Based on observation, interview and record review the facility failed to ensure residents were treated with respect for 1 of 1 residents reviewed. (Resident 30) Findings include: During an observation on 8/7/24 at 9:43 AM, Employee 4 used the term sweetheart to address Resident 30 when asking what hurt. Resident 30 became increasingly agitated when addressed by the label, sweetheart, rather than their name being used. Resident 30's record was reviewed on 8/6/24 at 1:05 PM. Diagnoses included dementia, chronic pain syndrome, history of stroke with residual deficits, and cognitive communication deficits. A review of Resident 30's current quarterly MDS (minimum data set) indicated their BIMS (basic interview for mental status) score was 1 (severely cognitively impaired). A review of Resident 30's current care plan indicated no care plan had been initiated regarding nicknames. In an interview on 8/6/24 at 1:18 PM, Resident 30's spouse indicated she would not like being called pet names, especially sweetheart. Resident 30 had not addressed others in that manner and would respond best to her own name being used in communication. In an interview on 8/8/24 at 12:57 PM Employee 5 indicated they had seen a trend of nicknames being used. They indicated they knew it was not appropriate. A current policy dated 8/8/24 provided by Administrator indicated residents have the right to be treated with respect. 3.1-3(a)

Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained during medication administration for 3 of 5 administration attempts observed. Findings include: During an observation on 8/5/2024 at 9:38 AM, Registered Nurse (RN) 2 on the 200 hall medication cart pulled a medication card from the cart, popped medication from the blister pack into their bare hand, then placed the medication into a medication cup that was on the cart. During an observation on 8/5/2024 at 11:24 AM, RN 2 at the 200 hall medication cart, popped medication from the blister pack into their bare hand, then placed the into a medication cup. During a medication pass observation on 08/06/24 08:16 AM, License Practical Nuse (LPN) 3 popped medication from the blister pack into their bare hands, then placed the medication into a medication cup. A record review of the Medication Administration ( Medication Pass Procedure) Skills Competency, Nursing skills competency, dated 7/2023 .Procedure steps: Medication are opened without contaminating . 3.1-18(a)

Based on observation, interview, and record review the facility failed to ensure care of communication deficit for 1 of 1 residents reviewed. (Resident 176) Findings include: During an observation on 07/24/23 at 10:21 AM, the Unit Manager was having difficulty understanding Resident 176. The Unit Manager requested Resident 176 start over from the beginning. The Unit Manager then repeated the parts she understood and asked Resident 176 if she was correct. There were no assistive devices used. Resident 176 was pacing with noted deficits to his left side. His lips and face had drooping on the affected side, he held left arm to his side, and he had an unusual gait. Resident 176 did not have oxygen on and was ambulating without assistance. In an interview, on 7/24/23 at 10:36, the Unit Manager indicated Resident 176 had a stroke prior to coming to facility. The Unit Manager was unable to understand him at times and at other times he was clearer. The Unit Manager indicated no assistive devices were used with Resident 176. Resident 176's record was reviewed, on 7/25/23 at 1:53PM, Resident 176 diagnoses included chronic obstructive pulmonary disease, cerebrovascular disease, history of cerebral infarction (stroke), and intermittent explosive disorder. Resident 176's current Quarterly MDS (Minimum Data Set) assessment Section B for hearing, speech, and vision indicated he had no deficits at the time of assessment. Section C of MDS for cognitive patterns assessed his BIMS (Brief Interview Mental Status) score to be 7 at the time of assessment. A score of 7 indicated moderate cognition deficit. Resident 176 had no speech therapy orders. In an interview, on 7/26/23 at 6:32AM, RN 6 indicated Resident 176 could be difficult to understand at times. RN 6 indicated agency staffing was utilized throughout the building. RN 6 indicated she was unaware of any communication assistive devices resident used i.e., pen and paper, dry erase board, cue cards, etc for any resident with communication difficulty. In an observation, on 7/26/23 at 8:00AM, Resident 176 was in a wheelchair. He was asked by LPN 7 where he would like to sit for breakfast. Resident 176 answered with what sounded like a possible name. LPN 7 stated a peer name in a questioning tone. Resident 176 shook his head no. LPN 7 asked if he wanted to sit by a different peer. Resident 176 shook his head no for a second time and repeated a name. LPN 7 asked if he wanted to sit by a 3rd peer. Resident 176 threw both hands up into the air and was visibly irritated. In an interview, on 7/26/23 at 1:36PM, the Unit Manager indicated Resident 176's speech was soft and at times mumbled, did at times get frustrated while attempting to communicate with others. The Unit Manager indicated Resident 176 care plan should include communication deficit. The Unit Manager indicated Resident 176 did not have any assistive devices for communication. Resident 176's comprehensive care plan did not include a problem of communication on 7/25/23. On 07/27/23 at 08:50 AM the Unit Manager provided a care plan updated to include the problem of communication. The problem with a start date of 7/26/23 indicated Resident 176 had difficulty making self-understood due to possible cerebrovascular disease. Resident 176's speech was soft and mumbled. Resident was able to communicate needs and wants when given time. The goal was: Resident will make self-understood. The approaches were documented as the following: Allow resident time to speak. Avoid interrupting. Gently inform resident you were unable to hear him and politely ask him to repeat himself. Observe for non-verbal signs of distress. Assess for pain. Provide liquids and food as needed. Provide a quiet, non-hurried environment, free of background noises and distractions. (The secured unit census had over a dozen other residents with activity room and dining area were close in proximity) Repeat what the resident said to validate him. Thank resident for communicating, conversing, and visiting with you, to praise him for continued communication. A policy dated 1/2010 with most recent revision 10/2019 titled, IDT Comprehensive Care Plan Policy was provided by DNS (Director of Nursing Services) on 7/27/23 at 9:48AM. The policy indicated each resident would have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan would include measurable goals and resident specific interventions based on resident needs to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial needs. 3.1-38(a)(2)(E)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents' right to be free from verbal abuse for 2 of 4 residents reviewed. (Resident B, Resident C). Findings include: A facility reported incident, dated 5/28/23, was provided by the Administrator on 6/1/23 at 10:14 AM. The report indicated Certified Nurse Aide (CNA) 3 had accused CNA 2 of verbal abuse towards Resident B and reported her accusation to the Director of Nursing (DON). An investigation file was provided by the Administrator on 6/1/23 at 10:14 AM. The filed included statements, as follows: CNA 3's, statement, dated 5/28/23, indicated she and CNA 2 had assisted Resident B. CNA 3 indicated Resident B had become combative with care, by hitting and kicking. CNA 3 indicated CNA 2 yelled at Resident B to stop hitting then told Resident B she can hit faster than he can. CNA 3 indicated she told CNA 2 to leave the room. CNA 4 assisted CNA 3 with Resident B's care. Resident B had told CNA 4 about CNA 2 had yelled at him and told him what to do. At that time, CNA 2 returned to Resident B's room. CNA 2 indicated Resident B had tried to hit CNA 2 and CNA 2 indicated I told him I can hit faster than him. CNA 4 and CNA 3 told CNA 2 to leave the room. CNA 3 indicated CNA 2 stated whatever, rolled her eyes and left the room. CNA 3 indicated she had reported the incident to the DON and LPN 6 once Resident B was safe. CNA 4's undated statement indicated CNA 3 had asked her to help with Resident B's care. CNA 4 indicated she entered the room and Resident B was upset. CNA 4 indicated Resident B had indicated you want me up, you're going to push, push, push. CNA 4 indicated she asked Resident B what was wrong. Resident B had responded that girl wanted to yell at me and tell me what I had to do. CNA 4 indicated then CNA 2 entered the room. CNA 2 told Resident B you have to get up to eat .because I said so CNA 3 told CNA 2 to exit the room. CNA 4 indicated at the doorway CNA 2 stated Ya, he was trying to hit me too, I told him I can hit faster than he can. He ain' t gonna beat on me. CNA 4 indicated she notified the DON once Resident B was safe. LPN 6's statement, dated 5/30/23, indicated she had not been present when CNA 2 was with Resident B. The investigation file included additional staff and resident interviews, as follows: Resident C was interviewed on 6/1/23 by the DON. In the interview Resident C indicated CNA 2 talked nasty to me. Resident C had also indicated CNA 2 indicated we are not here to listen about that when the resident was talking about her health. Housekeeper 5 was interviewed on 6/1/23 by the DON. In the interview Housekeeper 5 indicated Resident C told him CNA 2 had been rude to her. In an interview on 6/1/23 at 11:11 AM, Housekeeper 5 indicated Resident C told him this week after the incident CNA 2 had a bad attitude towards Resident C and other residents. In an interview on 6/1/23 at 11:43 AM, Resident C indicated CNA 2 was mean and hateful. Resident C indicated CNA 2 talked nasty, especially at a time when the resident was discussing her health, the aide indicated we don't need to hear that. In an interview on 6/1/23 at 12:01 PM, the DON indicated on 5/28/23 she had worked the medication cart on the floor when CNA 3 and CNA 4 notified her of the verbal abuse allegations towards CNA 2. The DON indicated she had pulled CNA 2 into her office and called the Administrator. CNA 2 was escorted from the facility. The DON and Administrator indicated CNA 2 had not come into the facility but was instructed to write a statement and bring it in on 6/1/23. The Surveyor indicated CNA 2 could speak to her at the time of the survey. CNA 2's statement, dated 6/1/23 was provided by the DON on 6/1/23 at 2 PM. The DON indicated CNA 2 had left the building already. CNA 2 did not speak with the Surveyor. The statement indicated Licensed Practical Nurse (LPN) 6 alerted CNA 2 when Resident B had fallen and needed assistance. CNA 2 indicated Resident B was combative. CNA 2 indicated CNA 3, CNA 4 and LPN 6 all encouraged the resident to get up for dinner. CNA 2 indicated she did not abuse Resident B. 1. A record review was completed for Resident B on 6/1/23 at 11:21 AM. Diagnoses included depressive episodes and panic disorder. A quarterly Minimum Data Set (MDS) assessment, dated 3/13/2023, indicated Resident B had a Brief Mental Interview Status (BIMS) score of 10/15 (moderately impaired). 2. A record review was completed for Resident C on 6/1/23 at 11:16 AM. Diagnosis included depressive episodes. A quarterly MDS dated [DATE], indicated Resident C had a BIMS score of 15/15 (cognitively intact). A policy, revised January 2023, titled Abuse Prohibition, Reporting and Investigation, was provided by the Administrator on 6/1/23 at 10:14 AM. The policy indicated verbal abuse: oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend or disability. This Federal Finding relates to Complaint IN00409614. 3.1-27(b)

Based on interview and record review the facility failed to ensure security of medications from misuse for 1 of 10 residents reviewed. (Resident B) Findings Include: An investigation file was provided by the Administrator on 12/27/22 at 11:30 AM. The file included a facility reportable dated 12/15/22 the facility was notified by a detective from the local police department about an investigation regarding Registered Nurse (RN) 2. The detective indicated RN 2 was found to be in procession of a Resident B's bottle of gabapentin (anticonvulsant). A statement, dated 12/19/22, by RN 3 indicated she spoke with the detective. RN 3 indicated she had admitted resident B and no medication was brought into the facility by the family at the time of admission. RN 3 indicated the family indicated the medications were brought into the facility that evening and given to a floor nurse. The statement indicated after Resident B's discharge, RN 3 pulled cards out of the medication cart and placed them into the pharmacy return bag in the medication room. RN 3 and RN 2 were the only nurses in the building at the time with keys to the medication room containing the pharmacy return bag. RN 3 indicated she later returned to the medication room, found the medications pulled back out of the pharmacy bag in the sink. RN 3 indicated she thought RN 2 was under the impression the medications were new medications to be separated into the halls for distribution and RN 3 started to return them to the bag. RN 3 indicated she noticed 2 cards of gabapentin flipped the opposite direction and pulled away from the pile a bit. RN 3 indicated she felt uncomfortable so she sealed the bag of medication, placed them in the locked medication cart and passed the information onto the 3rd shift for pharmacy return. In an interview on 12/27/22 at 11:30 AM, the Administrator indicated on 12/15/22 a local police detective reported to the facility a bottle of gabapentin labeled with Resident B's name was found in possession of RN 2. The Administrator indicated she was unsure exactly how the nurse obtained possession of the medication as the nurse never administered medication to Resident B per documentation. The Administrator indicated she spoke with RN 3. She indicated on 10/13/22, RN 2 and RN 3 worked together. The Administrator indicated the resident's family had brought in medication from home after the resident was admitted . RN 3 indicated she did not receive any medication from the family at the time of admission or throughout her shift. In an interview on 12/27/22 at 2:35 PM, RN 6 indicated when a resident's family brought in medication from home the nurse obtained an order from the Nurse Practioner (NP) before administrating the medication. If the NP was not available, the medication would be placed in the locked medication cart or medication room until an order had been obtained. In an interview on 12/27/22 at 2:11 PM, the Director of Nursing (DON), indicated when a family brought in medication for a resident. The medication would be placed in the locked medication room and labeled with the resident's name until an order was received. In an interview on 12/27/22 at 11:04 AM, Licensed Practical Nurse (LPN) 7 indicated medications are only given to those who are prescribed the medication. A policy, last revised 2/2020, titled Abuse Prohibition, Reporting and Investigation, indicated .each resident should be provided an environment free from abuse, neglect, misappropriation of resident property misappropriation of resident funds or property: deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident's property or money without the resident's consent. This Federal Finding relates to Complaint IN00397437. 3.1-28(a)