utilizing hair restraints properly, having a personal item on a spice shelf, not disposing of food items by the use by date, not labeling and dating food with proper dating, not ensuring stored items are wrapped tightly and not exposed to the air for 43 of 46 residents who consume food served from the kitchen. (Facility) Findings include: An initial kitchen tour was conducted on 5/4/23 at 9:49 a.m. with DM (Dietary Manager). During the tour, the following was observed: 1. The kitchen's dishwasher was not reaching temperature. An interview with DM during the tour indicated, the dishwasher has been down for a about a week because it was not reaching the needed temperature for the wash cycle. So, the resident's are being served meals using Styrofoam plates, bowls, and cups. They are also using plastic silverware at meals. 2. An observation of KS (Kitchen Staff) 1 and 2 during the tour indicated, they both had facial hair in excess of 1/4 inch in length that was not covered by a hair restraint. 3. An opened and half consumed bottle of Calypso Ocean Blue Lemonade was sitting on the same shelf as the spices. DM indicated, she wasn't sure who the drink belonged to in the kitchen. 4. Bulk cereals stored under a prep table had the following use by dates on the stickers on each container: Fruit Loops 5/3/23, [NAME] Bran cereal 5/1/23, Frosted Flakes 5/4/23, and [NAME] Crispies 5/1/23. 5. The lid to the bulk container of bread crumbs in the dry storage room was left open to air. 6. In the walk-in Fridge: - Two trays of Styrofoam serving bowels containing precut watermelon pieces (one tray was stacked on top of the second tray) had no labels nor was dated; 15 of the watermelon bowls under the top tray did not not have lids and were open to air with the potential to touch the bottom of the top tray. - An opened box of egg patties was left open to air as the plastic inside the box was left open. - A plastic bag of cut Zucchini had no label or opened date, - An opened box of cinnamon roll dough was left open to air as the plastic bag inside was left open. - A plastic bag of sausage was dated with a use by date of 4/30/23. - A plastic bag of chicken patties was dated with a use by date of 4/12/23. An interview with DM conducted during the kitchen tour indicated, all food should not be left open to air and labeled and dated with use by dates or dates opened. An interview with ED (Executive Director) conducted on 5/11/23 at 10:15 a.m. indicated, the facility's dishwasher had broke on 12/12/22 and served residents on Styrofoam and plastic until the week of 1/15/23. At that time a 'new' dishwasher was installed. The 'new' dishwasher stopped meeting the required wash temperatures on 4/20/23 and since 4/20/23, the residents have been served on Styrofoam and with plastic utensils since then. The dishwasher was still broken down at the end of the survey period. A Culinary Personal Hygiene policy was received on 5/11/23 at 12:11 p.m. from RNC (Regional Nurse Consultant). The policy indicated, Personal Cleanliness a. All employees working in the culinary department must wear a clean hair restraint which effectively covers all hair. A ball cap, chef beanie or similar may be worn over a proper hair restraint. Culinary employees with facial hair must also wear a beard restraint .d. Personal items would not be stored on food preparation equipment or in food storage areas. A Food Storage policy was received on 5/11/23 at 12:11 p.m. from RNC. The policy indicated, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing .Leftover prepared foods and processed meats .are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicated the date by which the food shall be consume or discarded .Dry Storage .Containers with covers must be used for storing cereals, cereal products, flour, sugar, pasta .when removed from their original container. These containers should be labeled and dated on both the container and the lid .All foods shall be covered or wrapped tightly, labeled, and dated. This Federal tag relates to Complaints IN00399680 and IN00402254. 3.1-21 (i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a clean, sanitary, and homelike environment by having: a broken window in a residents room, black substance on P-Tack unit vents, a purple stain on marble surround on window sill, toilet not securely fastened to the floor, missing bathroom light covers, not maintaining walls in good repair from scratches, peeling paint on walls and bathroom door, bedside table missing a wheel, missing closet doors, mechanical lift equipment covered with dirt and debris, toilet paper not fitting on toilet paper holder, and a missing piece of hallway handrail. (Facility) Findings include: An observation of Resident 17's room was conducted on 5/4/23 at 3:22 p.m. The P-Tack unit (heating and cooling unit) had a black substance on the unit's vents, one of the windows had blue tape all around it, the window sill had a large purple stained area, the toilet was loose from the floor, and the bathroom light did not have a cover. An observation made on 5/5/23 at 9:28 a.m. of Resident 40 and 42's room. The walls were marred behind both beds, the paint on the wall near the bathroom was peeling off the wall and paint was peeling off the inside of the bathroom door. An environmental tour of the facility was conducted with ED on 5/11/23 at 11:40 a.m. During the tour the following was witnessed: - Inside Resident 17's room, the P-Tack unit still had a black substance on the air vents, the ED removed the blue tape from the window and exposed shards of broken glass still in the window framing and the window was missing the inside pane of glass, the purple area on the window sill was still present, the toilet bowl was shifted off to the right side and needed to be tightened into its correct position, and the bathroom light fixture was missing its cover. - In the hallway, the mechanical lift was parked next the wall and it had dirt and debris all over the base of the unit. - room [ROOM NUMBER]'s bathroom toilet paper was on the sink, next to the wall farthest away from the toilet. The toilet paper did not fit the toilet paper holder because the toilet paper tube's hole was too small to fit on the toilet paper holder and a toilet riser was blocking access to the toilet paper holder. The walls behind both beds were marred. - Resident 137's bedside table had a broken wheel and the closet was missing its doors. - Resident 40 and 42's wall near the bathroom and the inside of the bathroom door had peeling paint. - In the hallway, between a storage room and room [ROOM NUMBER], a section of the handrail was missing exposing metal hardware. An interview with ED conducted at the end of the environmental tour indicated, the observed items needed to be fixed/repaired as soon as possible. This Federal tag relates to Complaint IN00399680 and IN00402254. 3.1-19(f) 3.1-19(f)(3) 3.1-19(f)(5) 3.1-19(m)(4)(E) 3.1-19(x)

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) had worked 8 hours in the facility. This had a potential to effect 44 of 44 residents on 10/1/22, 46 of 46 residents on 10/2/22, 44 of 44 residents on 10/16/22, 43 of 43 residents on 10/22, 43 of 43 residents on 10/23/22, 43 of 43 residents on 11/12/22 and 44 of 44 residents on 12/17/22. Findings include: The PBJ Staffing Data Report that was generated from October 1, 2022 - December 31, 2022 indicated the following days the facility did not have an RN working 8 hours in the building: 10/1/22, 10/2/22, 10/8/22, 10/16/22, 10/22/22, 10/23/22, 11/12/22 and 12/17/22. An interview was conducted with the Float Director of Nursing Services (FDNS) on 5/9/23 at 3:30 p.m. She indicated an RN had not worked an 8 hour shift in the facility on the following days: 10/1/22, 10/2/22, 10/16/22, 10/22/23, 10/23/22, 11/12/22 and 12/17/22.